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Erythroleukemia Treatment & Management

  • Author: Beata Holkova, MD; Chief Editor: Emmanuel C Besa, MD  more...
 
Updated: Dec 29, 2015
 

Approach Considerations

The approach to the treatment of acute erythroleukemia is similar to the approach used for other subtypes of acute myelogenous leukemia (AML) (see Acute Myelogenous Leukemia).

Admit the patient for induction chemotherapy. Admit the patient for febrile neutropenia or any grade III or IV chemotherapy-related toxicity. Patients with poor cardiac function may be at increased risk of cardiotoxicity with anthracycline-based chemotherapy regimens.

Placement of an indwelling central venous catheter and/or port for chemotherapy infusion is usually recommended. This access can also be used to draw blood samples for periodic analysis.

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Chemotherapy

The management of AML (including the M6 subtype) usually constitutes induction chemotherapy and postinduction/consolidation chemotherapy. Cytarabine is the most active agent in the management of AML; therefore, various regimens are designed around this agent.

The regimen for induction therapy is the “7 + 3” regimen: Cytarabine at 100 mg/m2/d intravenously (IV) by continuous infusion on days 1-7 plus an anthracycline (idarubicin 12 mg/m2 or commonly used daunorubicin 45-60 mg/ m2) or anthracenedione (mitoxantrone 12 mg/ m2) ( IV) push on days 1-3.[11, 12]

The regimen for consolidation therapy includes 2 options. The high-dose ara-C (HiDAC) regimen includes cytarabine at 3 g/m2 IV q12h on days 1, 3, and 5 for 4 cycles.[13] The “5+2” regimen includes cytarabine at 100 mg/m2/d IV continuously infused on days 1-5 plus daunorubicin at 45 mg/m2 IV on days 1 and 2 for a total of 2 cycles.[14]

A bone marrow biopsy should be performed 14 days after induction therapy to assess remission status. If persistent blasts are noted, a second course (with dose-reduced “5 +2” regimen) is recommended. If marrow is hypoplastic, the second course is delayed until the bone marrow is recovered enough to clearly distinguish the type of recovery (ie, leukemic versus normal).

If the recovering marrow appears to have many immature cells, a wait-and-watch strategy is reasonable for as long as a week. Then, a repeat marrow biopsy is performed to clearly distinguish between relapse and remission.

Patients in whom 2 cycles fail are deemed primary refractory and should be considered for experimental therapeutic approaches.

Supportive care during chemotherapy treatment includes antiemetic prophylaxis, antiviral prophylaxis in herpes simplex – negative patients, and transfusion support.

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Dietary Measures

Patients should be on a neutropenic diet. All fruits and vegetables should be cooked or peeled.

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Activity Modification

During the neutropenic phase, all visitors and personnel should wash their hands before entering the patient’s room.

In patients with thrombocytopenia, pay special attention to oral hygiene, with frequent rinsing and brushing of teeth only with a disposable oral swab. Such patients should avoid nonsteroidal anti-inflammatory agents and other medications that can inhibit platelet function. Make sure that these patients do not receive intramuscular injections while thrombocytopenic.

Patients should refrain from strenuous physical activity and should avoid potted plants and flowers. During chemotherapy, they should stay away from crowded public places and avoid contact with people with infectious diseases.

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Long-Term Monitoring

Patients in remission should be examined periodically by their physicians to evaluate their state of health, blood cell counts, and bone marrow, if necessary. The interval between visits may be lengthened, but monitoring should continue indefinitely.

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Contributor Information and Disclosures
Author

Beata Holkova, MD Assistant Professor, Massey Cancer Center, Medical College of Virginia, Virginia Commonwealth University School of Medicine

Beata Holkova, MD is a member of the following medical societies: American College of Physicians, American Society of Hematology

Disclosure: Nothing to disclose.

Coauthor(s)

Kenichi Takeshita, MD Adjunct Associate Professor, Department of Medicine, Division of Hematology, New York University School of Medicine; Medical Director, Clinical Research and Development, Celgene

Kenichi Takeshita, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Nothing to disclose.

Asher A Chanan-Khan, MD Assistant Professor, Department of Medicine, Division of Lymphoma and Bone Marrow Transplantation, Roswell Park Cancer Institute, State University of New York at Buffalo

Asher A Chanan-Khan, MD is a member of the following medical societies: American College of Physicians, American Medical Association, American Society of Hematology

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

David Aboulafia, MD Medical Director, Bailey-Boushay House, Clinical Professor, Department of Medicine, Division of Hematology, Attending Physician, Section of Hematology/Oncology, Virginia Mason Clinic; Investigator, Virginia Mason Community Clinic Oncology Program/SWOG

David Aboulafia, MD is a member of the following medical societies: American College of Physicians, American Medical Association, AMDA - The Society for Post-Acute and Long-Term Care Medicine, American Society of Hematology, Infectious Diseases Society of America, Phi Beta Kappa

Disclosure: Nothing to disclose.

References
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  2. Acevedo-Olvera LF, Diaz-Garcia H, Parra-Barrera A, Caceres-Perez AA, Gutierrez-Iglesias G, Rangel-Corona R, et al. Inhibition of the Na+/H+ antiporter induces cell death in TF-1 erythroleukemia cells stimulated by the stem cell factor. Cytokine. 2015 Sep. 75 (1):142-50. [Medline].

  3. Mazzella FM, Kowal-Vern A, Shrit MA, et al. Effects of multidrug resistance gene expression in acute erythroleukemia. Mod Pathol. 2000 Apr. 13(4):407-13. [Medline].

  4. Santos FP, Faderl S, Garcia-Manero G, Koller C, Beran M, O'Brien S, et al. Adult acute erythroleukemia: an analysis of 91 patients treated at a single institution. Leukemia. 2009 Sep 10. [Medline].

  5. Kowal-Vern A, Mazzella FM, Cotelingam JD, et al. Diagnosis and characterization of acute erythroleukemia subsets by determining the percentages of myeloblasts and proerythroblasts in 69 cases. Am J Hematol. 2000 Sep. 65(1):5-13. [Medline].

  6. Liu W, Hasserjian RP, Hu Y, Zhang L, Miranda RN, Medeiros LJ, et al. Pure erythroid leukemia: a reassessment of the entity using the 2008 World Health Organization classification. Mod Pathol. 2011 Mar. 24(3):375-83. [Medline].

  7. Peng J, Hasserjian RP, Tang G, Patel KP, Goswami M, Jabbour EJ, et al. Myelodysplastic Syndromes Following Therapy with Hypomethylating Agents (HMAs): Development of Acute Erythroleukemia May Not Influence Assessment of Treatment Response. Leuk Lymphoma. 2015 Aug 21. 1-19. [Medline].

  8. Bennett JM, Catovsky D, Daniel MT, et al. Proposed revised criteria for the classification of acute myeloid leukemia. A report of the French-American-British Cooperative Group. Ann Intern Med. 1985 Oct. 103(4):620-5. [Medline].

  9. Swerdlow SH, Campo E, Harris NL, et al. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. 4th ed. Geneva, Switzerland: WHO Press; 2008.

  10. Cuneo A, Van Orshoven A, Michaux JL, et al. Morphologic, immunologic and cytogenetic studies in erythroleukaemia: evidence for multilineage involvement and identification of two distinct cytogenetic-clinicopathological types. Br J Haematol. 1990 Jul. 75(3):346-54. [Medline].

  11. McHayleh W, Sehgal R, Redner RL, Raptis A, Agha M, Natale J, et al. Mitoxantrone and etoposide in patients with newly diagnosed acute myeloid leukemia with persistent leukemia after a course of therapy with cytarabine and idarubicin. Leuk Lymphoma. 2009 Oct 8. [Medline].

  12. Stoneking CJ, Mason MJ. Mg2+ modulation of the single-channel properties of KCa3.1 in human erythroleukemia cells. Pflugers Arch. 2013 Nov 6. [Medline].

  13. Mayer RJ, Davis RB, Schiffer CA, et al. Intensive postremission chemotherapy in adults with acute myeloid leukemia. Cancer and Leukemia Group B. N Engl J Med. 1994 Oct 6. 331(14):896-903. [Medline].

  14. Wiernik PH, Banks PL, Case DC Jr, et al. Cytarabine plus idarubicin or daunorubicin as induction and consolidation therapy for previously untreated adult patients with acute myeloid leukemia. Blood. 1992 Jan 15. 79(2):313-9. [Medline].

 
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Bone marrow aspirate showing erythroblasts in a patient with erythroleukemia. Courtesy of Maurice Barcos, MD, PhD, Department of Pathology, Roswell Park Cancer Institute, Buffalo, NY.
 
 
 
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