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.
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. [20, 21]
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. [22] 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. [23]
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.
Less-intensive chemotherapy
Given the poor prognosis for older adults with acute erythroleukemia, the impact of treatment intensity on quality of life should be given consideration. The benefits of less-intensive chemotherapy regimens include fewer adverse events and outpatient administration with less frequent hospitalization. [24]
The American Society of Hematology (ASH) recommends less-intensive therapy with hypomethylating agents (azacitidine and decitabine) for older adults with adverse disease biology, including complex karyotype, history of myelodysplastic syndromes, and TP53 mutations. [25]
Dietary Measures
Patients should be on a neutropenic diet. All fruits and vegetables should be cooked or peeled.
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.
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.
-
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.
