For full accreditation info click here: https://www.carevive.com/whats-new-in-acute-myelogenous-leukemia/ Acute myelogenous leukemia (AML) is a disease of older adults, with a median age of presentation of 67 years; only 5-10% of patients are alive at 5 years. Traditionally older patients have not received intensive induction chemotherapy to avoid toxicities, yet current research shows fit patients treated with intensive chemotherapy have better outcomes than patients with no treatment. The goal of this program is to close existing cancer clinician competency gaps regarding new data on investigational agents for AML along with evolving evidence-based guidelines and current understanding of treatment outcomes among older patients with AML. Hematology care teams will receive updates on current treatment treatments, the new data on investigational agents for AML, and how to make risk-based decisions among older patients with AML.L. Target Audience This activity is intended for hematologists, hematology Nurse Practitioners (NPs) and Physician Assistants (PAs) and oncology nurses engaged in the care of patients with acute myelogenous leukemia (AML). Educational Objectives At the conclusion of these educational initiatives, participants should be able to: Assess clinical data on newly approved agents for relapsed/refractory AML Select appropriate treatment for AML according to patient risk group Integrate evidence-based guidelines into practice to treat patients with AML guided by molecular and cytogenetic and testing and patient-specific characteristics Faculty Thomas W. LeBlanc, MD Associate Professor of Medicine Duke Cancer Institute

1. What’s New in Acute
Myelogenous Leukemia?
Acute myelogenous leukemia (AML) is a disease of older adults, with a median
age of presentation of 67 years; only 5-10% of patients are alive at 5 years.
Traditionally older patients have not received intensive induction chemotherapy
to avoid toxicities, yet current research shows fit patients treated with intensive
chemotherapy have better outcomes than patients with no treatment.
The goal of this program is to close existing cancer clinician competency gaps
regarding new data on investigational agents for AML along with evolving
evidence-based guidelines and current understanding of treatment outcomes
among older patients with AML. Hematology care teams will receive updates on
current treatment treatments, the new data on investigational agents for AML, and
how to make risk-based decisions among older patients with AML.
TARGET AUDIENCE
This activity is intended for hematologists, hematology Nurse Practitioners (NPs)
and Physician Assistants (PAs) and oncology nurses engaged in the care of
patients with acute myelogenous leukemia (AML).
EDUCATIONAL OBJECTIVES
At the conclusion of these educational initiatives, participants should be able to:
• Assess clinical data on newly approved agents for relapsed/refractory AML
• Select appropriate treatment for AML according to patient risk group
• Integrate evidence-based guidelines into practice to treat patients with
AML guided by molecular and cytogenetic and testing and patient-specific
characteristics
FACULTY
Thomas W. LeBlanc, MD
Associate Professor of Medicine
Duke Cancer Institute
PHYSICIAN CONTINUING MEDICAL EDUCATION
Joint Accreditation Statement
In support of improving patient care, this activity has been
planned and implemented by the Postgraduate Institute for
Medicine and Carevive Systems, Inc. Postgraduate Institute
for Medicine is jointly accredited by the Accreditation Council
for Continuing Medical Education (ACCME), the Accreditation
Council for Pharmacy Education (ACPE), and the American
Nurses Credentialing Center (ANCC), to provide continuing
education for the healthcare team.
Credit Designation
The Postgraduate Institute for Medicine designates this enduring material for a
maximum of 0.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the
credit commensurate with the extent of their participation in the activity.
NURSING CONTINUING EDUCATION
Credit Designation
The maximum number of hours awarded for this Continuing Nursing Education
activity is 0.7 contact hours. The maximum number of Pharmacotherapy contact
hours awarded for Advanced Practice Registered Nurses is 0.5 contact hours.
DISCLOSURE OF CONFLICTS OF INTEREST
Postgraduate Institute for Medicine (PIM) requires instructors, planners,
managers and other individuals who are in a position to control the content of this
activity to disclose any real or apparent conflict of interest (COI) they may have as
related to the content of this activity. All identified COI are thoroughly vetted and
resolved according to PIM policy. PIM is committed to providing its learners with
high quality CME activities and related material that promote improvements or
quality in healthcare and not a specific proprietary business interest of a
commercial interest. Faculty reported the following financial relationships or
relationships
to products or devices they or their spouse/life partner have with commercial
interests related to the content of this CME activity:
Faculty Disclosures
Thomas LeBlanc, MDRoyalty, UpToDate, Inc., Consulting Fees, Amgen, Herron,
Helsinn, Otsuka; Speaker Bureau, Celgene, Contracted Research, AstraZeneca,
Seattle Genetics.
Planners and Managers
The PIM planners and managers have nothing to disclose.
The following Carevive Systems, Inc. planners and managers reported the
following: Timothy J. DiChiara, PhD, Consulting Fees, Daiichi Sankyo, Inc.
METHOD OF PARTICIPATION AND REQUEST FOR CREDIT
There are no fees for participating and receiving CME/CNE credit for this activity.
During the period October 17, 2018 through October 16, 2019, participants must read
the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete
the posttest and evaluation on www.cmeuniversity.com. On the navigation menu,
click on “Find Post-test/Evaluation by Course” and search by course ID 13497. Upon
registering and successfully completing the posttest with a score of 50% or better
and the activity evaluation, your certificate will be made available immediately.
Processing credit requests online will reduce the amount of paper used by nearly
100,000 sheets per year. If you have questions regarding obtaining your certificate or
the accreditation of this activity, please contact PIM at www.pimed.com.
MEDIA
e-Monograph
HARDWARE AND SOFTWARE REQUIREMENTS
• A computer with an internet connection
• A PDF viewing software: Adobe Acrobat Reader or Apple Preview
• Internet Browser: Latest versions of Internet Explorer, Firefox, Safari, or any other
W3C standards compliant browser
• Additional Software: PowerPoint, Adobe Flash Player and/or an HTML 5 capable
browser maybe required for video or audio playback.
DISCLOSURE OF UNLABELED USE
This educational activity may contain discussion of published and/ or
investigational uses of agents that are not indicated by the FDA. The planners of this
activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty
and do not necessarily represent the views of the planners. Please refer to the
prescribing information for each product for discussion of approved indications,
contraindications, and warnings.
DISCLAIMER
Participants have an implied responsibility to use the newly acquired information
to enhance patient outcomes and their own professional development. The
information presented in this activity is not meant to serve as a guideline
for patient management. Any procedures, medications, or other courses of
diagnosis or treatment discussed or suggested in this activity should not be
used by clinicians without evaluation of their patient’s conditions and possible
contraindications and/or dangers in use, review of any applicable manufacturer’s
product information, and comparison with recommendations of other authorities.
FEE INFORMATION
There is no fee for this educational activity.
Release date: October 17, 2018
Expiration date: October 16, 2019
Estimated time to complete activity: 0.75 hours
This activity is supported by independent educational grants from
AbbVie Inc., Astellas Scientific and Medical Affairs, Inc., Celgene
Corporation and Jazz Pharmaceuticals
(Carevive Activity ID: G-422)

2. What’s New in Acute Myelogenous Leukemia?
Thomas W. LeBlanc, MD, MA, MHS
INTRODUCTION
In 2018, an estimated 19,520 new cases of acute myelogenous
leukemia (AML) will be diagnosed, resulting in 10,670 deaths
(SEER, 2018). The incidence of AML increases with age; the
median age at diagnosis is approximately 68 years. Older
patients with AML often have a poorer prognosis than younger
patients due to a higher incidence of comorbidities, higher
rates of treatment-related mortality, and adverse disease
characteristics associated with resistant disease and relapses.
Some of these characteristics also prevent older patients from
tolerating standard intensive induction regimens without high
treatment-related morbidity and mortality. Survival sharply
decreases with age, with median overall survival (OS) of patients
≥75 years old being less than 1 year (Klepin et al, 2014). The
5-year survival rate of all patients with AML is only 27.4% (SEER,
2018). Fortunately, multiple novel agents for the treatment of
AML have been approved by the FDA in the last 2 years, which
promise to improve outcomes for this aggressive disease.
RISK STRATIFICATION
Genetic and molecular testing is increasingly important for
diagnosing AML, determining patient prognosis, and selecting
optimal therapy. The 2018 National Comprehensive Cancer
Network (NCCN) guidelines (O’Donnell et al, 2018) include the
following evidence-based recommendations for cytogenetic/
molecular testing in patients with AML:
• Bone marrow core biopsy and aspirate analyses, including
immunophenotyping, immunocytochemistry, and flow
cytometry
• Cytogenetic analyses (karyotype ± fluorescence in situ
hybridization [FISH])
• Molecular analyses (KIT, FLT3 [ITD and TKD], NPM1, CEBPA,
IDH1, IDH2, TP53, and other mutations)
• Multiplex gene panels and next-generation sequencing
analysis may be used to obtain a more comprehensive
prognostic assessment by identifying other mutations of
significance, including ASXL1, RUNX1, and others.
These data can then be used to risk-stratify patients, as
indicated in the table below (O’Donnell et al, 2018).
TREATMENT OF OLDER PATIENTS
Survival outcomes for patients ≥60 years of age are poor, even
among those with favorable cytogenetics, likely due to the
heterogeneous clonal evolution of AML (Wheatly et al, 2009;
Juliusson et al, 2012; Grimwade et al, 2016). Nevertheless,
recent trials demonstrate that some treatment is better than
none: although ~60% of older patients with AML remain
untreated following diagnosis, treated patients (i.e., treated
utilizing intensive regimens and hypomethylating agents)
exhibited a 33% lower risk of death compared to untreated
patients (Medeiros et al, 2015). The challenge for clinicians
is to identify which older patients are likely to benefit from
intensive therapy.
What’s New in Acute Myelogenous Leukemia?
1
RISK STATUS CYTOGENETICS MOLECULAR ABNORMALITIES
Favorable • Core binding factor: inv(16) or t(16;16) or
t(8;21) or t(15;17)
• Normal cytogenetics with NPM1 mutation in the absence
of FLT3-ITD or presence of FLT3-ITDlow
or isolated biallelic
(double) CEBPA mutation
Intermediate • Normal cytogenetics t(9;11)
• Other non-defined
• Core binding factor with KIT mutation
• Mutated NPM1 and FLT3-ITDhigh
• Wild-type NPM1 without FLT3-ITD or with FLT3- ITDlow
(without poor-risk genetic lesions)
Poor • Complex (≥3 clonal chromosomal
abnormalities)
• Monosomal karyotype
• -5, 5q-, -7, 7q-
• 11q23 - non t(9;11)
• inv(3), t(3;3)
• t(6;9)
• t(9;22)
• Normal cytogenetics wth FLT3-ITD mutation
• TP53 mutation
• Mutated RUNX1
• Mutated ASXL1
• Wild-type NPM1 and FLT3-ITDhigh

3. RECENT TREATMENT ADVANCES
Although the combination of cytarabine and an anthracycline
(the “7+3” regimen) has been the gold standard of treatment for
over 40 years, recurrences are common, and AML remains the
most common cause of leukemia-related mortality. Fortunately,
several agents with novel mechanisms of action have been
FDA approved for the management of AML in the past 2 years,
including isocitrate dehydrogenase-1/2 (IDH1/2) inhibitors,
anti-CD33 antibodies, FMS-like tyrosine kinase 3 (FLT3)
inhibitors, and a liposomal formulation of daunorubicin and
cytarabine. As a result, clinical decision-making has become
much more complex.
ENASIDENIB
In August 2017, enasidenib (AG-221) was approved for the
treatment of adult patients with relapsed or refractory AML
with an IDH2 mutation, as detected by an FDA-approved test
(the RealTime IDH2 Assay). Enasidenib is the first-in-class
oral therapy for this population, which represents between
8% and 19% of patients with AML. The approval was based
on the open-label, single-arm AG221-C-001 trial of 199 AML
patients with an IDH2 mutation (Stein et al, 2017). Patients had
a median age of 68 years (range: 19-100 years) and received
a median of two prior therapies. Enasidenib demonstrated an
overall response rate of 40.3%, with a complete remission (CR)
or complete remission with partial hematologic recovery (CRh)
rate of 23% (n=46), with a median duration of 8.2 months. The
median OS was 9.3 months; for patients achieving a CR, the
median OS was 19.7 months, and in the non-CR responders,
the median OS was 13.8 months. It is noteworthy that even
many of the partial responses (6.3%) were associated with
meaningful patient improvements, such as transfusion
independence and fewer infections due to neutrophil recovery.
In addition, approximately 10% of patients proceeded to
stem cell transplant, suggesting that enasidenib may
provide a bridge to potentially curative treatment. Fourteen
percent of patients treated with enasidenib experienced
IDH differentiation syndrome, a potentially life-threatening
systemic hyperinflammatory state characterized by dyspnea,
fever, pulmonary infiltrates, and hypoxia (Fathi et al, 2018).
Treatment, including systemic corticosteroids, is effective in
most patients, but awareness and early recognition are critical.
Other common adverse reactions (≥20%) of any grade were
nausea, vomiting, diarrhea, elevated bilirubin, and decreased
appetite.
IVOSIDENIB
In July 2018, the FDA approved ivosidenib (AG-120), an oral
inhibitor of IDH1, for use in adult patients with IDH1 mutation-
positive relapsed/refractory AML (6-10% of patients with AML).
The RealTime IDH1 Assay was simultaneously approved for use
in selecting patients with IDH1+ AML who can be treated with
ivosidenib. The Phase 1 AG120-C-001 trial evaluated ivosidenib
500 mg monotherapy in 179 patients with relapsed or refractory
AML (DiNardo et al, 2018). In the efficacy population, the rate of
CR or CRh was 30.4% (with a median duration of 8.2 months),
the CR rate was 21.6% (with a median duration of 9.3 months),
and the overall response rate was 41.6%. In addition, transfusion
independence was attained in 29 of 84 patients (35%). The most
frequent adverse events were diarrhea (31%), leukocytosis (30%),
febrile neutropenia (29%), nausea (28%), fatigue (26%), dyspnea
(25%), prolongation of the QT interval (25%), peripheral edema
(22%), anemia (22%), pyrexia (21%), and cough (21%). Treatment-
related Grade 3 prolongation of the QT interval occurred in 7.8%
of patients and IDH differentiation syndrome occurred in 10.6%
(5.0% Grade ≥3). As with enasidenib, awareness and prompt
management of differentiation syndrome are critical.
MIDOSTAURIN
Midostaurin (PKC412) is a multi-targeted small-molecule FLT3
inhibitor with single-agent activity in both internal tandem
duplication (ITD) and tyrosine kinase domain (TKD)-mutant
FLT3 AML. Midostaurin was approved in April 2017 for the
treatment of adult patients with newly diagnosed AML who
are FLT3 mutation-positive, as detected by an FDA-approved
test (LeukoStrat CDx FLT3 Mutation Assay), in combination
with standard cytarabine and daunorubicin induction and
high-dose cytarabine consolidation. In the pivotal Phase III
RATIFY (CALGB 10603) trial (Stone et al, 2017), patients who
received midostaurin and standard induction and consolidation
chemotherapy experienced a significant improvement in OS
compared to those who received standard induction and
consolidation chemotherapy alone: the median OS for patients
in the midostaurin treatment group was 74.7 months versus
25.6 months for patients in the placebo group, a 22% lower risk
of death. The benefit of midostaurin was consistent across all
FLT3 subtypes. Midostaurin was associated with higher rates
of anemia and rash than the placebo group; otherwise, there
were no statistically significant differences in Grade 3 or higher
hematologic and non-hematologic adverse events.
GEMTUZUMAB OZOGAMICIN
In September 2017, the anti-CD33 antibody-drug conjugate
gemtuzumab ozogamicin (GO) was reapproved for the treatment
of newly diagnosed CD33-positive AML in adults and for
treatment of relapsed or refractory CD33-positive AML in adults
and in pediatric patients 2 years of age and older. Gemtuzumab
ozogamicin may be used in combination with daunorubicin
and cytarabine for adults with newly diagnosed AML, or as a
stand-alone treatment for certain adult and pediatric patients.
2
What’s New in Acute Myelogenous Leukemia?

4. Although it was initially approved in 2000 on the basis of
Phase 2 data, it was withdrawn by the manufacturer in 2010
due to increased induction deaths and no observed survival
benefit, only to be reapproved based on new Phase 3 data
using a lower dose and a new fractionated dose schedule. In
the pivotal Phase 3 ALFA-0701 trial of 271 patients with de
novo AML, GO plus daunorubicin/cytarabine was evaluated in
comparison to daunorubicin/cytarabine alone (Castaigne et
al, 2014). The median event-free survival was 17.3 months for
patients receiving GO versus 9.5 months for those receiving
chemotherapy alone, although remission rates and OS were
not significantly different between the groups. Although higher
hematological toxicity was observed in the GO arm, increased
risk of death due to toxicity was not observed. A meta-analysis
of this and other trials demonstrated that GO significantly
improved survival in patients with favorable (20.7%) and
intermediate (5.7%) risk cytogenetics (Hills et al, 2014).
The most common adverse events (15%) in patients receiving
GO in clinical trials were hemorrhage, infection, fever, nausea,
vomiting, constipation, headache, increased aspartate
aminotransferase, increased alanine aminotransferase,
rash, and mucositis. Serious adverse events associated with
treatment included hepatotoxicity, infusion-related reactions, and
hemorrhage. Gemtuzumab ozogamicin carries a boxed warning
for hepatotoxicity, including severe and fatal hepatic veno-
occlusive disease (VOD). However, the VOD risk may be less with
the lower-dose, fractionated dosing schemas used in the more
recent studies (Norsworthy et al, 2018).
LIPOSOMAL DAUNORUBICIN/CYTARABINE (CPX-351)
In August 2017, the FDA approved a liposome-encapsulated
combination of daunorubicin and cytarabine for use in adults
for the treatment of two types of AML that have a poor
prognosis: newly diagnosed therapy-related AML (t-AML) or
AML with myelodysplasia-related changes (AML-MRC). In
the pivotal Phase 3 trial, 309 patients aged 60 to 75 years
with newly diagnosed high-risk/sAML received one to two
induction cycles of CPX-351 or the 7+3 regimen followed by
consolidation therapy with a similar regimen (Lancet et al,
2018). CPX-351 significantly improved median OS (9.56 v. 5.95
months) and remission rates (47.7% v. 33.3%) although the
time to neutrophil and platelet count recovery was longer with
CPX-351. The safety profile of CPX-351 was similar to that of
conventional 7+3 therapy. Adverse events were similar to the
standard 7+3 regimen: febrile neutropenia (68.0%), pneumonia
(19.6%), and hypoxia (13.1%). However, bleeding events of
any grade were more common with CPX-351 than with 7+3
(74.5% v. 59.6%). An unusual AE associated with CPX-351 is
copper overload; clinicians are advised on the label to monitor
patients’ total serum copper, serum non-ceruloplasmin-bound
copper, and 24-hour urine copper levels, as well as conducting
serial neuropsychological examinations in patients with
Wilson’s disease or other copper-related metabolic disorders.
NCCN GUIDELINES
The new 2018 NCCN guidelines highlight the many significant
changes to AML treatment that have occurred in recent years
(O’Donnell et al, 2018). Recommended therapies for relapsed/
refractory disease are summarized below.
Treatment selection is based on multiple disease- and
patient-related factors, including age, performance status,
comorbidities, prior treatment, molecular and genetic features,
and patient preference.
3
AGGRESSIVE THERAPY
• Cladribine + cytarabine + granulocyte colony-stimulating
factor (G-CSF) ± mitoxantrone or idarubicin
• HiDAC (if not received previously in treatment) ± (idarubicin
or daunorubicin or mitoxantrone)
• Fludarabine + cytarabine + G-CSF ± idarubicin
• Etoposide + cytarabine ± mitoxantrone
• Clofarabine ± cytarabine + G-CSF ± idarubicin
LESS AGGRESSIVE THERAPY
• Hypomethylating agents (5-azacytidine or decitabine)
• Low-dose cytarabine (category 2B)
Therapy for AML with FLT3-ITD mutation:
• Hypomethylating agents (5-azacytidine or decitabine) +
sorafenib
Therapy for AML with IDH2 mutation:
• Enasidenib
Therapy for AML with IDH1 mutation
(in patients with favorable- or intermediate-risk):
• Ivosidenib
Therapy for CD33-positive AML:
• Gemtuzumab ozogamicin
What’s New in Acute Myelogenous Leukemia?

5. REFERENCES
Castaigne S, Pautas C, Terre C, et al. Final analysis of the
ALFA 0701 Study. Blood. 2014;124:376.
DiNardo CD, Stein EM, de Botton S, et al. Durable remissions
with ivosidenib in IDH1-mutated relapsed or refractory
AML. N Engl J Med. 2018;378(25):2386-2398.
Fathi AT, DiNardo CD, Kline I, Kenvin L, Gupta I, Attar EC,
Stein EM, de Botton S; AG221-C-001 Study Investigators.
Differentiation Syndrome Associated With Enasidenib, a
Selective Inhibitor of Mutant Isocitrate Dehydrogenase
2: Analysis of a Phase 1/2 Study. JAMA Oncol. 2018 Aug
1;4(8):1106-1110.
Grimwade D, Ivey A, Huntly BJ. Molecular landscape of
acute myeloid leukemia in younger adults and its clinical
relevance. Blood. 20167;127(1):29-41.
Hills RK, Castaigne S, Appelbaum FR, et al. Addition of
gemtuzumab ozogamicin to induction chemotherapy
in adult patients with acute myeloid leukaemia: a meta-
analysis of individual patient data from randomised
controlled trials. Lancet Oncol. 2014 Aug;15(9):986-96.
Juliusson G, Lazarevic V, Hörstedt AS, et al. Acute myeloid
leukemia in the real world: why population-based registries
are needed. Blood. 2012;119(17):3890-3899.
Klepin HD, Rao AV, Pardee TS. Acute myeloid leukemia and
myelodysplastic syndromes in older adults. J Clin Oncol.
2014;32(24):2541-2552.
Lancet JE, Uy GL, Cortes JE, et al. CPX-351 (cytarabine and
daunorubicin) Liposome for injection versus conventional
cytarabine plus daunorubicin in older patients with newly
diagnosed secondary acute myeloid leukemia. J Clin Oncol.
2018:JCO2017776112. [Epub ahead of print]
Medeiros BC, Satram-Hoang S, Hurst D, Hoang KQ, Momin
F, Reyes C. Big data analysis of treatment patterns and
outcomes among elderly acute myeloid leukemia patients
in the United States. Ann Hematol. 2015;94(7):1127-1138.
Norsworthy KJ, Ko CW, Lee JE, et al. FDA Approval Summary:
Mylotarg for Treatment of Patients with Relapsed or
Refractory CD33-Positive Acute Myeloid Leukemia.
Oncologist. 2018 Apr 12. [Epub before print]
O’Donnell MR, Tallman MS, Abboud CN, et al. NCCN
Guidelines Version 2.2018 – Acute Myeloid Leukemia.
Accessed August 15, 2018 at https://www.nccn.org/
professionals/physician_gls/pdf/aml.pdf
SEER. Cancer Stat Facts: Leukemia - Acute Myeloid
Leukemia (AML). Accessed August 15, 2018 at https://
seer.cancer.gov/statfacts/html/amyl.html
Stein EM, DiNardo CD, Pollyea DA, et al. Enasidenib in mutant
IDH2 relapsed or refractory acute myeloid leukemia. Blood.
2017;130(6):722-731.
Stone RM, Mandrekar SJ, Sanford BL, et al. Midostaurin plus
chemotherapy for acute myeloid leukemia with a FLT3
mutation. N Engl J Med. 2017;377(5):454-464.
Taksin AL, Legrand O, Raffoux E, et al. High efficacy
and safety profile of fractionated doses of Mylotarg
as induction therapy in patients with relapsed acute
myeloblastic leukemia: A prospective study of the ALFA
group. Leukemia. 2007;21(1):66-71.
Wheatley K, Brookes CL, Howman AJ, et al. Prognostic factor
analysis of the survival of elderly patients with AML in
the MRC AML11 and LRF AML14 trials. Br J Haematol.
2009;145(5):598-605.
4
What’s New in Acute Myelogenous Leukemia?