Postremission therapy

Postremission therapy may consist of varying numbers of courses of intensive chemotherapy and/or allogeneic hematopoietic stem cell transplant (HSCT). For example, the Children’s Oncology Group (COG) and the United Kingdom Medical Research Council (MRC) use similar chemotherapy regimens consisting of two courses of induction chemotherapy, followed by two to three additional courses of intensification chemotherapy.[10-12]

Maintenance chemotherapy is no longer part of pediatric AML protocols because two randomized clinical trials failed to show a benefit for maintenance therapy when given after modern intensive chemotherapy.[13,14] Contemporary APL therapy also does not use maintenance chemotherapy. A tretinoin- and arsenic trioxide–based treatment is used instead.[15] Maintenance therapy with targeted therapies is gaining interest. Treatment of patients with AML and FLT3 internal tandem duplication (ITD) using sorafenib (a FLT3 inhibitor) during chemotherapy cycles and maintenance (following completion of chemotherapy or HSCT) significantly improved survival.[16]

Attention to both acute and long-term complications is critical in children with AML. Modern AML treatment approaches are usually associated with severe, protracted myelosuppression with related complications. Children with AML should receive care under the direction of pediatric oncologists in cancer centers or hospitals with appropriate supportive care facilities (e.g., specialized blood products; pediatric intensive care; provision of emotional and developmental support). With improved supportive care, toxic death constitutes a smaller proportion of initial therapy failures than in the past.[10] Two COG trials reported an 11% to 13% incidence of remission failure, mainly because of resistant disease. Only 2% to 3% resulted from toxic death during the two induction courses.[12,17]

Children treated for AML are living longer and require close monitoring for cancer therapy side effects that may persist or develop months or years after treatment. The high cumulative doses of anthracyclines require long-term monitoring of cardiac function. The use of some modalities, including total-body irradiation with HSCT, have declined because of increased risk of growth failure, gonadal and thyroid dysfunction, cataract formation, and second malignancies.[18] For more information, see the Survivorship and Adverse Late Sequelae of Treatment for AML section and Late Effects of Treatment for Childhood Cancer.