Acute Lymphoblastic Leukemia (B-cell) Flashcards
immunophenotypic categories of ALL
B-precursor ALL
B-precursor with myeloid features
Mature B cell
T-cell
signs/symptoms
painless lymphadenopathy, HSM, painless testicular swelling, constitutional symptoms (fever, fatigue), bruising/bleeding, leukostasis, TLS, mediastinal mass, MSK pain
Variables predicting clinical course of ALL
age, immunophenotype, WBC count, genetic aberrations, CNS involvement, response to therapy
General treatment approach of patients less than 70 without major comorbidities who are Ph+
induction chemo + TKI’s –> If Cr is achieved, pt undergoes ASCT in first remission followed by consideration for use of maintenance TKI for period of time following allogeneic transplant
Treatment for ALL in general
Combination chemotherapy
hyper-CVAD regimen
cyclophosphamide, vincristine, doxorubicin (also known by its trade name, Adriamycin), and dexamethasone.
General treatment strategy for PH + ALL
Induction with multiagent chemotherapy -and TKI –> once first CR achieved, find HLA matched sibling –> consolidation with allogeneic stem cell transplant
Treatment in general for PH+
Multi agent chemotherapy and a BCR/ABL TKI
Major branch point in ALL
Presence of philadelphia chromosome (Philadelphia negative or positive ALL)
Why is leucovorin given with MTX?
Chemoprotectant – since MTX depletes folic acid in cells, it also targets non-cancerous cells, so leucovorin (reduced folinic acid) is added as a rescue agent 24 hours after methotrexate is given
Why do you need to draw MTX levels on a regular basis?
At a specified level, it is safe to stop leucovorin administration
WBC count in b-cell ALL
Anything – May be decreased, normal, or very high
Clinical course
Variable – can be indolent or aggressive
Diagnosis in general
- Detection of lymphoblasts with characteristic immunophenotype by flow cytometry/IHC
Essential characteristic of B-ALL on flow cytometry
Expression of B cell antigens + absence of T cell antigens
What is an immunophenotype?
Antigens or markers expressed on cell surface
Characteristic b cell antigens
CD19, 22, 79
Prognostic importance of philadelphia chromosome?
Used to be considered bad, but don’t really know now that TKI’s are available
Term for quantifying remaining burden of leukemia cells after induction therapy
MRD – measurable or minimal residual disease)
Preferred induction therapy regimen
No agreed upon standard, center specific. None have been directly compared in prospective RCTs.
Most chemo regimens for ALL contain….
Vincristine
steroid
anthracycline
*rituxan if CD20 positive
Prognosis
- Most achieve CR after induction chemo
Definition of CR in ALL
Less than 5% blasts from bone marrow and blood + restoration of normal hematopoiesis
Better marker for prognosis than CR
MRD