LWBK1006-31 LWW-Govindan-Review December 12, 2011 19:43
Chapter 31•Acute Leukemias 447Answer 31.19. The answer is B.
Although most patients with AML will relapse without consolidation
therapy, the appropriate consolidation therapy remains unclear for the
majority of these patients. Young patients with good-risk cytogenetics
are one of the few cohorts with AML in whom specific consolidation rec-
ommendations are supported by clinical data. A study sponsored by the
Cancer and Leukemia Group B (CALGB) found that young patients with
inv(16) had a 78% CR rate at 5 years after four cycles of HIDAC therapy,
whereas 57% remained in CR in the IDAC arm and only 16% remained
in CR with conventional 100 mg/m^2 dosing. Patients with normal cyto-
genetics fared less well as a group with equivalent outcomes (47% vs.
37% CR at 5 years) in the HIDAC and IDAC arms and worse outcomes
with conventional dosing (20%). Patients with unfavorable cytogenetics
should be considered for allogeneic transplant in first CR. Arsenic has
shown benefit in a consolidation protocol for APL, but it has not been
evaluated in general AML consolidation protocols.Answer 31.20. The answer is C.
Nonmyeloablative conditioning regimens require a graft-versus-leukemia
effect to improve the clearance of residual AML blasts not eliminated by
the conditioning regimen.Answer 31.21. The answer is D.
High-dose busulfan decreases the seizure threshold of patients, and there-
fore seizure prophylaxis is commonly used. Mucositis commonly follows
busulfan therapy, especially during prolonged neutropenia. Pancytopenia
naturally follows a myeloablative regimen. Risk for MDS may increase
after alkylator and topoisomerase II inhibitor therapy. However, MDS is
not a risk of myeloablative preparatory regimens.Answer 31.22. The answer is D.
CNS prophylaxis may consist of intrathecal chemotherapy (methotrex-
ate, cytarabine, corticosteroids), high-dose chemotherapy (methotrexate,
cytarabine, L-asparaginase), or CNS irradiation. Patients with ALL with
increased risk for CNS disease include those with an elevated WBC count,
an elevated lactate dehydrogenase, a traumatic lumbar puncture, and
T-lineage ALL. Although APL may relapse in the CNS, relapse is uncom-
mon in patients with a presenting WBC less than 10,000/L. CNS eval-
uation and prophylaxis are not routinely recommended in patients with
APL. There is no role for CNS prophylaxis in elderly patients with AML
without neurologic deficits. Although CNS disease must be considered
in a patient with AML and headaches, a new headache caused by CNS
leukemia on day 9 of induction therapy would be unusual and treatment
could be delayed until proper evaluation is completed.Answer 31.23. The answer is D.
Dexamethasone has improved penetration in the CNS. Given the high
risk of CNS disease in patients with ALL, dexamethasone is preferred
over prednisone.