Treatment Of Relapsed Disease

Patients with relapsed AML cannot be cured with standard chemotherapy. On the other hand, relapsed leukemia is generally treated with reinduction therapy for two reasons. First, this is an important part of the effort to get a patient in second remission, which may have palliative benefit. Most importantly, once the disease is under control, high-dose chemotherapy with hematopoietic stem cell transplant is possible. Second, patients in second remission can be salvaged with high-dose chemotherapy and autologous peripheral stem cell rescue (so-called autologous transplant) with the likelihood of disease-free survival in a second remission being about 30%.54 In most cases, if an allo-geneic donor is available, then it is preferable to consider an allogeneic stem cell transplant. With improved molecular HLA typing, in the absence of a sibling donor, an unrelated molecularly matched donor is an acceptable alternative. Allogeneic transplant can be used in situations where the remission is incomplete; however, this procedure is more likely to be successful if the patient is in fact in a second remission. This topic is covered in greater detail in Chapter 9.

The optimal therapy to use to induce a second remission is not clear. Although in this era most patients under the age of 60 with AML have received a high-dose ara-C-based consolidation regimen during first remission, the same regimen can be used for reinduction. If the first remission duration, the most important prognostic factor for success with reinduc-tion,55 is greater than 1 year, then standard reinduction therapy can be given with a good chance of success. Otherwise, high-dose ara-C or a combination of high-dose ara-C plus mitoxantrone and etoposide56 can be employed. Patients with a relatively short first complete remission (CR) duration are reasonable candidates to be enrolled on clinical trials involving novel chemotherapeutic agents and/or targeted agents.

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