Division of Hematology-Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
Bone Marrow Transplant. 2013 Nov;48(12):1497-505. doi: 10.1038/bmt.2013.67. Epub 2013 May 6.
AML treatment presents significant challenges in the elderly, who more often have poor risk cytogenetic and molecular markers, comorbidities and compromised performance status. Although population-based studies indicate that treated patients' survival is better than those who are not treated, there is an understandable reluctance of physicians to choose aggressive therapy. Even in this older population 40-60% CR rates are achievable. Several scoring systems and web-based programs help to predict TRM and CR rates. These sources can assist physicians in the difficult decision-making process of aggressive therapy in an individual patient. Clofarabine and hypomethylating agents are reasonable options and can induce CR in patients who cannot receive standard induction with anthracyclines and cytarabine. Despite encouraging CR rates, median survival remains short (<12 months) in elderly AML patients. Even those patients achieving CR have limited long-term survival (∼20% at 3 years) without allogeneic hematopoietic cell transplantation (alloHCT). AlloHCT is feasible and can provide approximately 40% survival at 2 years in appropriately selected patients. Although increased age is associated with poorer survival, higher comorbidities and poor performance status have more negative impact than age per se. The short duration of CR demands that leukemia and transplant physicians collaborate immediately after diagnosis to move quickly toward alloHCT. This collaboration is also essential to choosing the right individuals to transplant and to bridging post-remission therapy (intermediate-dose cytarabine, a hypomethylating agent or FLT-3 inhibitor) in this sometimes frail population. Future studies should be designed not only to address who should receive alloHCT, but also to improve our understanding of AML biology and the process of its cure.
AML 治疗在老年人中存在重大挑战，因为他们往往具有较差的风险细胞遗传学和分子标志物、合并症和受损的体能状态。尽管基于人群的研究表明，接受治疗的患者的生存率优于未接受治疗的患者，但医生不愿意选择积极治疗是可以理解的。即使在这个老年人群中，也有 40-60%的 CR 率是可以实现的。几种评分系统和基于网络的程序有助于预测 TRM 和 CR 率。这些资源可以帮助医生在为个别患者做出积极治疗的艰难决策过程中。克拉屈滨和低甲基化剂是合理的选择，可诱导不能接受标准蒽环类药物和阿糖胞苷诱导的患者获得 CR。尽管 CR 率令人鼓舞，但老年 AML 患者的中位生存期仍然较短（<12 个月）。即使那些达到 CR 的患者的长期生存也有限（3 年时约为 20%），除非进行同种异体造血细胞移植（alloHCT）。alloHCT 是可行的，在适当选择的患者中可以提供约 40%的 2 年生存率。尽管年龄增长与生存率降低相关，但合并症和体能状态较差比年龄本身具有更大的负面影响。CR 的持续时间较短，要求白血病和移植医生在诊断后立即合作，迅速转向 alloHCT。这种合作对于选择正确的患者进行移植以及在这个有时脆弱的人群中桥接缓解后治疗（中剂量阿糖胞苷、低甲基化剂或 FLT-3 抑制剂）也至关重要。未来的研究不仅应设计用于确定谁应该接受 alloHCT，还应提高我们对 AML 生物学和治愈过程的理解。
