LeukemiaAwaiting clinical review

Acute myeloid leukemia (AML)

Less common than ALL and harder to cure: short intensive cycles, heavy supportive-care burden, and transplant for high-risk cytogenetics.

Recognize it

Same marrow-failure triad as ALL, plus myeloid-specific findings: gingival hyperplasia and leukemia cutis (monocytic subtypes), chloroma/myeloid sarcoma, DIC.
Auer rods and myeloperoxidase positivity distinguish myeloblasts from lymphoblasts.
Predisposition matters: Down syndrome (transient abnormal myelopoiesis then megakaryoblastic AML), Fanconi anemia, Li-Fraumeni, GATA2 and RUNX1 germline syndromes.

Acute promyelocytic leukemia presents with bleeding out of proportion to platelet count. Start ATRA on clinical suspicion — before cytogenetics return — and support fibrinogen and platelets aggressively.
Hyperleukocytosis in AML causes leukostasis at a lower WBC than ALL (~>100,000/µL, symptomatic earlier): hypoxia, confusion, priapism.

Backbone is cytarabine plus an anthracycline in short, very intensive cycles with long aplastic periods between them.
Favorable cytogenetics: t(8;21), inv(16), NPM1 and CEBPA mutations — chemotherapy alone is often sufficient.
Adverse: monosomy 7, KMT2A rearrangements (some), FLT3-ITD with high allelic ratio — consider allogeneic hematopoietic stem cell transplant in first remission.
Gemtuzumab ozogamicin (anti-CD33) and FLT3 inhibitors are now used in defined subgroups.

Expect 3–4 weeks of profound neutropenia per cycle: inpatient monitoring, antifungal prophylaxis, low threshold for empiric therapy.
Invasive fungal disease (Aspergillus, Candida) is a leading cause of death — persistent fever beyond 96 hours triggers CT chest and galactomannan.
Cytarabine: conjunctivitis (steroid eye drops), cerebellar toxicity at high doses, fever syndrome that mimics infection.
Watch cumulative anthracycline dose closely; AML regimens push toward cardiotoxic thresholds.

Auer rods = myeloid. Gum infiltration = monocytic. Bleeding + DIC = suspect APL and give ATRA now.
Differentiation syndrome (fever, hypoxia, weight gain, effusions) follows ATRA/arsenic — treat with dexamethasone, do not stop supportive care.
Down syndrome AML is biologically distinct, chemo-sensitive, and has excellent outcomes at reduced doses.

1Know the daily fibrinogen and coagulation trend on any suspected APL patient.
2Confirm antifungal and antibacterial prophylaxis are active during aplasia.
3Track the running anthracycline total and the most recent ejection fraction.
4Check line site daily — this population lives with a central line through months of aplasia.

2 vignette questions on this topic.

Children's Oncology Group — Protocol families and risk stratification frameworks used across US pediatric centers.
NCCN Guidelines (Pediatric) — US consensus guidance on treatment and supportive care pathways.