Acute myeloid leukaemia (AML)

Disseminated intravascular coagulation (DIC) is a serious problem that can happen when you have AML. In DIC, the body’s clotting system is switched on by mistake. This causes many small blood clots to form. These clots use platelets, which are needed to stop bleeding. As a result, a person may have severe and uncontrolled bleeding.

Blood clots can block blood vessels and cause deep vein thrombosis (DVT) or pulmonary embolism (PE). Severe bleeding can lead to breathing problems or organ failure. If DIC is not treated, it can be life-threatening.

DIC can happen more often in acute promyelocytic leukaemia (APML), but it can happen in any type of AML.

• Acute promyelocytic leukaemia with PML::RARA fusion.
• Acute myeloid leukaemia with RUNX1::RUNX1T1 fusion.
• Acute myeloid leukaemia with CBFB::MYH11 fusion.
• Acute myeloid leukaemia with DEK::NUP214 fusion.
• Acute myeloid leukaemia with RBM15::MRTFA fusion.
• Acute myeloid leukaemia with BCR::ABL1 fusion.
• Acute myeloid leukaemia with KMT2A rearrangement.
• Acute myeloid leukaemia with MECOM rearrangement.
• Acute myeloid leukaemia with NUP98 rearrangement.
• Acute myeloid leukaemia with NPM1 mutation.
• Acute myeloid leukaemia with CEBPA mutation.
• Acute myeloid leukaemia, myelodysplasia-related.
• Acute myeloid leukaemia with other defined genetic alterations.

AML which develops as a side effect of previous cancer treatments, such as chemotherapy or radiation. It often has a poorer prognosis than other AML types.

A bone marrow biopsy is the best test to diagnose AML. A bone marrow biopsy uses a needle to take a sample of bone marrow, usually from the back of the hip. A small amount of liquid bone marrow is removed and sent to the lab for testing. Often, a tiny piece of the bone itself is also taken to be examined.

Blood tests are taken: 

• at diagnosis (baseline bloods) and throughout treatment
• to see how the AML is affecting your blood cells, electrolytes, or other organs such as the liver or kidneys
• to check for genetic changes.

If your haematologist thinks you have AML, you will have a full blood count (FBC) with a differential panel. This measures the number of blast cells in the blood and compares it with other white blood cells.

Blood tests also include human leukocyte antigen (HLA) testing. This checks which HLA genes you have inherited. It is an important test if you are eligible for a stem cell transplant. The goal is to match your HLA genes with a donor to see if they are a match.

Genetic tests look for changes in genes, also called mutations, in the AML cells. These gene changes help your doctor choose the best treatment, decide whether you may need a stem cell transplant, and estimate your prognosis.

Genetic tests include:

• fluorescence in situ hybridisation (FISH)
• polymerase chain reaction (PCR)
• next generation sequencing (NGS)

They are done from blood and bone marrow, so you don’t need to do an extra test.

Other tests you may have include:

• medical history and physical exam
• chest x-ray
• heart and lung tests
• computed tomography (CT) scan
• positron emission tomography (PET) scan
• magnetic resonance imaging (MRI).

These tests help your treatment team work out your prognosis. They can also be used to see how you are responding to treatment as well as look for complications of treatment such as infections.

Intensive chemotherapy for AML may be recommended if you are well enough to cope with the treatment. Your doctor will consider your age, the type of AML you have, your general health, and whether the benefits of treatment are likely to outweigh the side effects.

Treatment plans are shortened to letters like FLAG or 7-3. The letters and numbers represent the name of the medicines or the timings of that plan.

Treatment with intensive chemo has two or three phases.

Phase one – Induction

Induction treatment aims to destroy the leukaemia cells and bring on remission. You will receive different types of chemo over a week and usually stay in hospital for 4 to 5 weeks while you recover. You will have a bone marrow biopsy once you’ve recovered, to see how the treatment worked.

Phase 2 – Consolidation

Consolidationtreatment helps prevent cancer from coming back. You will receive similar chemo to induction, but the doses and timing will be different. This treatment normally takes 5 days. You will stay in hospital for 3 to 4 weeks to recover.

Phase 3 – Maintenance

Some patients who complete induction consolidation therapy may be recommended to start maintenance treatment. Maintenance treatments are used to make the leukaemia stay in remission. These are only suitable for people not undergoing a stem cell transplant and for certain genetic types of AML.

There is information on maintenance therapy on the Cancer Institute NSW website.

If you’re not eligible for intensive chemo, you might be offered low dose chemo. Venetolcax and azacitadine is a low dose chemotherapy treatment plan.

Venetoclax is an oral targeted therapy, and azacitidine is a chemotherapy that is injected under the skin (subcutaneous).

This treatment is usually given for at least 6 months, depending on how the leukaemia responds.  

Targeted therapy is a cancer treatment that finds and blocks parts of cancer cells that help them grow and spread.

Venetoclax is a targeted therapy called a BCL2 inhibitor. It is an oral tablet that is used to treat AML in combination with chemotherapy. Some cancer cells make the BCL2 protein to prevent them from dying. The BCL2 inhibitor blocks that protein, and the cancer cells die.

Midostaurin and Gilteritinib are targeted therapies called FLT3 tyrosine kinase inhibitors. They are oral tablets used to treat AML in people who have a change (mutation) in the FLT3 gene. Midostaurin and Gilteritinib block this faulty FLT3 protein, helping to stop or slow the cancer.

Targeted therapy can cause different side effects to chemotherapy. If you’re taking more than one drug, you might have a mix of side effects.

You can read more on our immunotherapies and targeted therapies webpage.

People with AML who have high dose chemo might need a stem cell transplant to build their bone marrow back up. Stem cells are collected from a donor and given to you. This is called an allogeneic stem cell transplant.

There are two aims of a stem cell transplant:

• the new (donor) stem cells create an immune system that can kill any remaining cancer cells
• restore normal blood cell growth with healthy donated stem cells.

A stem cell transplant comes with a lot of risk and serious side effects. Your haematologist will talk with you about these.

Radiation therapy, also called radiotherapy, is a type of treatment that uses high energy x-rays to kill cancer cells. It isn’t commonly used for AML, but it may be recommended if the disease has spread, or may spread, to the brain or spine. It can also be used as total body irradiation (TBI) before a stem cell transplant.

You can read more on our radiation therapy webpage.

Clinical trials may be available for some types of AML. They often compare new or combination therapies with current treatments, including side effects.

Many are randomised, meaning some patients receive the new treatment, and others receive standard care. Trials help improve future treatments and may offer access to costly new therapies not on the Pharmaceutical Benefits Scheme (PBS) in Australia.

If you are considering a clinical trial, your doctor will explain:

• the possible risks and benefits
• how it compares to standard treatment
• what is involved.

You will need to give informed consent before taking part.