What is the role of postinduction therapy in pediatric acute myelocytic leukemia (AML) treatment?

Updated: Sep 12, 2017
  • Author: Mark E Weinblatt, MD; Chief Editor: Jennifer Reikes Willert, MD  more...
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Answer

After remission is induced, postinduction treatment is necessary, because more than 90% of patients otherwise relapse without additional treatment. In patients without HLA-matched donors from their family, sequential cycles of chemotherapy are administered by using combinations of cytosine arabinoside and etoposide, mitoxantrone and cytosine arabinoside, and, finally, high-dose cytosine arabinoside with L-asparaginase.

Allogeneic bone marrow transplantation has been shown to reduce relapse rates but does not always improve overall survival because of treatment-related mortality. Autologous bone marrow transplantation has also been shown to reduce relapse rates but does not improve overall survival compared with chemotherapy alone because of treatment-related mortality.

In the COG trials, transplants are not recommended for "low-risk acute myeloid leukemia," which is characterized by chromosome inv(16) and t(8;21) abnormalities; these patients receive additional "consolidation" chemotherapy and are only transplanted in second remission. Allogeneic stem cell transplantation from an HLA-matched sibling or parent is recommended during the first complete remission (ie, after 3 cycles of chemotherapy) for other patients (ie, those with standard-risk acute myeloid [normal cytogenetics] who enter remission with 2 induction courses and those with high-risk acute myeloid leukemia [abnormal karyotypes, including monosomy 7, trisomy 3, 5q- or complex karyotypes]). Transplantation is reserved for the second remission after a relapse for patients with Down syndrome and acute myeloid leukemia. Patients with APL should not receive a transplant during the first remission.

Upon relapse and the achievement of a molecular remission in a child treated with chemotherapy only, stem cell transplantation offers the best chance of cure. If an HLA-matched family donor is not available, the use of unrelated matched donors and autologous bone marrow transplant are options that have shown promise.

Other approaches have met with success in other parts of the world. Nordic and Japanese researches have reported promising results using multiple cycles of high-dose cytosine arabinoside. [4, 13]


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