eMedicine Specialties > Pediatrics: General Medicine > Oncology
Acute Myelocytic Leukemia: Follow-up
Updated: Jul 15, 2009
Follow-up
Further Inpatient Care
- Hospitalization is necessary in patients with acute myeloid leukemia (AML) for managing chemotherapy and for treating complications related to the disease and its treatment, usually infections or febrile neutropenic episodes. Some hospitalizations can be lengthy. Numerous changes in antibiotics may be necessary until infections and neutropenia resolve.
- After transplantation, most febrile episodes require in-patient treatment and observation until profound neutropenia and clinically significant infection resolves.
Further Outpatient Care
- Because early intervention can often cytopenic complications, blood counts must carefully be monitored during and between phases of treatment.
- After all planned therapy, careful physical examinations and blood work are important to ensure continued hematologic remission.
Inpatient & Outpatient Medications
- Most supportive medications can be discontinued when chemotherapy is completed. Such medications include prophylactic antibiotics, agents for nutritional support (eg, appetite stimulants), and antiemetics.
- Patients usually require prolonged immunosuppressive therapy with prednisone and cyclosporine after transplantation. Penicillin, antifungal medications, acyclovir, and trimethoprim-sulfamethoxazole are continued until all immunosuppressive medications are discontinued.
Transfer
- Transfer to a pediatric cancer center is usually necessary for initial diagnostic studies and management of both chemotherapy and treatment-related complications.
- For patients with suitable donors, transfer to a center capable of performing blood and marrow transplants is usually necessary.
Deterrence/Prevention
- As detailed in Causes, the association of acute myelocytic leukemia with radiation, toxins, and drugs is well documented. Reduced exposure to ionizing radiation should be an important maxim for every physician who orders diagnostic testing for patients, certainly pregnant women.
- Until more evidence is available, general avoidance of chemicals and toxins should be a priority.
- No dietary changes are known to affect a person's risk of developing acute myelocytic leukemia.
Complications
- Immediate and short-term complications
- Serious infections
- Alopecia
- Emesis
- GI erosions and bleeding
- Hemorrhage
- Malnutrition
- Nausea
- Death
- Long-term or delayed complications
- Congestive heart failure and arrhythmia (rare)
- Growth and other endocrine disorders
- Second malignancies
- Death
- Infection
- Infection is a major cause of morbidity and mortality.
- The predisposition to infection is a consequence of granulocytopenia. The risk of sepsis is greatest when the absolute granulocyte count is more than 200 cells/μL.
- Sepsis and pneumonia are particularly common. Causative agents cover the entire gamut of bacterial, fungal, viral, and other pathogens.
- Septic shock is usually secondary to gram-negative bacteria and often lethal.
- Because of prolonged neutropenia, immunosuppression, and treatment with broad-spectrum antibiotics, common causes of death are fungal, antibiotic-resistant bacterial, and other opportunistic infections.
- Bleeding
- Bleeding is the second most common cause of death.
- Severe GI, pulmonary, or intracranial hemorrhage is frequently observed.
- Disseminated intravascular coagulation is a serious potential problem in all patients with acute promyelocytic leukemia (APL) and, to some extent, in those with other acute myelocytic leukemia subtypes. It can occur in association with thrombosis and hemorrhage.
- Tumor lysis syndrome
- Patients with high leukemic cell counts or massive organomegaly are at significant risk for tumor lysis syndrome.
- This condition is often characterized by pronounced metabolic abnormalities, including hyperkalemia, hypocalcemia, hyperuricemia, and renal failure.
- Effects of chemotherapy
- The aggressive chemotherapy necessary to cure the patient also results in a great deal of morbidity.
- Profound myelosuppression due to high-dose, intensive treatment regimens contribute to a high risk of infection and bleeding.
- Mucositis and typhlitis in association with intestinal perforation, renal, and pulmonary complications are common problems patients and clinicians face.
- CNS complications
- CNS involvement, with leukemic cell infiltration, hemorrhage, or infection, often cause devastating complications or death.
- The risk is particularly high for patients with hyperleukocytosis and WBC counts of more than 200 X 109/L (>200,000/μL). These patients are at high risk of intracranial hemorrhage, and their conditions must be treated as true emergencies.
Prognosis
- With an overall survival rate of 45-55%, the prognosis for children with acute myeloid leukemia has improved significantly over the past 2 decades. A Japanese consortium has recently reported overall 5-year survival rate of 62%.4 The long-term, disease-free survival rate is approximately 65% for patients receiving human leukocyte antigen (HLA)-matched stem cell transplants from family donors, but, as with chemotherapy, this rate is lower in high-risk patients. When patients die during treatment or after relapse, the cause is most commonly infection, bleeding, or refractory disease.
- For children with Down syndrome, current outcomes favor younger children, with a survival rate of 84-86% for children younger than 2 years, 79% for children aged 2-4 years, and only 33% for children older than 4 years.9
- Acute promyelocytic leukemia prognosis has an event-free survival rate of 70-80%, with overall survival close to 90%.10
Patient Education
- Family members should be familiar with signs of infection other than fever. Dermatologic clues of bleeding, especially petechiae and purpura, should be recognized and investigated.
- Discuss the adverse effects of chemotherapy and transplantation at length with family members.
- Psychosocial intervention is often necessary for the patient and his or her parents and siblings. A diagnosis of leukemia has profound effects on all family members, with a dramatic change in the patient's lifestyle until all treatment is completed.
- Home tutoring is often necessary during the entire period of treatment.
- For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Leukemia.
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize associated complications, such as infections, hemorrhage, metabolic complications, or early organ dysfunction
- Failure to inform the patient and family about potential treatment complications
Special Concerns
- Children may not have well-known symptoms of leukemia, such as adenopathy, overt bleeding, and serious infections. Nonspecific symptoms such as fatigue, irritability, fevers, or bruising are common in childhood and might not be recognized as symptoms of leukemia, thus delaying a diagnosis of leukemia. Persistence of these symptoms should prompt further investigation.
- Signs of serious infections in children with leukemia are often subtle. Fever at any time must be taken seriously, and appropriate cultures and investigations must be ordered to diagnose and treat it early because this still remains one of the most frequent causes of hospitalizations, morbidity, and mortality in children with leukmia.
More on Acute Myelocytic Leukemia |
| Overview: Acute Myelocytic Leukemia |
| Differential Diagnoses & Workup: Acute Myelocytic Leukemia |
| Treatment & Medication: Acute Myelocytic Leukemia |
 Follow-up: Acute Myelocytic Leukemia |
| Multimedia: Acute Myelocytic Leukemia |
| References |
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Further Reading
Keywords
acute myeloid leukemia, AML, acute myeloblastic leukemia, acute myelogenous leukemia, acute nonlymphoblastic leukemia, leukemia, malignancy, cancer, acute promyelocytic leukemia, APL, splenomegaly, childhood leukemia, childhood cancer, disseminated intravascular coagulation, colitis, urinary tract infection, respiratory insufficiency, superior vena cava syndrome, chloromas, Bell palsy, congestive heart failure, hypotension, respiratory distress, organomegaly, facial palsy, cranial nerve dysfunction, typhlitis, appendicitis, Hodgkin lymphoma, Shwachman-Diamond syndrome, Bloom syndrome, Diamond-Blackfan anemia, Fanconi anemia, dyskeratosis congenita, Kostmann syndrome, neurofibromatosis, treatment, diagnosis
