305. Leukeamia

Question 1

How do you approach a leukeamic patient that feels unwell?

Answer 1

Take seriously, can deteriorate quickly

Bloo dcultures, FBC, U&E’s, LFt’s, Ca2+, glucose and clotting

Consider CNS bleeding

Discuss with patient aims of treatment

Question 2

What neutropenic regimen should they abide by when in hospital?

Answer 2

Full barrier nursing

Avoid IM injections

Look for infection (mouth, axillae, perineum, IVI site)

Check FBC, platelets, INR, U&E, LFT, LDH,CRP, cultures, CXR

Wash perineum after defication

Oral hygiene (mouthwash every 2 hours)

Check vital signs 4 hourly

Question 3

How do you use antibiotcs in those who are neutropenic

Answer 3

If fever then give piperacillin tazobactam and vancomycin

If fever persists despite antibiotics consider CMV or Fungi

Question 4

What is tumour lysis syndrome?

Answer 4

Results in a high potassium, high urate and AKI. Low calcium

Question 5

What is Hyperviscocity in those with leukaemia?

Answer 5

WCC can exceed 100 leading to thrombi forming in the brain, lung and heart.

Lower WBC with hydroxycarbamide or leukapheresis

Question 6

What is DIC

Answer 6

Release of pro coagulants into the circulation causes widespread activation of coagulation consuming factors

Fibrin strands fill small vessels

Question 7

What are the causes of DIC

What are the signs of DIC

Answer 7

Malignancy, Sepsis, Trauma, obstetric events

Bruising, bleeding, renal failure

Question 8

What are the tests for DIC

Answer 8

Plateltes, prthrombin time, APTT, decreased fibronogen. Increase of fibrin

Schisctocytes

Question 9

How is DIC treated?

Answer 9

Treat the cause

Replace platelets if <50.

Cryoprecipitate

Question 10

How should sepsis be prevented in those with neutropenia?

Answer 10

Can give fluoroquinolone before neutropenia gets serious

Granulocyte colony stimulators can increase production of WBC

Herpes,pneumocystis and CMV prophylaxis has a role

Question 11

What are the four main classes of leukemia?

Answer 11

Acute lymphoid luekemia- affects young and under 40’s

Acute myeloid leukemia-high mortality

Chronic myeloid leukemia- three stages

Chronic lyphoblastic leukemia- most common

Question 12

What is acute myeloid leukemia?

Answer 12

A malignancy of lymphoid cells affecting B or T lymphocytes causing uncontrolled maturation of blast cells

Question 13

What are the important associations with acute lymphoid leukemia?

Answer 13

Ionizing radiation dueing pregnancy

Down’s syndrome

Question 14

What are the signs of Acute lymphoblastic leukemia?

Answer 14

Marrow failure- pancytopenia

Infilatration- hepato/splenomegaly, lymphadenopathy, CNS, Orchidomegaly

Question 15

What are common infections that those with ALL might encounter?

Answer 15

Chest, mouth, perineum and skin

Bacterial septicaemia

Zoster

CMV

measles

Candidiasis

Pnemocystis pneumonia

Question 16

What tests are undertaken in ALL?

Answer 16

Blast cells seen on blood film

CXR and CT scan for mediastinal and abnormal lymphadenopathy

Lumbar puncture for CNS involvement

Question 17

What support can you give to those with ALL?

Answer 17

Blood/platelet transfusions

IV fluids

Allopurinol

Subcutanous port/hickman line

Question 18

Discuss the treatment for ALL?

Answer 18

4 chemotherapy stages:

Remission inducing
Consolidation
CNS prophylaxis
Maintenance

Matched related allogenic marrow transplantation

Question 19

What indicates a poor prognosis in ALL?

Answer 19

Adult, male

Philadelphia chromosome (chromosomes 9 and 22)

Presentation with CNS signs

low Hb, low WCC

Question 20

What is chronic myeloid leukemia?

Answer 20

Uncontrolled proliferation of myeloid cells.

Occurs mainly in those 40-60

Question 21

What is different about CML and ALL with regards to genetic

Answer 21

Those with the Philadelphia chromosome do better in CML

Question 22

What are the stages of chronic myeloid leukemia?

Answer 22

Chronic phase- lasts months or years, hardly any symptoms-30% detected by chance

Accelerated phase- increasing symptoms of spleen size and difficulty controlling counts

Blast transformation features of acute leukemia and death

Question 23

What are the signs and symptoms of CML?

Answer 23

Weight loss
Tiredness
Fever 
Sweats
gout
splenomegaly
hepatomegaly
bruising
anaemia

Question 24

What are the tests involved in chronic myeloid leukemia?

Answer 24

Increased white blood cells

Increased spectrum of myeloid cells- increased neutrophils, monocytes, basophils, eosinophils

Increased urate and b12

Hypercellular bone marrow

Question 25

How is CML treated?

Answer 25

Imatinib, specifically targeted biologic to BCR-ABL

2nd generation bcr-abl drugs e.g. dasatinib and nilotib

Similar treatment to ALL, chemo (doesn’t have good outcomes), allogenic transplant (better in younger patients)