Treatment Options for Leukemia
Treatment for leukemia should be tailored to the specific subtype, with induction and consolidation chemotherapy forming the backbone of acute leukemia treatment, while targeted therapies like BTK inhibitors and venetoclax-based regimens are preferred for chronic lymphocytic leukemia to improve survival outcomes. 1, 2
Acute Myeloid Leukemia (AML) Treatment
Induction Therapy
- Standard induction chemotherapy should include an anthracycline and cytosine arabinoside 1
- For acute promyelocytic leukemia (APL), all-trans retinoic acid (ATRA) must be added to anthracycline-based chemotherapy 1
- Patients with excessive leukocytosis may require emergency leukapheresis before starting chemotherapy 1
Consolidation Therapy
- Post-remission therapy is essential for all patients achieving complete remission 1
- Risk-stratified approach:
- For APL: Maintenance chemotherapy and ATRA are beneficial 1
Relapsed/Refractory AML
- Second or subsequent remission patients should be considered for allogeneic transplantation 1
- For relapsed APL: Arsenic trioxide can induce remission even in ATRA-refractory cases 1
Chronic Myeloid Leukemia (CML) Treatment
First-Line Therapy
- Imatinib (tyrosine kinase inhibitor) is indicated for newly diagnosed Philadelphia chromosome positive CML in chronic phase 3
- Standard dosing:
- Chronic phase: 400 mg/day
- Accelerated phase or blast crisis: 600 mg/day
- Pediatric CML: 340 mg/m²/day 3
Chronic Lymphocytic Leukemia (CLL) Treatment
Early-Stage Disease
- Watch and wait strategy with blood count monitoring every three months for early-stage disease without symptoms (Binet stage A and B without symptoms; Rai 0, I, II without symptoms) 1, 2
Advanced Disease
- Treatment indications: B-symptoms, cytopenias, progressive lymphadenopathy/splenomegaly/hepatomegaly, progressive lymphocytosis, autoimmune complications 1, 2
First-Line Treatment Options
- BTK inhibitors (ibrutinib, acalabrutinib, zanubrutinib) are preferred first-line therapy, especially for high-risk disease 2
- Venetoclax plus obinutuzumab (time-limited therapy) for IGHV-mutated disease 2
- For older/less fit patients: Venetoclax plus obinutuzumab or BTK inhibitors 2
- For very frail patients with renal insufficiency: Reduced-dose therapy or chlorambucil monotherapy 2
Relapsed/Refractory CLL
- If relapse occurs >12 months after initial therapy, consider repeating first-line treatment 2
- If relapse occurs <12 months or disease is refractory, switch to alternative therapy class 2
- After BCR inhibitor failure, venetoclax-based therapy is preferred 2
- For high-risk relapsed disease, consider allogeneic stem cell transplantation 2
Supportive Care Considerations
- Regular monitoring of blood counts is essential during treatment 1, 2
- Pneumococcal and seasonal influenza vaccination is recommended for CLL patients 2
- Antibiotic prophylaxis for high-risk patients 2
- Monitor for treatment complications:
Important Considerations and Pitfalls
- Age is a critical factor: Elderly patients (>60 years) have worse prognosis and higher treatment-related complications 1
- Genetic testing is crucial: Cytogenetic analysis should be performed on all diagnostic specimens as it provides important prognostic information 1, 6
- Don't delay appropriate treatment: Untreated acute leukemia is uniformly fatal with median survival <3 months 6
- Don't use chemoimmunotherapy in CLL patients with del(17p) or TP53 mutations - use targeted therapies instead 2
- Allogeneic stem cell transplantation remains the only potentially curative option for high-risk relapsed disease 2
Treatment of leukemia has evolved significantly, with targeted therapies improving outcomes for many patients. However, the approach must be tailored to the specific leukemia subtype, patient age, comorbidities, and genetic risk factors to optimize survival and quality of life.