Acute Leukaemia (ALL & AML)

Question 1

Name 2 acute & 2 chronic leukaemia’s & state whether they are primitive or less primitive

Answer 1

Acute myeloid leukaemia - primitive
Acute lymphoblastic leukaemia - primitive
Chronic myeloid leukaemia - primitive
Chronic lymphocytic leukaemia - less primitive

Question 2

What is an acute leukaemia

Answer 2

Clonal proliferative disorder of progenitor cells with blocked differentiation/ maturation. Defined by an excess of ‘blasts’ (>20%) in either peripheral blood or bone marrow

Question 3

AML vs ALL affected cells

Answer 3

AML - Proliferation of myeloid progenitor cell (myeloblasts)
ALL - Proliferation of lymphoid progenitor cell (lymphoblasts)

Question 4

What characterises acute leukaemia (AML/ALL)

Answer 4

Defined by an excess of ‘blasts’ (>20%) in either peripheral blood or bone marrow

Question 5

Is AML more common in younger or older people

Answer 5

Older age group (>60yrs)

Question 6

Is ALL more common in younger or older people

Answer 6

Younger age group (most common childhood cancer)

Question 7

Shared clinical characteristics (S&S) of both AML & ALL

Answer 7

Marrow failure (pancytopenia)
- anaemia (low RBCs)
- infections (neutropenia)
- bleeding (thrombopenia)

Question 8

What extra-medullary manifestations can occur in ALL

Answer 8

Lymphoblastic cells can migrate to areas outside of the marrow & blood, most commonly the CNS &/ testes.
Lymphoblastic cells can also gather in the blood and obstruct circulation.

Question 9

Summarise the typical clinical presentation of a patient with ALL

Answer 9

Young patient
Bone pain
Marrow failure (anaemia, neutropenia, thrombopenia)
Leukaemic effects (extra-medullary lymphoblasts - CNS…)

Question 10

Acute promyelocytic leukaemia is a subtype of AML and has a specific characteristic presentation. What is this?

Answer 10

Coagulation defect - DIC common

Question 11

Infiltration of what area of the body occurs in multiple subtypes of AML

Answer 11

Gum infiltration

Question 12

Summarise the typical clinical presentation of a patient with AML

Answer 12

Older patient
Marrow failure (anaemia, neutropenia, thrombopenia)
Subtype specific - coagulation defect/ DIC, gum infiltration

Question 13

Acute leukaemia investigations

Answer 13

1. Blood count & film (morphology)
2. Coagulation screen for DIC
3. Bone marrow aspirate (morphology)
4. Bone marrow aspirate (immunophenotyping)(ALL vs AML)

Other
- cyto/molecular genetics of aspirate (prognostic significance)
- trephine biopsy (if aspirate sub-optimal)

Question 14

Blood film findings of a patient from acute leukaemia

Answer 14

• WCC not always raised!
• possible pancytopenia
• presence of abnormal cells - blasts (>20%) = characteristic!
• Auer rod in AML

Question 15

What test is diagnostic of acute leukaemia?
What test must be used to differentiate between AML vs ALL?
What test(s) can be used to identify the specific cancer subgroup?

Answer 15

Acute leukaemia - Blood film or bone marrow (>20% blasts)
AML vs ALL - Bone marrow aspirate immunophenotyping
Subgroup - immunophenotyping or cyto/molecular genetics

Question 16

Acute lymphoblastic leukaemia management

Answer 16

Multi-agent chemotherapy - can least up to 2-3 years
- Different phases of treatment of varying intensity
- Targeted treatments in certain subtypes
- CNS-directed treatment
- Immunotherapy
- Hickman line for long-term central venous access

Question 17

Acute myeloid leukaemia management

Answer 17

• Multi-agent chemotherapy
  
  • Between 2-4 cycles of chemotherapy
  • Prolonged hospitalisation
  • Targeted treatments in subtypes
  • Hickman line for long-term central venous access

Question 18

Acute leukaemia supportive management

Answer 18

Blood products
Antibiotics (prophylaxis or for e.g. neutropenic fever)

Question 19

Patients with acute leukaemia are often neutropenic, what does this put them at risk of?

Answer 19

• Gram negative bacteria, fulminant life-threatening sepsis.
• Fungal infections
• Opportunistic infections e.g. PJP

Question 20

How would you treat neutropenic fever

Answer 20

Empirical treatment with broad spectrum antibiotics
Particularly covering gram negatives
Started as soon as fever starts, don’t wait for culture results

Question 21

What would make you suspect fungal infection (in a patient with acute leukaemia)

Answer 21

Prolonged neutropenia &
Resistant fever that is unresponsive to anti-bacterial agents

Question 22

Effects of leukaemia treatment

Answer 22

• N&V
• Hair loss
• Liver & renal dysfunction
• Tumour lysis syndrome (during first course of treatment)
• Infection (bacterial, fungal, opportunistic protozoal e.g. PJP)
• late effects e.g. infertility, cardiomyopathy

Question 23

Do all patients with acute leukaemia have excess blasts in their blood

Answer 23

No - excess blasts will always be in the bone marrow but not necessarily the blood

Question 24

Describe the morphology of a blast cell

Answer 24

High nucleur:cytoplasmic ratio
Smooth, open chromatin
Nucleoli