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Case history

image A 71-year-old man presented to his GP with gum bleeding and easy bruising. On further questioning he admitted to feeling fatigued for several months, had lost weight and had a poor appetite. His past medical history included a myocardial infarction 8 years ago (no ongoing angina), type 2 diabetes, hypothyroidism and benign prostatic hypertrophy (BPH). Medications were levothyroxine, metformin, tamsulosin and aspirin. His new GP had also recently started bisoprolol and ramipril at his annual ischaemic heart disease review.

He was married but lived alone, as his wife had severe dementia and resided in a nearby nursing home. He was independent and could walk 100 yards with a stick. Eastern Cooperative Oncology Group performance status (PS) was 0. On examination, he was pale, BP 110/75 mmHg, pulse 70 bpm. His abdominal examination revealed some suprapubic fullness.

Full blood count revealed pancytopenia (white cell count 3×109/l, Hb 83 g/l, platelets 35×109/l), and a blood film demonstrated macrocytic anaemia, hypogranular neutrophils and occasional blasts. Bone marrow examination confirmed a diagnosis of acute myeloid leukaemia (AML) with background myelodysplastic changes; a cytogenetic abnormality of monosomy 7 was detected. Fms-related tyrosine kinase 3 status was wild type. HbA1c was 45 mmol/mol.

What was his likely prognosis and how can it be determined?

What are the treatment options?

Which patient factors and comorbidities should be assessed and modified?

Can anything be done for his fatigue?

What was his likely prognosis and how can it be determined?

AML is a disease of older patients: the median age at presentation is 70 years.1 The goal of pretreatment assessment is to determine whether a patient will benefit from intensive (and therefore curative) therapy. Prognostic factors in older patients with AML have been identified from cohort studies, prospective trials and international databases. This has resulted in the development of a number of prognostic scores,2-6 although none is widely accepted as a gold standard tool.7 These scores are based around a combination of cytogenetics, PS, age, white cell count and other laboratory variables. For example, Kantarjian et al.4 found patients aged >60 years with poor-risk disease had a less than 10% chance of being alive at 1 year compared with 30% and >50% for standard- and good-risk disease, respectively. Age >75 years was an adverse risk factor in this analysis.

Our patient has poor prognostic factors including monosomal karyotype, possible preceding myelodysplastic syndrome (indicated by the dysplastic morphology and longer history of fatigue), medical comorbidities and age ≥60 years. Based on trial data analysis, the poor prognostic factors in this case would result in a predicted 5 year survival of only 2% even with curative intent aggressive treatment.3

What are the treatment options?

Therapeutic options in AML should not be determined by a patient's chronological age. Consideration, however, should be given to comorbidities which ...

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