acute and chronic myeloid leaukemia

Question 1

risk factors for AML

Answer 1

• inc age
• prior chemo
• cigarette smoking
• radiation, benzene, pesticide and petrochemical exposure

Question 2

how to diagnose AML and what is required

Answer 2

• how: Bone marrow biospy, Echo/EKG, D/C panel (PT, fibrinogen), CNS imaging, TLS
• Required: 20% and up blast or cytogenetic abnormalities (translocations, deletions, etc.)

Question 3

AML Prognostic markers

Answer 3

• predicts pt ability to obtain/ stay/survive in remission w/ induction chemo
  -performance status, age, comorbidities, primary vs econdary AML, WBC at diagnosis

Question 4

S/S AML

Answer 4

• anemia (↓ RBC) → give blood transfusions
• thrombocytopenia (bleed risk) → give platelets
• neutropenia (risk of inf)
• TLS
• CNS involvement (rare)
• hyperleukocytosis (↑ WBC > 100,000)

Question 5

what is and how to treat hyperleukocytosis in AML; pearls of med , ae

Answer 5

• Oncologic emergency; hyperviscosity syndrome → blood sludging
• stroke, resp failure, cardiac ischemia, renal failure, retinal hemorrhage
• Hydroxyurea - titrate based on WBC count and response (takes ~5 days) → acute: mouth sores, GI; long term: aleopica, hyperpig, ulceration, mucositis

Question 6

Targeted mutation therapies AML, what to do if patient refractory

Answer 6

• FLT3-ITD ← Quizatinib, Midostaurin
• FLT3- TKD ← Midostaurin
• if they didnt recieve Venetoclax + Azacitidine GIVE
• FLT3 relapse/refractory ← Gilteritib
• IHD1 ← Ivosidenib
• IDH2 ← Enasidenib

Question 7

goal of induction chemo therapy (high intensity and who gets it) AML

Answer 7

• get rid of macrodisease
• <60, >60 w/o significant comorbidities , good performance
• pts w/ aggressive disease (hyperleukocytosis, TLS at pres)
• candidates for allogenic stem cell transplant

Question 8

Chemo therapy time frame/ clinical pres AML

Answer 8

• day 1-7 chemo admin, dramatically WBC drop
• day 8-24 cell count nadir (WBC=0) & recovery; platelet transfusion required
• day 25+ complete cell recovery, discharge whenANC>500 and platelets good

Question 9

what are our high intensity induction options

Answer 9

• Cytarabine continuous IVX 7 days + Daunorubicin or Idarubicin x 3 days
• Liposomal Duanrobicin + Cytrabine (2ndary leaukemia)
• clinical trials

Question 10

what is the criteria for complete remission w/ complete response- day 28+ AML

Answer 10

<5% blast + ANC >1000 +platelets >100,000

Question 11

what is the criteria for leukemia free state - day 14 AML

Answer 11

• after 2nd bone biopsy patient should have <5-10% blast and be hypocellular (no more hyperviscosity/blood slugging)

Question 12

low intensity options

Answer 12

• Hypomethylating agents (Azacitidine, Decitabine) + Venetoclax
• low dose cytrabine (~50) + Venetcolax
• Ivosidenib + Ventetoli
• Gemtuzumab Ozo (add on)

Question 13

who gets allogeneic stem cell transplant

Answer 13

• Intermediate + poor risk disease
• 2nd or treatment related AML
• fit enough
• complete induction & 1 or more cycles of consolidation

Question 14

clinical peatl of quizaritinib

Answer 14

causes qt prolongation, dose adj for DDIs

Question 15

midostaurin clinical pearls

Answer 15

BID, poorly tolerated, stinks, FDA approved newly diagnosed ITD

Question 16

who is liposomal Duanorubicin + Cytarabine a good opion for

Answer 16

2ndary leukemias

Question 17

Clinical pearls of HMAs (Azacitidine, Decitabine, Venetoclax)

Answer 17

Severe constipation, start bowel regimen
- Venetoclax: DDIs, myleosuppression

Question 18

clinical pearls of gemtuzumab

Answer 18

• monoclonal antibody
• inflammation related syndrome pre med w/methyl

Question 19

Clinical pearls of cytarabine

Answer 19

• neurotoxicity
• head and foot syndrome
• conjugivitis (give dexa eye drops 3 days a/f. treatment)
  what

Question 20

clinical pearls for anthracyclines (Duanrubicin)

Answer 20

• Cardiac toxicity

Question 21

what is post AML remission therapy aka consolidation therapy

Answer 21

• High dose Cytarabine (HiDac)
• Liposomal duanorubicin + cytarabine

Question 22

Clinical pearls of Anthracyclines

Answer 22

• cardiac toxicity→ HF
• lifetime dose
• significant WBC

Question 23

myeloid growth factors

Answer 23

• dec chemo recovery time
• agents: filgrastim
• bone pain : give loratidine or hydroxyzine
• used w/ neutropenia concerns

Question 24

supportive care for infections prophylaxis AML

Answer 24

give coverage for each
- HSV/VZV: Acyclovir
- Antibacterial: Cipro or Levo or Augmentin
- Invasive Fungal: Posaconazole, Voriconazole

Question 25

CML diagnosis

Answer 25

Philadelphia Chromosome PH + (translocation of 9 and 22) which causes that formation of BCR-ABL, Causing proliferation

Question 26

Tyrosine Kinase inhs and clinical pearls, aes CML

Answer 26

• Imatinib: peripheral edema
• Dastinib: edema in lungs (plureal), AVOID PPIs + H2RAs (needs acidic environment)
• Nilotinib: empty stomach BLACK BOX: QT prolongation
• Asciminb: empty stomach
• Bosutinib: Diarrhea (give loperamide) subsides
• Ponatinib: BLACK BOX: Hepatoxicity, HF, vacular occulsions) - Aspirin prophylaxis

Question 27

Why might someone have TKI resistance and how to treat

Answer 27

• Gatekeeper mutation : T3151→Asciminib, Ponatinib

Question 28

Monitoring for CML

Answer 28

gold standard: achieve complete cytogenetic response w/in 12 months

Question 29

how to treat accelerated phase

Answer 29

• Treat w/ TKIs w/ inc doses
• consider allogenic transplant

Question 30

How to treat blast phase

Answer 30

TKI +/- Chemo then allogenic stem cell transplant

Question 31

how to choose CML agent

Answer 31

• Low risk: Imatinib, Bosutinib, Dosatinib, Nilo
• Intermediate- high risk: Bosutinib, Dasatinib, Nilotiinib