Dr. Pence - Leukemia And Lymphoma Case Studies Flashcards
66yo males comes in with anemia for 2 years Dx him with MDS which is ? Comes in with fever, tachy, HTN, petechiae, conjunctiva pallor bilaterally, bruising - low WBC - low plt - low hct - low hgb BS : 25% blasts, large nuclei = what is it and how to confirm
MDS : macrocytic anemia, pre-leukemic (only anemia sx)
AML , confirm with flow cytometry
MDS is what
Happens usually after 70yo, genetic mutation causes damage to hematopoietic cells = no hematopoiesis
- macrocytic
- pre-leukemic
ANC is what what does it mean
Absolute N count = (WBC) (N% + Band%)
Neutropenia = ANC < 1,500, severe Neutropenia = < 500
How to TX AML and neutropenic fever
- Get urine (1) and blood culture (2 different sites)
- CXR (for pneumonia)
- Begin ABs
- Confirm AML confirmed by BM biopsy
- Begin chemotherapy (treat AML), 2 weeks
What are them most common infection to get for a neutropenic fever
What is the most severe infection you can get
- Gram + staph or strep
2. Gram - pseudomonas,
How to TX for neutropenic fever
- Cefepime, Piperacillin-tazobactam, Meropenem, Ceftazidine (covers pseudomonas and gram +)
- Is line infection of soft tissue infection (think MRSA) and add Vancomycin
- If still not removed : it’s probably fungal so add anti-fungal (Amphotericin B, Voriconazole)
How to confirm AML
BM biopsy of at least 20% blasts
How to administer chemotherapy
Central line with 2 catheters and into the SVC that’s next to the RA + with abs
While on chemo for a while pt is still having a fever and you see the pt has a fungal
What do I need to do
Remove central line and replace it (since fungal is sticky) and then you give them anti-fungal + CSF(nupogen)
How to dx gram -, gram + fungal
Gram - : pink
Gram + : purple
Fungal : Silver stain
Induction
Consolidation
Maintenance
Meaning is chemotherapy
- chemotherapy given to get to remission
- intensified chemotherapy to make sure no cancer cells are left
- long term therapy or drug to prevent relapse (Stem cell transplant is only successful in younger populations and 20% of the time)
ALL is common in what populations
Children
ALL SX
Fatigue, anemia, bleeding, infection, cytopenia,
+ LYMPHADENOPATHY + SPLENOMEGALY (not seen in AML)
+ at least 20% Lymphoblastic found in BM
38yo mother of 2 children, Weakness, bruising, heavy menstruation
Tachy, purpura, conjunctiva pallor bilaterally
- low WBC
- LOW plt
- hct
- hgb
High PT, PTT, low fibrinogen, high D-dimer
BS : blasts with Auer rods in them
DIC (thrombin, bleeding, fibrin deposition—> ischemia and organ failure)
- usually in malignancy (blasts have more tissue factor) or sepsis
APL : 15:17 translocation a type of AML
Panocytopenia
Aplastic Anemia
AML/ALL
DIC
DIC TX
Right away as fast as you can give fluids and platelet transfusion, factor replacement (esp if you see Aure rods and suspect APL)
What does it usually mean when you see Auer rods
APL (15:17) a type of AML
APL/AML is what
- PML + RARa next to each other
- Need to give them RA that it will like
- has tissue factor and annexin on surface of cells
Tissue factor
Annexin2
TF : F10a —> F2a —> Fibrin
Annexin 2 : Plasmin —> D-diners from fibrinogen
What specific chemo do you give someone who has APL
ATRA : all-trash retinoic acid replaces the RA (VIT A derivative) = short lived
ATO : Arsenic trioxide (causes blasts to force differentiation or apoptosis) = longer lived
** give both
68yo F elderly women comes in saying she’s fatigues even though she’s had a cream cheese bagel and her stomach is full
10lb weight loss in 2mos, abd fullness, very fatigued
- moderate spelomegally
- EXTREME HIGH WBCs
- low hct
- mild low hgb
- plt normal
- normal MCV
- normal Retic count
- LOW Leukocyte Alkaline Phosphate
BS : all types of cells (mostly mature WBCs)
CML
LOW LAP : alkaline phosphatase + reactive cells (that are reacting to infection, autoimmune or stressed)
WBC : normal is 4-11
- 20-30
- Over 50
- Infection, autoimmune, stress
2. Leukemia (C-diph rip roaring infection)
What is LAP score
LOW LAP : alkaline phosphatase + reactive cells (that are reacting to infection, autoimmune or stressed) = probability uncontrolled overproduction reason
HIGH LAP : means infection, stress, autoimmune
Confirming CML
- BS : many mature WBCs
- High Buffy layer when continuing blood (CBC says high WBCs)
- Low LAP score
- Hypercellular BM
- Pseudo-Gaucher cells
- Philadelphia chr
CML has what type of anemia
Normocytic mild anemia
You can see high number of platelets
Reason for CML splenomegaly
Due to increased production happening extramedullary when BM cant keep up making right amount and good functioning WBCs
Pseudo-Gaucher cells
High blue M that clean up debri in CML
CML translocation
9:22
ABL-BCR
Philadelphia chr
Turns on tyrosine kinase
How to TX CML
Gleevec/Imatinib
Blocks TK
Testing for Philadelphia chr
- FISH fluorescent
- PCR : most sensitive (1 in 100,000) to find a 9:22 translocation
* flow cytometry is not that great
Special thing about CML
It has 3 stages
3 stages of CML
- Chronic CML phase : fatigue, asymptomatic, CBC has hgih WBCs
- Accelerated CML : 10-19% blasts circulating, low Plt,
- Plast phase CML : 20% higher blasts
Causes of Lymphadenopathy
M L malignancy I : infection A : autoimmune M : miscellaneous I : Iatrogenic (vaccination)
When to really looks into a lymphadenopathy
- older then 40yo
- Longer then 4-6 weeks
- More then 2 locations
- SUPRACLAVICULAR : everything drains to this so can be any organ or place
- Fever, night sweats, weight loss, heptatosplenomegally
* (Hard, 4cm or bigger, subclavian)* = DO BIOPSY
Tender Lymphadenopathy
Usually benign , HOWEVER
**However Burkitts and DLBCL (rapid growth of LN = Very tender) and very aggressive
FINE NEEDLE BIPOSY
Not that great
Only good if you know exactly what you’re looking for (past patient
(Marker detection in flow cytometry)
Core needle biopsy
Good way to do a biopsy and then look at cells under microscope and see what is happening in the BM
Excisional biopsy
GOLD STANDARD
Best way to Dx lymphoma (** only way to dx Hodgkin lymphoma and see the owl cells)
Take entire LN out , full picture of the LN
14yo F with abd pain in ER
CT : large abd mass next to appendix
- after 2 days of Abs the mass grew by 50%
- she went to surgery
- a bunch of cells in on of the LNs that looks like a starry night
What is it
Burkitts Lymphoma
- Ruptured appendix = provide Ab and IV
- appendix has many LN
Burkitt lymphoma translocation
8:14
IgH/MYC
Very aggressive
Burkitt Lymphoma TX
High risk of intracranial involvement
1. Chemotherapy + chemotherapy with intrathecal into CSF
(Easy to tx since its fast growing and you target all fast growing cells, however it has room for many complications)
Female with Burkitts lymphoma tx with chemotherapy has stoped making urine
- BUN and Cr are very high : kidney failure or down
What’s happened
Tumor Lysis Syndrome
Tumor Lysis Syndrome what 4 things happen in
- High K = arrhythmia (sudden cardiac death)
- High Uremic acid (nucleuic acids from cells become uremic acid crystals and acute tubular necrosis)
- High P (binds to free Ca+2 and hides them)
- LOW Ca+2
Tumor Lysis Syndrome happens when
With rapid killing of tumor cells that are fast growing (there contents spill out)
- DLBCL
- Hodgkin
- Burkitts
How to TX TLS
Give fluids before chemotherapy (flushing kidneys constantly)**
ALLOPURINOL : xanthine oxidase inhibitor (no uric acid)
TX hyperkalemia
Furosemide/LASIX (pee it out)
- give glucose/insulin to help since this takes time
- if that doesn’t work dialysis
TX hyperuricemia
Rasburicase (allows urate oxidase to happen from uric acid neutralizing it)
** can cause hemolytic anemia in G6PD patients** KNOW THAT**
TX Hyperphosphatemia or hypocalemia
Calcium Gluconate
22yo male home from college and fatigues easily CP when drinking alcohol
Night sweats, fever, jocks itch
PE : 10lb last, no lymphadenopathy or splenomegally
What should I order :???? Nd what do I SEE????
What biopsy ??? And what should you see
CXR : mediastinal widening (unable to see aortic arch ) Excisional biopsy (owl cells, and t-cells all around it) Hodgkin lymphoma (with B sx)
Hodgkin Lymphoma is what type of lymphoma
Highly inflammatory Has 4 stages 1. Neck 2. Axillar 3. Below liver 4. Many parts involved
Hodgkin lymphoma TX
21-28days chemotherapy
Hodgkin Lymphoma likes hiding where
Mediastinum
Elderly male, petechiae, fatigue, conjunctiva pallor bilaterally, axillary and cervical Lymphadenopathy - high WBCs - high plt - high hgb BS: many mature lymphocytes (90%) WHAT DOES HE HAVE - he was already DX with this years ago and was told not to worry about it WHAT DOES HE HAVE NOW
BS : monoclonal B-cells
CLL (+ thrombocytopenia and anemia)
Richters Transformation (due to thrombocytopenia and anemia)——> IT BECAME DLBCL
Richters Transformation
CLL ——> DLBCL or another small grade lymphoma to high grade lymphoma
CLL with Richters Transformation TX
Chemotherapy + RITUXIMAB = CD20 inhibitor (better outcome the more fit and healthy the patient is)
= treat the DLBCL
How to monitor CLL
Look for B SXs to see if there is a possibility of a Richters Transformation to DLBCL or another HGIH grade lymphoma
What can be more effective then Rituximab
CD19 targeting drug since that is absolutely all B-cells from the stem cells
