Acute leukaemias

Question 1

What are acute leukaemias? acute leukaemias exist?

Answer 1

20% or more blasts in either peripheral tissue or bone marrow
-rapidly progressing clonal malignancy and maturation defect(s) and decrease or loss of haemopoeitic reserve

Acute myeloid leukaemia - AML (acute cancer of RBCs and WBCs)

Acute lymphoblastic leukaemia (acute cancer of lymphocyte progenitors)

Question 2

What age does AML vs ALL affect?

Answer 2

AML - disease of the elderly

ALL - most common childhood cancer

Question 3

How does AML and ALL present?

Answer 3

Similarly - due to marrow failure:

• anaemia
• infection
• bone pain (as a result of marrow infiltration)
• bleeding and bruising

Question 4

What is seen on the examination of AML

Answer 4

• Pallor
• Fever due to infection
• petechiae
• violaceous skin lesions

Question 5

what is seen on the examination in ALL

Answer 5

• pallor
• fever due to infection
• petechiae
• lymphadenopathy
• hepatosplenomegaly
• testicular enlargement
• rarely CN palsies

Question 6

What is seen on the FBC and in AML and ALL

Answer 6

low Hb, High WCC, Decreased platelets

Question 7

What is seen on the blood film in AML and ALL?

Answer 7

Blast cell nearly always seen on both

Auer rods - pathognomonic for AML

Large blast cells more likely to be seen in ALL

Question 8

What is seen on bone marrow aspirate for AML and ALL?

Answer 8

decrease in erythropoeisis
decrease in megakaryocytes
>20% blast cell but may reach 100%

Question 9

What is done after the bone marrow aspirate to make a definitive diagnoses of acute leukaemia?

Answer 9

Immunophenotyping:

-lineage of tumour i.e. myeloid or lymphoid found as they cells will express lineage assoc. proteins

Question 10

What other two tests apart from FBC/Film/bone marrow aspirate can be used to investigate acute leukaemias?

Answer 10

Cytogenetics - look at chromosome numbers and translocations

Trephine (piece of bone) to assess cellularity when aspirate = suboptimal

Question 11

How are acute leukaemias managed generally 5?

Answer 11

Supportive care
Multiagent chemotherapy
Allogeneic stem cell transplantation
targetted treatments

(hickman line is used to give chemo and take blood samples)

Question 12

Describe what is meant by supportive care in acute leukaemia?

Answer 12

Reducing symptoms of anaemia

Prevention/control of bleeding

Treatment of infection

Question 13

what are the disadvantages of chemotherapy when treating acute leukaemias? 4

Answer 13

Bone marrow suppression

1: anaemia
2: neutropenia (can get neutropenic sepsis with gram -ve infections)
3: thrombocytopenia so need platelet transfusions

4: others
- tumour lysis syndrome (can cause renal failure)
- hair/fertility
- N+V
- late effects e.g. cardiac with anthracycline

Question 14

Neutropenic sepsis:

• how is this treated?
• what different organisms can cause this and how is this distinguished or managed?

Answer 14

Neutropenia and sepsis and <6SEWS - piperacillin and tazobactam

Neutropenia and sepsis and >6SEWS/acute leukaemia/allogeneic transplant - piperacillin and tazobactam and gentamicin

• Bacterial organisms
• Fungal organisms: if prolonged neutropenia and fever unresponsive to abiotics
• protozoal: give prophylaxis for PCP

Question 15

What is the cure rate in general for chemotherapy in acute leukaemia?
What makes failure of treatment more likely?

Answer 15

Childhood ALL >85-90%
Adult ALL 30-40%
Adult AML <60years 40-50%, >60years 10% or less

Failure of treatment is more likely with a high blast count or with a T(9:22) translocation

Question 16

What is allogeneic transplantation of stem cells? when is this considered?

Answer 16

donor stem cell transplantation

• potentially curative in minority and can be used after initial therapy
• in others it’s considered at relapse