Welcome to the twelth part of a series on Hemato-oncology.
Question: Dr. Chiragbhai, thank you for explaining about respecting possible acute leukemia like a heart attack. I liked the word “Blood Attack”
Answer: Yes, it is important to understand the difference between most cancers and blood cancers. Later can be very fast growing and unpredictable, like an attack.
Que: So, Chiragbhai, how do we diagnoseacute myeloid leukemia-AML?
Ans: Most important first step is to consider this diagnosis, in a patient with suggestive features e.g. low or high wbc count, especially with low platelet and Hb. Next step is a complete blood count with Hb, WBC, DC, Platelet count, and examination of a peripheral smear.
Further tests include bone marrow examination, and special tests to differentiate various types of acute leukemia. Special tests include immunohistochemistry (e.g. sudan black stain – now rarely considered adequate for such a serious diagnosis), immuno phenotyping by flow cytometry – current confirmatory test, and cytogenetics (by karyotyping, FISH, PCR as required), and others. Acute leukemia has two main subtypes – myeloid and lymphoid. There are many further subtypes e.g. myeloid has many subtypes like AML M1, M2, M3 etc.
However, the most important information for treatment plan and prognosis both come from cytogenetics.
Initial therapy i.e. INDUCTION for all subtypes of AML, except M3, is essentially same, with a combination commonly known as 3+7 i.e. 3 days of Daunorubicin and 7 days of Ara-C. M3 or APL (acute promyelocytic leukemia) has some important differences in initial therapy and various regimens exist. In fact, in APL, some pts can be treated even without any chemotherapy, using some newer medicines. We have treated few patients in this manner without any chemotherapy, with good results.
INDUCTION is the period that is most high risk and is associated with significant morbidity, mortality, and cost. It should be done under care of expert and in centers treating this disease regularly for better results and safety. At most centers, about 20-30% patients die during induction phase. At our center, we have 95% success rate in last three years, as we treat probably maximum AML in private sector. These results are better than most of the places in whole of India. This is a result of TEAM work. Cost of Induction phase is about 3-4 lakh in most cases.
After induction, there is CONSOLIDATION phase. Earlier, chemotherapy for 3-4 cycles was the only option for consolidation. However, now Stem Cell Transplant is an option for many patients, especially if their cytogenetics test is not very favorable. According to NCCN guidelines, it could be Autologus, using one’s own stem cells OR Allogeneic, using someone else’s stem cells, depending on the risk level, age etc. There is no role for maintenance chemotherapy, except in M3-APL. Addition of Transplant has led to significant improvement in results for many patients.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 98243 12144, 98988 31496
Diplomate American Board of Oncology and Hematology. Ahmedabad. email@example.com
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad.