3 - Leukemias Flashcards by Samuel Halajian

What is leukemia?

Malignancy of hematopoietic progenitor cell -> uncontrollable proliferation and marrow replacement

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Acute phase

Blasts > 20 percent

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Chronic phase

Blasts < 20 percent

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Effects of too many blasts

Bone marrow “replacement”

Solid organ infiltration

Coagulation activation

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Etiologies of AML

Radiation
Prior chemo
Marrow toxic drugs
Benzene
Pre-existing d/o’s

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Clinical approach to leukemia

Myeloid or lymphoid?

Myeloid - myeloproliferative d/o’s

Lymphoid - lymphomas

Acute or chronic?

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Median age of AML

60 yrs

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Peak age of ALL

3 to 7 yrs

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80% of adult acute leukemia is which type?

AML

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80% of acute leukemias of childhood are which type?

ALL

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BLUF for ages in acute leukemia

Myelogenous - adults

Lymphoblatic - kids

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Sxs of acute leukemias

Fatigue
Anorexia
Weight loss
Fever 
SOB
Bleeding

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Which acute leukemia associated with DIC?

Acute promyelocytic leukemia

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Infection risks in acute leukemia?

Due to decreased neutrophils

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PE for acute leukemias

Pallor
Petechiae
Bone / joint pain
Gingival hypertrophy due to leukemic infiltration 
Hepatosplenomegaly 
Lymphadenopathy (ALL)

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Sxs of hyper-leukocytosis (WBC >100K)

Impaired circulation
HA
Confusion
Dyspnea

Urgent txt - leukapheresis and chemo

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Definitive dx of acute leukemia>

Bone marrow bx

Labs for acute leukemias

CBC - pancytopenia
Variable WBC’s
Anemia, typically severe
Decreased platelets

Smear for ALL

Lymphoblasts

Smear for AML

Myeloblasts

Auer rod (eosinophilic, rod-shaped granule) - think:

AML

W/u for acute leukemias

Bone marrow bx ASAP (distinguish ALL vs AML)

AML = relative emergency

REFER to HEME-ONC

CNS involvement common in which acute leukemia?

ALL

Perform LP

First step in txt of acute leukemia?

Induction chemo with goal of complete remission

What does remission look like?

Normal peripheral blood, normal bone marrow (decreased blast to no blast), normal clinical status (disappearance of all signs and sxs)

Induction

Implies induction of remission - very aggressive chemotherapy in order destroy visible leukemic cells but doesn’t always lead to cure

Post-remission therapy

Under control, now cure it Standard chemo, stem cell transplant

CNS prophylaxis?

Done with ALL - intrathecal chemo with or without cranial irradiation

Prognosis for acute leukemia?

Cure rate • Under 60 years: post-remission chemo leads to cure of 35-40% of patients • Under 60 years and allogeneic bone marrow transplant: curative 50-60% of patients • Cure rates for older patients approx 10-15%

Median age of CML?

55 yrs

Features of CML

Philadelphia chromosome Bcr/abl Fatigue / splenomegaly / bone pain +++WBC in chronic phase May progress to accelerated or blast phase Imatinib = 1st line txt

CLL

Chronic lymphocytic leukemia Replication of a malignant clone of mature B cell leading to progressive accumulation of immune- incompetent lymphocyte • Inadequate antibody production from abnormal B cells

MC leukemia in adults in western countries>

CLL MC’ly found in older guys (70 yrs)

Sxs of CLL

Painless swollen cervical lymph nodes that wax and wane Fatigue Some asymptomatic CBC - absolute lymphocytosis

MC finding in CLL

Lymphadenopathy Usually cervical, supraclavicular, axillary Firm, round, freely mobile, nontender

Hallmark of CLL

Isolated lymphocytosis (absolute count >5k)

Smudge cells, think:

CLL

Txt for CLL

If early, asymptomatic - observe If advanced (progressive fatigue, anemia, thrombocytopenia, symptomatic lymphadenopathy, repeat infections) - treat -> chemo, rituximab, bone marrow transplant (tailored to patient)

Richter’s transformation?

75 y/o dude with CLL, suddenly loses weight night sweats, aggressive diffuse large b-cell non-Hodgkin lymphoma 5-8 month median survival

Why couldn’t Chloe comb her hair?

She had leukemia