Acute Myelocytic Leukemia

Back in February of 2006, my father was diagnosed with Acute Myelocytic Leukemia.

Acute myeloid leukemia (AML), also known as acute myelogenous leukemia, is a cancer of the myeloid line of blood cells, characterized by the rapid growth of abnormal white blood cells that accumulate in the bone marrow and interfere with the production of normal blood cells. AML is the most common acute leukemia affecting adults, and its incidence increases with age. The symptoms of AML are caused by replacement of normal bone marrow with leukemic cells, which causes a drop in red blood cells, platelets, and normal white blood cells. These symptoms include fatigue, shortness of breath, easy bruising and bleeding, and increased risk of infection. (reference: wikipedia.com)

We never saw it coming. We never expected it and so it was no surprise that we were so shocked with the news. We never took note of the symptoms because we never considered AML as a possibility for any member of the family. Initially, he was only supposed to have the polyps in his sinuses removed but then his laboratory result showed he had very low blood counts (RBC,WBC, Platelet count).

Complete Blood Count ( CBC) - used as a broad screening test to check for such disorders as anemia, infection, and many other diseases. It is actually a panel of tests that examines different parts of the blood and includes the following:

• White blood cell (WBC) count is a count of the actual number of white blood cells per volume of blood. Both increases and decreases can be significant.
• White blood cell differential looks at the types of white blood cells present. There are five different types of white blood cells, each with its own function in protecting us from infection. The differential classifies a person's white blood cells into each type: neutrophils (also known as segs, PMNs, granulocytes, grans), lymphocytes, monocytes, eosinophils, and basophils.
• Red blood cell (RBC) count is a count of the actual number of red blood cells per volume of blood. Both increases and decreases can point to abnormal conditions.
• Hemoglobin measures the amount of oxygen-carrying protein in the blood.
• Hematocrit measures the percentage of red blood cells in a given volume of whole blood.
• The platelet count is the number of platelets in a given volume of blood. Both increases and decreases can point to abnormal conditions of excess bleeding or clotting. Mean platelet volume (MPV) is a machine-calculated measurement of the average size of your platelets. New platelets are larger, and an increased MPV occurs when increased numbers of platelets are being produced. MPV gives your doctor information about platelet production in your bone marrow.
• Mean corpuscular volume (MCV) is a measurement of the average size of your RBCs. The MCV is elevated when your RBCs are larger than normal (macrocytic), for example in anemia caused by vitamin B12 deficiency. When the MCV is decreased, your RBCs are smaller than normal (microcytic) as is seen in iron deficiency anemia or thalassemias.
• Mean corpuscular hemoglobin (MCH) is a calculation of the average amount of oxygen-carrying hemoglobin inside a red blood cell. Macrocytic RBCs are large so tend to have a higher MCH, while microcytic red cells would have a lower value.
• Mean corpuscular hemoglobin concentration (MCHC) is a calculation of the average concentration of hemoglobin inside a red cell. Decreased MCHC values (hypochromia) are seen in conditions where the hemoglobin is abnormally diluted inside the red cells, such as in iron deficiency anemia and in thalassemia. Increased MCHC values (hyperchromia) are seen in conditions where the hemoglobin is abnormally concentrated inside the red cells, such as in burn patients and hereditary spherocytosis, a relatively rare congenital disorder.
• Red cell distribution width (RDW) is a calculation of the variation in the size of your RBCs. In some anemias, such as pernicious anemia, the amount of variation (anisocytosis) in RBC size (along with variation in shape – poikilocytosis) causes an increase in the RDW. (reference: http://www.labtestsonline.org )

My father's Surgeon found the result of his CBC to be highly unusual and so advised for the surgery to be cancelled. He was referred instead to another doctor, this time a Hematologist.

Hematology - the branch of internal medicine, physiology, pathology, clinical laboratory work, and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases. (reference: wikipedia.com)

Hematologist - A doctor who specializes in the field of Hematology.

His new doctor did a Bone Marrow Aspiration on him and I gotta say that just by watching the entire procedure I could tell that it was very painful.

A Bone marrow aspiration removes a small amount of bone marrow fluid and cells through a needle put into a bone. The bone marrow fluid and cells are checked for problems with any of the blood cells made in the bone marrow. Cells can be checked for chromosome problems. Cultures can also be done to look for infection.

A bone marrow biopsy removes bone with the marrow inside to look at under a microscope. The aspiration (taking fluid) is usually done first, and then the biopsy.

A bone marrow aspiration, biopsy, or both are done to:

• Look for the cause of problems with red blood cells, white blood cells, or plateletsin people who have conditions such as thrombocytopenia, anemia, or an abnormal white blood cell count.
• Find blood disorders, such as leukemia, certain anemias, or problems that affect the bone marrow, such as multiple myeloma or polycythemia vera.
• Check to see if a known cancer, such as Hodgkin's lymphoma or non-Hodgkin's lymphoma, has spread to the bone marrow. This is part of what is called staging. It is done to find out if the cancer has spread and how much it has spread. This helps plan cancer treatment. Staging can be done for other cancers, such asprostate, breast, or lung cancer that may have spread to the bone marrow.
• Find infections or tumors that may start in or spread to the bone marrow. If you have an infection, a culture and sensitivity test of the bone marrow sample may be used to find out which antibiotics will work best to treat the infection.
• Find the best treatment for a bone marrow problem. Once treatment has been started, a bone marrow aspiration and biopsy may be done to see if the leukemia cells are gone, which means the treatment is working.
• Collect a sample of bone marrow for medical procedures, such as stem cell transplantation or chromosomal analysis. (reference: http://www.webmd.com)

After the doctor delivered the news to us (first to me, then to my father), we were left with a feeling of hopelessness. That was a dark part in our lives. My father, although he never did break down, hinted of giving up. He told us that he might as well wait for his time to come instead of go through treatments when he would not be assured of recovery.

Treatment Options for AML:

Induction

All FAB subtypes except M3 are usually given induction chemotherapy with cytarabine (ara-C) and an anthracycline (such as daunorubicin or idarubicin).^[32] This induction chemotherapy regimen is known as "7+3" (or "3+7"), because the cytarabine is given as a continuous IV infusion for seven consecutive days while the anthracycline is given for three consecutive days as an IV push. Up to 70% of patients will achieve a remission with this protocol.^[33] Other alternative induction regimens, including high-dose cytarabine alone or investigational agents, may also be used.^[34][35] Because of the toxic effects of therapy, including myelosuppression and an increased risk of infection, induction chemotherapy may not be offered to the very elderly, and the options may include less intense chemotherapy or palliative care.

The M3 subtype of AML, also known as acute promyelocytic leukemia, is almost universally treated with the drug ATRA (all-trans-retinoic acid) in addition to induction chemotherapy.^[36][37][38] Care must be taken to prevent disseminated intravascular coagulation (DIC), complicating the treatment of APL when the promyelocytes release the contents of their granules into the peripheral circulation. APL is eminently curable with well-documented treatment protocols.

The goal of the induction phase is to reach a complete remission. Complete remission does not mean that the disease has been cured; rather, it signifies that no disease can be detected with available diagnostic methods.^[32] Complete remission is obtained in about 50%–75% of newly diagnosed adults, although this may vary based on the prognostic factors described above.^[39] The length of remission depends on the prognostic features of the original leukemia. In general, all remissions will fail without additionalconsolidation therapy.^[40]

Consolidation

Even after complete remission is achieved, leukemic cells likely remain in numbers too small to be detected with current diagnostic techniques. If no further postremission or consolidation therapy is given, almost all patients will eventually relapse.^[41] Therefore, more therapy is necessary to eliminate non-detectable disease and prevent relapse — that is, to achieve a cure.

The specific type of postremission therapy is individualized based on a patient's prognostic factors (see above) and general health. For good-prognosis leukemias (i.e. inv(16), t(8;21), and t(15;17)), patients will typically undergo an additional 3–5 courses of intensive chemotherapy, known as consolidation chemotherapy.^[42][43] For patients at high risk of relapse (e.g. those with high-risk cytogenetics, underlying MDS, or therapy-related AML), allogeneic stem cell transplantation is usually recommended if the patient is able to tolerate a transplant and has a suitable donor. The best postremission therapy for intermediate-risk AML (normal cytogenetics or cytogenetic changes not falling into good-risk or high-risk groups) is less clear and depends on the specific situation, including the age and overall health of the patient, the patient's personal values, and whether a suitablestem cell donor is available.^[43]

For patients who are not eligible for a stem cell transplant, immunotherapy with a combination of histamine dihydrochloride (Ceplene) and interleukin-2 (Proleukin) after the completion of consolidation has been shown to reduce the absolute relapse risk by 14%, translating to a 50% increase in the likelihood of maintained remission.^[44]

Relapsed AML

For patients with relapsed AML, the only proven potentially curative therapy is a hematopoietic stem cell transplant, if one has not already been performed.^[45][46][47] In 2000, the monoclonal antibody-linked cytotoxic agent gemtuzumab ozogamicin (Mylotarg) was approved in the United States for patients aged more than 60 years with relapsed AML who are not candidates for high-dose chemotherapy.^[48]

Patients with relapsed AML who are not candidates for stem cell transplantion, or who have relapsed after a stem cell transplant, may be offered treatment in a clinical trial, as conventional treatment options are limited. Agents under investigation include cytotoxic drugs such as clofarabine as well as targeted therapies such as farnesyl transferase inhibitors, decitabine, and inhibitors of MDR1 (multidrug-resistance protein). Since treatment options for relapsed AML are so limited, another option which may be offered ispalliative care.

For relapsed acute promyelocytic leukemia (APL), arsenic trioxide has been tested in trials and approved by the Food and Drug Administration. Like ATRA, arsenic trioxide does not work with other subtypes of AML.^[49]

(reference: wikipedia.com)

It's a good thing my eldest sister was able to convince him to undergo treatment because it definitely helped. After my father agreed to have Chemotherapy, we immediately arranged for living arrangements as well as hospital accommodations (since it would be too much of a hassle and discomfort to have to travel back and forth between two cities while he was undergoing treatment).

When he was already in Chemotherapy, he would stay at the hospital for days to a week. The amount of medications he had to take and the strength of each one of those medicines took a toll on his body. Sometimes he would have hallucinations and would bruise all over. He became very thin, his hairs started to fall off (which was why he decided to shave his head off). He was very prone to infections and was always feverish. From time to time he would need blood transfusions.

Through all these, despite the emotional, mental and physical torture that my father went through, he still managed to survive and be in good health again. He has been cancer-free for almost five years and is as strong as can be at 69 years old. I and my family, including my father, have always been and will always be grateful to God for my father's second chance at life.

In serious medical conditions as my father once had, a strong support system is truly a really big morale booster. It helps keep the patient's hopes up and keeps him fighting for his life. I believe that is what happened with my father. Aside from the fact that he is a strong person (emotionally and physically), his unwavering faith in God and his family never leaving his side strengthened his resolve to overcome his sickness and continue living.