• Anemia
• Thrombocytopenia
• Neutropenia
• Skin manifestations (chloroma)
• Renal insufficiency (due to tumor lysis syndrome)
• Bone pain (increased WBC in bone and leukemic infiltration in bone)
• Disseminated Intravascular Coagulation
• Leukocytosis
• Peripheral blasts
• Increased serum lactate dehydrogenase
• Increased uric acid
• CNS manifestations (uncommon)

• Age (> 60)
• MDS or chemotherapy-induced AML
• Cytogenics
• Difficulty obtaining complete remission/Duration of remission < 6 mo
• M6, M7 subtype
• Elevated LDH > 3 x uln

• No peripheral leukemia cells
• Peripheral blood ANC > 1500
• Plt count > 100 x 10⁹/L
• Bone marrow < 5% blasts
• Extramedullary leukemia (soft tissue disease) not present

Cytarabine + Anthracycline (Idarubicin or Daunorubicin)

OR

Cytarabine + Mitoxantrone

• Tumor lysis syndrome
• Myelosuppression

• High dose Cytarabine (preferential in < 60 yo with intermediate or good-risk cytogenetics)
• Myeloablative therapy with allogeneic hematopoietic stem cell transplantation
• Myeloablative therapy and autologous hematopoietic stem cell transplantation
• Non-myeloablative allogeneic stem cell transplantation

• Cerebellar dysfunction characterized by ataxia, nystagmus, dysarthria
• Ocular toxicity
• Pulmonary edema
• GI toxicity
• Skin

• Additional chemo (back to induction)
• Gemtuzumab ozogamicin
• Myeloablative therapy with allogeneic hematopoietic stem cell transplantation
• Investigational therapies

• Fever
• Dyspnea
• Peripheral edema
• Serositis (pleural effusions, pericardial effusions)
• Hypotension
• Edema

• Arsenic Trioxide
• Matched sibling allogeneic hematopoietic stem cell transplantation
• Matched unrelated donor allogeneic hematopoietic stem cell transplantation

< 1 yr

Arsenic trioxide followed by autologous SCT

> 1 yr

Arsenic trioxide

OR

ATRA + Anthracycline followed by autologous SCT

• Anemia
• Thrombocytopenia
• Neutropenia
• Renal insufficiency
• Bone pain
• CNS manifestations
• Anorexia and weight loss
• Hepatomegaly, Splenomegaly
• Mediastinal mass
• Leukocytosis
• Peripheral blasts
• Increased LDH
• Increased uric acid

• L2, L3 morphology
• Philadelphia chromosome positive
• Abnormal cytogenetics
• High WBC count at diagnosis (> 30,000)
• Thrombocytopenia at diagnosis (< 10,000)
• Age > 30 yo
• Delayed remission reduction (> 14 days)
• Male > female
• African-American
• CNS disease
• Significant hepatomegaly
• Significant lymphadenopathy
• Mediastinal mass

• CNS (intrathecal administration of chemo)
• Testes

• IV Cyclophosphamide
• IV Daunorubicin
• IV Vincristine
• PO Prednisone
• IM/SC L-asparaginase

• Intrathecal MTX
• Cranial radiation therapy

• Same meds as induction
• Additional meds include 6-MP and 6-thioguanine

• IV Vincristine
• PO Prednisone
• PO 6-Mercaptopurine
• PO MTX

• Re-induction with initial regimen
• Re-induction with high dose chemotherapy (high dose cytarabine)
• High dose chemo with allogeneic HSCT

• Allopurinol + Hydration +/- Alkalinization
• Rasburicase

• PO Prednisone/Dexamethasone
• IV Vincristine
• IM Asparaginase/PEG Asparaginase
• Intrathecal MTX +/- Cytarabine and Hydrocortisone

• PO Prednisone/Dexamethasone
• IV Vincristine
• IM Asparaginase/PEG Asparaginase
• Daunorubicin
• Intrathecal MTX +/- Cytarabine and Hydrocortisone

• IV MTX
• IV Cyclophosphamide
• IV/SC Cytarabine
• PO Thioguanine
• IV Vincristine
• PO Prednisone
• IV Doxorubicin
• Asparaginase

• IV/IM/PO MTX
• PO Mercaptopurine
• IT MTX
• Periodic Vincristine, Prednisone pulses
• Doses adjusted to maintain ANC between 500-1500/mm³

• Age < 1, > 9
• WBC > 50,000
• T-cell ALL
• Translocations