Treatment of Acute Monocytic Leukemia
The standard treatment for acute monocytic leukemia (a subtype of acute myeloid leukemia) consists of intensive induction chemotherapy with an anthracycline (daunorubicin or idarubicin) plus cytarabine ("3+7" regimen), followed by consolidation therapy and consideration for allogeneic stem cell transplantation based on risk factors. 1
Initial Assessment and Risk Stratification
- Before initiating treatment, patients should undergo comprehensive evaluation including cytogenetic and molecular testing to guide therapy decisions 1
- Risk factors that influence treatment approach include:
- Initial workup should include cardiac assessment (echocardiography), infection screening, and coagulation studies 1
Induction Therapy
For Patients Eligible for Intensive Therapy:
- Standard "3+7" regimen remains the backbone of treatment 1:
- Higher daunorubicin doses (90 mg/m²) are more effective in younger patients (<65 years) with favorable or intermediate cytogenetics 2
- Idarubicin may provide better long-term outcomes compared to daunorubicin in some patients 3
- For specific genetic subtypes, targeted agents should be added:
- For therapy-related AML or AML with myelodysplasia-related changes, CPX-351 (liposomal daunorubicin/cytarabine) is recommended 1
For Patients Not Eligible for Intensive Therapy:
- Lower-intensity options include 1:
- Venetoclax combined with hypomethylating agents (azacitidine or decitabine) or low-dose cytarabine
- Glasdegib with low-dose cytarabine
- Hypomethylating agents alone (azacitidine or decitabine)
- For IDH1/2 mutant disease: ivosidenib or enasidenib, respectively
- For FLT3-mutated disease: hypomethylating agents with or without sorafenib
Post-Induction Assessment
- Bone marrow evaluation should be performed 14-21 days after start of induction therapy 1
- Response categories:
- Complete remission (CR): <5% blasts in bone marrow with recovery of blood counts
- CR with incomplete count recovery (CRi)
- Residual disease without hypoplasia
- Hypoplastic marrow 1
Consolidation Therapy
- For patients in CR/CRi, consolidation options include 1:
- High-dose cytarabine-based chemotherapy (especially for favorable-risk disease)
- Allogeneic stem cell transplantation (for intermediate and poor-risk disease)
- Continuation of induction regimen components 1
- Allogeneic stem cell transplantation decisions should be based on 1:
- Cytogenetic/molecular risk profile
- Age and performance status
- Availability of suitable donor
- Response to induction therapy
Special Considerations
- Hyperleukocytosis (WBC >100×10⁹/L) requires emergency management with hydration, rasburicase, and possibly leukapheresis 1
- Patients with monocytic subtypes may have higher risk of early complications including CNS involvement and coagulopathy 1
- Anthracycline-related cardiotoxicity should be monitored, especially in older patients or those with pre-existing cardiac conditions 4, 5
- Clinical trials should be considered at all stages of treatment when available 1
Treatment of Relapsed/Refractory Disease
- Options include 1:
- Clinical trial (preferred)
- Salvage chemotherapy with high-dose cytarabine-based regimens
- Targeted agents based on molecular profile
- Allogeneic stem cell transplantation if not previously performed
- Best supportive care for those unable to tolerate intensive therapy