LWBK1006-31 LWW-Govindan-Review December 12, 2011 19:43
Chapter 31•Acute Leukemias 445Answer 31.9. The answer is C.
Age greater than 50 years, poor performance status, African Ameri-
can ethnicity, and leukocytosis (>30,000/L B-lineage or>100,000/L
T-lineage) are associated with high-risk ALL. Immunophenotypes includ-
ing early and mature-T ALL and pro-B ALL are also considered high risk.
Cytogenetics including the Philadelphia chromosomet(9;22) andt(4;11)
are both high-risk prognostic factors. Normal diploid chromosomes on
karyotyping is not associated with poor prognosis.Answer 31.10. The answer is D.
Treatment of AML in the elderly (>65 years) is difficult because of the
heterogeneous nature of response and the generally high rate of treatment-
related mortality. Older patients at MD Anderson with a performance
status>2, bilirubin greater than 1.9 mg/dL, or serum creatinine greater
than 1.9 mg/dL had a treatment-related mortality of 62% and only a
27% complete remission rate. Thus, decision to undergo standard induc-
tion therapy must be based on a careful assessment of the patient’s ability
to tolerate the therapy and his/her prognosis. The patient’s age, perfor-
mance status, and low-risk cytogenetics might influence a physician to
recommend standard therapy.Answer 31.11. The answer is D.
Arsenic trioxide has demonstrated considerable activity in salvage therapy
for APL. Arsenic trioxide has been associated with prolonged QT c syn-
drome. Because of this, Electrocardiograms should be performed before
and during therapy. Electrolytes should also be monitored and corrected.
Additional medications that may prolong the QT c should be eliminated
if possible.Answer 31.12. The answer is C.
Prior alkylator therapy increases the risk of MDS and treatment-related
AML. Her recent history of progressive anemia and thrombocytopenia,
with dysplastic features seen in her marrow, are all suggestive of an under-
lying MDS. Her blast count greater than 20% meets criterion for AML
under current World Health Organization standards. AML evolved from
MDS could carry a loss of chromosome 5 or 7 associated with the prior
MDS, but most often is associated with complex cytogenetics. It also
carries an unfavorable prognosis in multiple studies.t(15;17) is associ-
ated with APL but is not associated with prior breast cancer or alkyla-
tor therapy.t(9;21) is associated with the Philadelphia chromosome and
seen in chronic myelocytic leukemia or acute lymphocytic leukemia, but
is rarely associated with AML or MDS. Trisomy 21 is associated with
AML-M7 with increased megakaryocytes. Recent data suggest this may
be associated with the concomitant overexpression of an miRNA carried
on chromosome 21.Answer 31.13. The answer is D.
Older patients with AML have worse outcomes when compared to
younger patients irrespective of their performance status or comorbidities.
Treatment with low-dose cytarabine has been shown to improve survival