INDUCTION THERAPY OF PREVIOUSLY UNTREATED AML (excluding APML)
 
  1. Pre-induction
      1. All patients should have pre-chemotherapy BM biopsy with cytogenetic, flow cytometry, FISH and molecular analysis on aspirated marrow.
      2. All patients should be HLA typed
      3. Patients with APML (M3 AML) will use a separate chemotherapy protocol
      4. Patients entered on ECOG or otherAML protocols are excluded
      5. All patients under 60 should have CMV serology
      6. MUGA scan or cardiac echo (to assess left ventricular function):
        1. All patients over 60 years old
        2. Any patient with history or clinical evidence of cardiac disease
        3. Not necessary to delay start of chemotherapy waiting for MUGA unless there is clinical suspicion of heart failure
      7. All patients should have a double lumen PICC line
        1. Patients should not be given thromboprophylaxis during induction therapy.
      8. If blast count > 50K: give hydroxyurea 6-8 gm/day until count < 50K
      9. Menstruating females: suppress menstruation until platelet count > 50K without transfusion and evidence of marrow recovery 
  2. Induction Chemotherapy (except for M3 AML or patients on clinical trials): Most newly diagnosed patients will receive "7+3" induction, with 3 daily infusions of an anthracycline (e.g., daunomycin or idarubicin) and a 7-day continuous infusion of cytarabine. These protocols can be accessed via the BEACON function in HealthLink.
  3.  Lumbar puncture/intrathecal chemotherapy
      1. Wait until circulating blasts cleared unless there is clinical evidence of CNS leukemia
      2. Platelet count should be > 50K or platelets should be running during LP
        1. For patients refractory to platelet transfusions consider deferring LP until marrow recovers
        2. For platelet-transfusion-dependent patients - recheck platelet count 12 hours post LP, consider repeat platelet transfusion if count < 20K
        3. Use 22 gauge spinal needle for thrombocytopenic patients
      3. If pt has FAB M4 or M5 or clinical evidence of CNS leukemia, give 50 mg Ara-C i.t. or 12 mg methotrexate i.t. empirically with first LP
        1. Consider giving i.t. hydrocortisone 20 mg
      4. Patient should lie prone for at least one hour after LP
      5. For patients with DIC, defer until DIC resolved if possible
      6. Studies to be ordered on spinal fluid:
        1. Tube 1: protein, glucose
        2. Tube 2: hold for culture. Culture only if protein elevated, glucose low or clinical suspicion of meningitis (note: this does not apply to specimens obtained from Ommaya reservoirs - these should always be cultured).
        3. Tube 3: cell count and cytospin. This tube should be flagged "bone marrow lab, attention pathologist"
      7. If initial CSF has definite or possible leukemic cells, repeat LP every 3-4 days, with 50 mg Ara-C i.t. each time, until spinal fluid clear x 3
  4.  Post-treatment marrow biopsy/aspirate I:
      1. Timing: day 13-16, (counting first day of ida/Ara-C as day 1; indicate when chemo started on bone marrow lab form)
      2. Cytogenetic and molecular analysis is generally not performed on the first post-treatment marrow
  5.  Marrow biopsy/aspirate II
      1. Timing: when blood counts recover (ANC > 1000, platelets > 100K, regardless of Hgb/Hct); sooner if clinical suspicion of recurrence or if evidence of residual disease in marrow
  6.  Laboratory testing
  7.  Blood cultures
  8.  Infection prophylaxis and treatment
  9.  Transfusion policy
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Reviewed August 2016

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