Acute myeloid leukemia
ICD-10 C92.0 · ICD-11 2A60

Treatment of Primary Refractory or Relapsed Acute Myeloid Leukaemia in Patients Suitable for Intensive Chemotherapy and Allogeneic Haematopoietic Cell Transplantation

Clinical Scenario

This protocol addresses fit patients with primary refractory or relapsed acute myeloid leukaemia (AML) who are candidates for intensive chemotherapy and allogeneic haematopoietic cell transplantation (alloHCT). Primary refractory AML carries a dismal prognosis without definitive consolidation; for patients with relapsed disease who remain fit for intensive salvage, a structured treatment approach is essential before transplant can proceed.

Treatment Approach (partial overview)

Salvage chemotherapy based on cytarabine-containing combinations is the backbone of treatment in this setting, with allogeneic transplantation representing the most effective consolidation strategy for eligible patients — the complete regimen selection, patient sub-group guidance, and sequencing algorithm are available in the full protocol.

Treatment Goal

Achievement of complete remission (second CR) — the essential prerequisite for consolidation with alloHCT and the only realistic path to long-term survival in this setting.

Instant Access to Structured Evidence-Based Regimens

References

  1. For fit patients with relapsed AML, the recommended treatment is salvage ChT followed by alloHCT [III, B]
  2. The outcome of patients with primary refractory AML is dismal, with no realistic prospect of long-term survival after salvage ChT; thus, alloHCT is the most effective treatment option providing long-term survival in 20%–30% of patients [III, B]
  3. The authors recommend a salvage protocol based on high- or intermediate-dose cytarabine in combination with an anthracycline and, optionally, a purine analogue (e.g. FLAG-Ida) [II, B].
  4. Outcomes for patients with primary refractory AML may be better with a sequential transplant conditioning regimen, in which a combination of cytarabine/amsacrine ChT is followed by a fludarabine-based RIC regimen (FLAMSA-RIC) [III, C].
  5. Patients with late relapse (≥12 months after the end of first-line treatment) may also benefit from retreatment with the previously successful induction regimen.
  6. AlloHCT should be considered for all fit, eligible patients who entered second CR [III, B], as it represents the only chance for long-term survival.
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