Acute myeloid leukemia in adults

Many people are familiar with leukemia under the term blood cancer. The most common sub-type of leukemia in adults is acute myeloid leukemia (AML).  

AML occurs when there is a mutation in the immature cells that normally develop into blood cells in the bone marrow. These cells become leukemia cells and cannot develop into functioning blood cells. They reproduce in an uncontrolled manner and suppress normal blood production in the bone marrow. 

AML has various sub-types. These progress very differently to one another and respond to treatment with varying degrees of success. Some are also treated differently. One example is acute promyelocytic leukemia (APL).  

The most common symptoms of acute myeloid leukemia (AML) are caused by the spread of leukemia cells in the bone marrow and in the blood. Their suppression of normal blood production causes a deficiency in the number of normal red blood cells, platelets, and correctly functioning white blood cells. This produces the following typical symptoms:  

• Weakness and fatigue are caused by the deficiency in red blood cells, which is often very pronounced. 
• Bleeding under the skin, nose bleeds, and bleeding gums are signs of poor blood clotting due to a platelet deficiency. 
• Fever and frequent infections are due to a lack of functioning immune-system cells. 

Leukemia cells may also migrate to other organs in the body. In this case, symptoms may include the following: 

• Swollen liver and/or spleen, leading to stomach ache and appetite loss.  
• Swollen lymph nodes in the neck, armpit, or groin. 
• If leukemia cells affect the central nervous system, this can cause headache, impaired vision, and vomiting. 
• Changes may also be observed in the skin or gums. 

The severity of symptoms experienced with AML differs from one patient to the next. However, the symptoms do not always indicate the presence of leukemia – many of these may also be due to conditions that are harmless by comparison. 

With acute myeloid leukemia (AML), a mutation occurs in a single immature cell in the bone marrow that would normally develop into a blood cell. The changes in the genetic material of the cell cause it to divide in an uncontrolled manner.

These changes to the genetic material are not normally inherited, but rather occur during the course of the patient’s life. While clustering of the disease in families is not unheard of, it is rare. 

Risk factors for acute myeloid leukemia

Examples of risk factors that may trigger AML by causing changes to the genetic material of immature cells that normally develop into blood cells are: 

• high doses of ionizing radiation, such as x-rays; 
• contact with certain chemical substances, such as benzene (cytostatics); 
• certain drugs used to treat cancer; or 
• smoking.

Some pre-existing illnesses may also increase the risk of developing AML. This is true, for example, of patients who have other diseases of the blood or bone marrow, such as myelodysplastic syndrome (MDS). Other individuals with rare genetic disorders, such as Down Syndrome (trisomy 21) are at an increased risk of developing AML.

Patients with acute myeloid leukemia (AML) usually develop symptoms within a few weeks. If left untreated, this serious disease can result in death within a short pace of time. Treatment must begin as soon as AML is diagnosed.  

With the treatment options available today, two-thirds of all AML patients respond to the first treatment. 30 to 40 percent of patients make a permanent recovery. The chances of a recovery depend to a large degree on the age of the patient and on the sub-type of AML involved.

If it is suspected that a patient’s symptoms may be due to acute leukemia, the doctor will begin by testing the blood. A differential blood count is essential – in this test, the number of different white blood cells as well as immature cells are counted in the blood under the microscope.  

If the suspicion of acute leukemia is corroborated by the findings, a specialist must confirm the diagnosis. For this purpose, the primary care physician will usually transfer the patient into the care of a specialist hospital with experience in diagnosing and treating diseases of the blood. There, doctors will perform further blood tests and a bone marrow aspiration.  

The patient is given a local anesthetic for the bone marrow aspiration. During the procedure, the doctor inserts a thin, hollow needle into the bone marrow and uses a syringe to draw out some of the liquid portion of the bone marrow. The patient usually feels pressure at the puncture site and a brief dragging pain as the bone marrow is drawn out of the bone. 

Specialists test the bone marrow using various methods to ensure a reliable diagnosis of acute myeloid leukemia (AML). They evaluate the leukemia cells based on their appearance, surface, and genetic characteristics.  

Further laboratory analyses and scans such as those listed below allow doctors to better assess the risks associated with the disease and decide on treatment options: 

• tests for coagulation disorders and infections  
• assessment of heart and lung function  
• ultrasound examination of the abdomen to assess the condition of the internal organs 
• testing of a sample of cerebrospinal fluid (liquor) if symptoms indicate that the central nervous system is affected 

For most patients with acute myeloid leukemia (AML), treatment is intended to cure the disease by permanently eliminating the leukemia cells and restoring normal, healthy blood cell production.  

The core component of AML treatment is intensive chemotherapy. It is divided into a number of treatment phases, in which doctors use various medications in different combinations. 

Some patients whose AML cells exhibit certain characteristics are treated with targeted drugs in addition to chemotherapy. These drugs attack the unique features of the leukemia cells.  

Induction therapy

The first phase of treatment is intended to kill most of the leukemia cells and restore normal blood cell production. If this phase is successful, experts refer to a full or complete remission.

This remission does not mean that the disease has been cured, as there are usually still leukemia cells in the body. Without further treatment, this would almost certainly cause a recurrence. For this reason, all patients who have completed induction therapy go on to have further treatment for their leukemia. 

Consolidation therapy 

Some patients have further conventional chemotherapy following induction therapy. Other patients receive a hematopoietic (blood) stem cell transplant with donor stem cells. Special treatment plans may be appropriate for older patients or patients with other accompanying illnesses. 

The following general principles apply: 

There is no one form of treatment for AML that is equally well suited to all patients. The treatment type, treatment plan, dosage, and therapy cycle may differ from one patient to the next. The most important factors here are the AML sub-type and the estimated risk of relapse.  

One rare sub-type of AML called acute promyelocytic leukemia (APL) presents a special case. Doctors treat this type of acute leukemia with completely different medication. In some cases, chemotherapy is not used at any stage.  

For detailed information on the treatment of acute myeloid leukemia and its side-effects, see the website of the Cancer Information Service of the German Cancer Research Center (in German). 

Even if no leukemia cells can be detected after intensive therapy has been completed, most patients cannot simply resume their previous lives straight away. The treatment they have undergone can be very debilitating, both physically and mentally. 

Medical rehabilitation (rehab) after cancer therapy aims to help patients regain their strength. It can also help them find the best way to deal with the effects of the disease and the treatment. A medical rehab program thus focuses on the personal medical history and existing limitations. 

Medical rehab following treatment for leukemia may include: 

• psycho-social counseling and support 
• nutrition advice 
• physiotherapy and sport 

Patients with acute myeloid leukemia (AML) normally receive very intensive treatment. Both the disease itself and the treatment can affect patients physically and psychologically. Some of these effects may only come to light as late complications after treatment has ended. There is also a risk of recurrence.  

Aftercare for patients with acute myeloid leukemia is intended to ensure early detection of a possible relapse and any long-term effects of treatment.  

Regular consultations with doctors, physical examinations, and blood and bone marrow testing are the pillars of follow-up care. These tests will initially be performed very frequently. As more time passes since the disease was diagnosed and since treatment ended, the intervals between tests become increasingly long.  

The patient and doctor should discuss how often and over how many years aftercare will be necessary and exactly which tests will be required. 

For general information about aftercare for cancer patients, see the website of the Cancer Information Service of the German Cancer Research Center (in German).

Everyday life will continue as normal for very few people who are diagnosed with leukemia, either during or after the disease. The rapid progression of acute myeloid leukemia (AML) and the lengthy treatment as an in-patient and out-patient present a challenge and a burden both to the patients themselves and to their loved ones.  

A patient’s quality of life can be significantly impacted by symptoms such as pain, tiredness, and physical limitations, combined with the strain of undergoing intensive treatment. 

Psycho-social and psycho-oncological counseling by trained experts is often provided to patients while they are still in hospital. Other supports for patients and their families include psycho-social cancer counseling centers and registered psycho-oncologists. Self-help organizations provide patients with important support in dealing with a range of issues and with information from other people in a similar situation. 

On the website of the Cancer Information Service of the German Cancer Research Center, you can find addresses of cancer counseling centers and outpatient psycho-oncologists working in psychotherapy (in German). There is also a list of the main contacts for any questions relating to social law. 

Most people with acute myeloid leukemia (AML) are treated in accordance with therapy plans that have been developed by experts in the field and are improved on an ongoing basis.

The study groups of the German Leukemia Competence Network provide valuable information (in German) on the diagnosis and treatment of AML.

The therapy protocols for children and adolescents with AML differ from those for adults. The focus of rehab and aftercare also differs due to the young age of these patients.

Information about leukemia in children and adolescents is provided on the information portal of the German competence network for pediatric oncology and hematology – kinderkrebs.info.

AML should be treated by a team of experienced doctors from a number of different specialties. Hospitals that are particularly experienced in the treatment of patients with leukemia can become certified as oncology centers specializing in “hematological neoplasms”. The German Cancer Society (DKG), in conjunction with the German Society for Hematology and Medical Oncology (DGHO), regularly checks these hospitals for compliance with certain requirements.

You can find the addresses of centers with this designation on the OncoMAP website. To do this, select “Hematological Neoplasms” in the search panel under “Centre”.