As you know, this is a high risk leukemia and can only be cured (if any) by transplantation.

However, it's not the same situation if you don't reach complete response but you get some improvement in the patitent's status (decrease in the number of blasts, etc)  than a case where the number of blasts is higher after induction chemotherapy. 

In our group, we try to use a tandem approach to transplantation using the FLAMSA scheme to achieve reduction in the tumour burden and then directly myeloablative transplantation with cy plus TBI or melphalan, etc.

http://www.nature.com/bmt/journal/v47/n1/full/bmt201115a.html

The regimen suggested by Dr. Romon is good providing you have access to amsacrine. If that is a problem, you can use CLAG-M regimen and take the patient to an allogeneic HSCT afterwards. I have seen good results with this regimen.

Cladribine (2-CdA) 5 mg/m2/d iv over 2 hrs d1-5

Cytarabine (Ara-C) 2 g/m2/d iv over 4 hrs starting 2 hrs after cladribine d1-5

Mitoxantrone (Novantrone) 10 mg/m2/d iv d1-3

Filgrastim (Neupogen) 300 mcg sc d0-5 

Wierzbowska A et al. Cladribine combined with high doses of arabinoside cytosine, mitoxantrone, and G-CSF (CLAG-M) is a highly effective salvage regimen in patients with refractory and relapsed acute myeloid leukemia of the poor risk: a final report of the Polish Adult Leukemia Group. Eur J Haematol 2008; 80:115

Can you supply us with the detailed chemotherapy protocols received?

I think that two questions have to be solved: first if it is a FLT3 positive leukemia. In this regard a good option could be AC220  ( see below) or ASP2215, both drugs in ongoing  experimental clinical trials, and both ongoing in several part of the USA and Europe.

Journal of Clinical Oncology, 2013 ASCO Annual Meeting Abstracts.

Vol 31, No 15_suppl (May 20 Supplement), 2013: 7021

© 2013 American Society of Clinical Oncology

Effect of quizartinib (AC220) on response rates and long-term survival in elderly patients with FLT3-ITD positive or negative relapsed/refractory acute myeloid leukemia.

Giovanni Martinelli, Alexander E. Perl, Hervé Dombret, Sabine Kayser, Bjoern Steffen, Philippe H. Rousselot, Elihu Estey, Alan K. Burnett, Neil P. Shah, Guy Gammon, Denise Trone, Mark J. Levis and Jorge E. Cortes

Seragnoli Institute of Hematology, Bologna University School of Medicine, Bologna, Italy; University of Pennsylvania, Philadelphia, PA; Hematologie Adultes, Hôpital Saint-Louis, Paris, France; Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany; Department of Medicine, Hematology/Oncology, Goethe University of Frankfurt, Frankfurt, Germany; Service d’Hématologie et Oncologie, Hôpital de Versailles, Université Versailles Saint Quentin en Yvelines, Le Chesnay, France; Division of Hematology, University of Washington, Fred Hutchinson Cancer Research Center, Seattle, WA; Department of Medical Genetics, Haematology and Pathology, Cardiff University School of Medicine, Cardiff, United Kingdom; University of California, San Francisco, San Francisco, CA; Ambit Biosciences Corporation, San Diego, CA; Department of Oncology, Division of Hematologic Malignancies, Johns Hopkins University School of Medicine, Baltimore, MD; The University of Texas MD Anderson Cancer Center, Houston, TX

Abstract Disclosures

Abstract

7021

Background: Advanced age and FMS-like tyrosine kinase 3 internal tandem duplications (FLT3-ITD) in acute myeloid leukemia (AML) are associated with early relapse after standard chemotherapy and poor survival. Quizartinib (AC220), an oral FLT3 inhibitor active against ITD mutant and wild type FLT3, has shown promising activity in Ph 1 and 2 studies. Methods: Patients (pts) in a Ph 2 open label study (N = 333) of quizartinib monotherapy included 154 aged ≥60 y with known FLT3-ITD status and AML relapsed in 52 wks. The median age of these pts surviving >52 wks was 69.5 y (range 66–80 y) and median OS was 76.3 wks (range 56.9–96.0 wks). All of these pts responded to quizartinib (2 CR, 2 CRp, 8 CRi, 4 partial remission [PR]). 2 pts were still alive >1 1/2 y (OS 93.0 and 96.0 wks). Median OS in FLT3-ITD(-) pts was 19.1 wks and 6/44 FLT3-ITD(-) pts (14%) survived >52 wks. The median age of these pts was 70.0 y (range 65–77 y) and their median survival was 76.6 wks (range 54.9–98.4 wks). 5 of these pts responded to quizartinib (1 CR, 3 CRi, 1 PR). Conclusions: These data for an FLT3-targeted agent show encouraging survival in a subset of elderly pts with relapsed/refractory FLT3-ITD(+) AML. Clinical trial information: NCT00989261.

Efficacy in elderly relapsed/refractory AML pts.

A second possibility could be a MDM2 inhibitor, also ongoing in experimental trial.

BW

Giovanni

                                     FLT3-ITD(+)                            FLT3-ITD(-)

Cumulative CRc, n (%)    63 (57)                                    16 (36)

CRc+PR, n (%)                86 (78)                                     20 (56)

Median CRc duration, wk (95% CI) 12.1 (6.3, 15.7)       10.8 (8.1, 26.1)

Median overall survival, wk (95% CI) 25.3 (21.3, 30.0)   19.1 (12.0, 29.4)

Abbreviations: CRc = composite complete remission; PR = partial remission.