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Therapeutics > Adult Leukemia > Flashcards

Adult Leukemia Flashcards

1
Q

Objectives

A

Describe commons signs/symptoms of acute leukemia
Define complete response following induction therapy
Identify specific dose-limiting toxicities for common chemotherapy agents used in the treatment of leukemias
Be able to identify clinical factors (hepatic, renal) that require dose-modifications for common chemotherapy agents used in the treatment of leukemias
Differentiate between autologous and allogeneic hematopoietic stem cell (bone marrow transplants) in terms of the source of donated cells
Define induction, consolidation, and maintenance in the context of chemotherapy regimens.

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2
Q

what two cell lines are implicated in the types of leukemias that can present?

A

Myeloid progenitor cells

Lymphoic cells

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3
Q

What does lymphoid progenitor cells lead to the creation of ?

A

B and T cells

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4
Q

what do myeloid progenitors lead to?

A

granulocytes
monocytes
megakaryocytes
erythrocytes

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5
Q

what are the four types of leukemia?

A

Acute lymphocytic leukemia ALL
acute myelogenous leukemia AML
chronic lymphocytic leukemia CLL
chronic myelogenous leukemia CML

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6
Q

what kinds of general treatment strategies are available for leukemia?

A

chemontherapy
no surgery
possible radiation

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7
Q

what is the difference between De-Novo vs secondary leukemia?

A

de novo means that we don’t know the cause and is generally less agressive than secondary
Secondary: we know the cause.
-radiation, chemical, chemotherapy exposure etc.
-generally more aggressive if due to chemotherapy

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8
Q

what is the main pathophysiology of leukemias?

A

mutations and disruptions of normal bone marrow function or bone marrow failure

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9
Q

what are the signs and symptoms oaf acute leukemias?

A

anemia: fatigue, weakness, pallor
thrombocytopenia: bleeding, bruising
neutropenia: infections
hyperleukocytosis: compromised circulation
splenamegaly, lympahdenopathy

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10
Q

how do you diagnose leukemia?

A 
perform a blood smear : CBC
perform a bone marrow biopsy 
cytogenetics
flow cytometry
lumbar puncture
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11
Q

what is the purpose of the biopsy?

A

to tell you what kind of leukemia the patient has

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12
Q

what is the purpose of the cytogentietcs and flow cytometry?

A

analyzing the chromosomes and studying the genetic makeup (mutations) of each of the cancers. This will allow you to tailor therapy and tell you about prognosis

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13
Q

what is the purpose of lumbar puncture?

A

to see if any of the cancer in the CNS hiding. generally harder to treat if there are some cells there, and should be more agressive with therapy.

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14
Q

in the CBC, what are they looking for that tells you it is leukemia?

A

blast looking cells and increasing WBC

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15
Q

why dont parents get used for HLA matching for bone marrow transplants?

A

because they cannot be 100% matches since they gave 50% of their genes to their children

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16
Q

which patients are candidates of standard-dose chemotherapy?

A

patients iwth favorable prognosiis

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17
Q

which patietns are candidates for radiation therpay?

A

for when the disease site is hard to be reached by chemotherapy

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18
Q

what is high dose chemotherapy wit h autologous stem cell rescue?

A

Auto BMT.
the patient will be given high doses of chemo. They then remove progenitor cells from the bone marrow. Then they will put back the bone marrow progenitor cells of the patient as a rescue.

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19
Q

what is an allogeneic bone marrow translplant or stem cell transplant?

A

IT is where they shut down the patients bone marrow but instead use someone else’s healthy donor cells from the bone marrow

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20
Q

what dues ALL stand for?

A

acute lymphocytic leukemia

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21
Q

what is the standard treatment plan of chemotherapy for ALL?

A
  1. induction: induce remission
  2. consolidation: cytoreduce remaining leukemic cells
  3. CNS prophylaxis: CNS can be sanctuary site
  4. Maintenance of remission
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22
Q

what is the definition of complete remission?

A

no leukemic cell
normall cell counts
no estramedullary disease
less than 5% blasts in the marrow

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23
Q

why use comibination chemo therapy?

A

different MOA
Cell cycle specificity
lower doses of each drug
lower risk of drug resistance

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24
Q

What is linker’s regimen induction for ALL?

A

it is induction therapy that invovles givving methotrexate IT at time of diagnostic lumbar puncture, daunorubicin IV, vincrisitine IV, high dose dexamethasone (18mg/m2), asparaginase. Patients need to stay in the hospital for 1 month. After that, they need 7-10 day of break then they start consolidation

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25
Q

what is involved in consolidation therapy 1B?

A

etoposide IV x 4 days and high dose cytarabine IV x 4 days. Then patient is in the hospital for a month. Given 7- 10 days break then starts 1 c.

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26
Q

what is involved in consolidation therpyp (linker’s) 1C ?

A

pt given high dose methotrexate iv infusion, leuocovorin IV rescue, daily po mercaptopurine. Patient is given a total of 2 methotrexated courses separated by 2 weeks. Total IC duration is one month

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27
Q

what is the consolidation schedule?

A

1A, 1B, 1C, IIA, IIB, IIC (4 courses of MTX instead of 2= 2 months)

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28
Q

what is the maintenance schedule for linker’s regimen/

A

daily oral mercaptopurine and weekly oral methotrexate after the completion of all IV chemotherapy (total chemo takes ~2 years)

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29
Q

what is the CNS prophylaxis dosing?

A

methotrhexated 12mg IT q week x 6 doses. first dose can be given at beginning of induciton therpay

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30
Q

what is the CNS Treatement dosing ?

A

methotrexated 12mt IT q week x 10 doseis with cranial radiation after consolidation IB

31
Q

what are the general side effects of agents that mess with DNA or RNA synthesis?

A

myelosupression, mucositis, alopecia

32
Q

what is the mechanism of aciton of the anthrayclines?

A

inhibition of topoisomerase II

33
Q

what are the class tocxicities and specific tosxicities of daunorubicin?

A

Class: myelosuppression, mucositis, alopecia
cardiomyopathy
Specific: vesicant: prefer centrla line
red urine, adjust dose for hepatic impairment

34
Q

what labs are required before starting the patient on daunorubicin?

A

ECHO

hepatic function

35
Q

what should you do if the patient sees red urine?

A

there is nothing to do except tell the patient to expect it and that it is not harmful.

36
Q

what if a central line cathether is not available?

A

nurses can pus medication peripherally in patient but should do it slowly and w/ awarness of damage to tissue

37
Q

what is the mechanism of action of the vincrisitine?

A

vinca alkaloids inhibit microtubules in the M phase.

38
Q

what are the side effects to expect with vincrisitne?

A

nuerotoxicity ( peripheral neuropathy)
ileus, constipation
vesicant

39
Q

which route should your never give vincristine through?

A

Intrathecally: FATAL

40
Q

renal or hepatic adjustment for vincristine?

A

hepatic adjustment

41
Q

what is the equivalence of dexamethasone and prednisone?

A

4mg dex = 30mg prednisone

42
Q

what are the immediate side effects of dexamethasone?

A 
depression/psychosis
insomnia
GI bleed
hyperglycemia
 adrenal supression 
opportunistic infections
43
Q

what is the mechanism of aciton of asparaginase?

A

deprives tumor cells of asparagine for protein synthesis

44
Q

what are the side effects of aspargianse?

A 
hypersensitivty rxn : watch x 2 hours 
hepatoxicity
coagulaopathy : depleting clottign factors
pancreatic dysfxn: pancreatitis
hyperglycemia
45
Q

what labs should you monitor for aspariginase?

A

LFTs
INR
blodo sugar

46
Q

what is the MOA of etoposide?

A

topoisomerase II inhibition

47
Q

main side effects for etoposide?

A

classs: muchositis, alopecial, meylousuppression
hypotension, fever, metabolic acidosis (only with high dose which is not used for ALL)
can be irritatn

48
Q

renal or hepatic adjustment?

A

renal if < 50ml/min dec dose by 25%

49
Q

what is the brand name of cytarabine?

A

Ara-C

50
Q

what is the MOA of cytarabine?

A

pyrimidine analogue inhibits DNA synthesis

51
Q

main side effects of cytarabine

A 
myelosuppression 
fever , rash
conjunctivitis if high dose Ara-C.  
skin toxicity
CNS toxicity at >200mg/m2/day high dose
52
Q

what do you do about the conjunctivitis caused by high dose Ara C ?

A

use steroid eye drops: fluromethalone or dexamehtasone 0.1% 1-2 drops both eyes till 48 hrs after completion of Ara-C

53
Q

what to do about skin toxicity with Ara-C

A

showers BID otherwise pt will get a chemical burn

54
Q

what is the MOA of MTX?

A

dihydrofolate reductase inhbitor

55
Q

side effects of MTX?

A

myelosupression, mucositis dose related
can cause renal failure
CNS effects > wit hIT MTX

56
Q

renal or hepatic dose adjustment for MTX?

A

renal, can cause renal failure

57
Q

when is leucovorin rescue for MTX mandatory?

A

when using high-dose MTX > 200mg/m2

58
Q

what is mandatory for high dose MTX?

A

leucovoin rescue

hydration and alkalization of urine

59
Q

what isth e MOA of 6-MP

A

antimetabolite: purine analoge

60
Q

what are the SEs with 6MP ?

A

myelosuppression: leukopenia is dose limiting toxicity

cholestatis (inc in LFTs)

61
Q

renal or hepatic adjustement in 6MP

A

hepatic

62
Q

what is the supportive care for ALL?

A

tumor lysis prophylaxis w/ allopurinol + agressive hydration or rasburicase
-PCP prophylaxi
-growth factors and antibiotics for febrile neutropenia
antiemetics during chemo
-transfusion ofr anemia, thrombocytopenia

63
Q

what is acute myeloid leukemia?

A

leukemia of the granulocytes, monocytes, erythrocytes, and platelets

64
Q

what is the UCSF method to treating AML?

A

induction therapy
consolidation and autologous stem cell collection
high dose chemo w/ atologous stem cell rescue

65
Q

what is induction therpy for AML? UCSF

A

high does cytarabine x 6 days

daunorubicin x 3 days

66
Q

what is AML consolidation?

A

high dose cytarabine x 4 days
etoposide continuous infusio nx 4 days (not high dose)
high dose G-CSF

67
Q

what is given for the autologous stem cell transplant?

A 
busulfan x 4 days 
high dose etoposided of the fift day
rest x 2 days 
autologsous stem cell infusion on seventh day
palifarin q x 3 pre-chemo
68
Q

What is the MOA of busulfan?

A

it is an alkylating agent

69
Q

what are the SE s of busulfan?

A

myelosuppression, mucositis
skin pigmentation
veno occlusive disease

70
Q

what is the purpose of autologous bone marrow transplant?

A

to rescue the lethal side effect of high-dose

71
Q

what agent is used to treat AML-M3 ?

A

tretinoin =ATRA

72
Q

what is the MOA of tretinoin?

A

it binds to the chimeric gene product of a translocation that has occurred in the cancer cell on chormosome 15. this causes the leukemic clone to mature and undergo apoptosis

73
Q

what is ATRA Syndrome?

A 
= dirfferentiation syndrome 
-SOB,
-pleural effusions
 fever
 peripheral edema

Therapeutics (23 decks)

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