Haem VI (Leukaemias) Flashcards
1
Q
What is the treatment of choice for chronic myeloid leukaemia? [1]
A
Imatinib
2
Q
A
CLL
3
Q
A
Anaemia
4
Q
A
ALL
5
Q
A
CML
6
Q
A
CLL
7
Q
A
BCR-ABL fusion protein
The Philadelphia chromosome is present in more than 95% of patients with chronic myeloid leukaemia (CML). It is due to a translocation between the long arm of chromosome 9 and 22 - t(9:22)(q34; q11). This results in part of the ABL proto-oncogene from chromosome 9 being fused with the BCR gene from chromosome 22. The resulting BCR-ABL gene codes for a fusion protein that has tyrosine kinase activity in excess of normal.
8
Q
A
t(9:22)
9
Q
A
Decreased leukocyte alkaline phosphatase
10
Q
A
CML
11
Q
A
inhibitor of the tyrosine kinase associated with the BCR-ABL defect
12
Q
A
hypogammaglobulinaemia
13
Q
What is the first line therapy for patients with CML?
Hydroxyurea
FCR
Imatinib
R-CHOP
Ibrutinib
A
What is the first line therapy for patients with CML?
Hydroxyurea
FCR
Imatinib
R-CHOP
Ibrutinib
14
Q
Which of the following is used in NHL?
FOLFOX
FOLFIRI
FOLFIRINOX
ABVD
R-CHOP
A
R-CHOP
15
Q
Which of the following is used in HL?
FOLFOX
FOLFIRI
FOLFIRINOX
ABVD
R-CHOP
A
Which of the following is used in HL?
FOLFOX
FOLFIRI
FOLFIRINOX
ABVD
R-CHOP
16
Q
A 55 yr old is having chemotherapy for her NHL.
Days after treatment, she notices blood in her urine.
Which treatment is most likely to have caused this?
Doxorubicin
Vincristine
Cyclophosphomide
Cisplatin
Bleomcyin
A
A 55 yr old is having chemotherapy for her NHL.
Days after treatment, she notices blood in her urine.
Which treatment is most likely to have caused this?
Doxorubicin
Vincristine
Cyclophosphomide - causes haemorrhagic cystitis
Cisplatin
Bleomcyin
17
Q
A patient is diagnosed with CML
What is the first line treatment?
- Infliximab
- Imatinib
- Vincristine
- Ritixumab
A
A patient is diagnosed with CML
What is the first line treatment?
- Infliximab
- Imatinib - Vincristine
- Ritixumab
18
Q
A
19
Q
A
20
Q
A
21
Q
What are the common genetic alterations seen in CLL?
A
- most common genetic change is the deletion in chromosome 13
- TP53 mutation
- Trisomy 12: presence of an extra 12th chromosome
- Overexpression of BCL2 proto-oncogene: suppresses programmed cell death (i.e. increases cell survival)
22
Q
Describe the natural history of CLL
A
- An initial inciting event or abnormal reaction to an antigen stimulus leads to genetic alterations that allow the formation of a clone of B lymphocytes
- This is a premalignant disorder, which is referred to as monoclonal B cell lymphocytosis (MBL).
- Overtime, further genetic mutations and bone marrow microenvironment changes promote the progression to CLL. This transformation from MBL to CLL occurs at a rate of 1% per year.
- A proportion of patients who develop CLL may remain asymptomatic for many years. However, others may get rapidly progressive disease with complications associated with the defective immune function including cytopaenias and hypogammaglobulinaemia (i.e. low antibody levels).
The symptomatic stage of CLL is characterised by progressive lymphadenopathy, which includes splenomegaly and hepatomegaly, that occurs due to the accumulation of incompetent lymphocytes.
23
Q
The hallmark feature of CLL is [] due to the infiltration of []
A
The hallmark feature of CLL is lymphadenopathy due to the infiltration of malignant B lymphocytes.
- symmetrically enlarged lymph nodes in the neck, armpits or groin which is seen in more than 80% of patients at the time of diagnosis
24
Q
What are the features associated with complications of CLL?
A
Autoimmune haemolytic anaemia: pallor, dyspnoea, weakness, dizziness
Immune thrombocytopaenia: petechiae, bruising, mucosal bleeding
Hypogammaglobulinaemia: recurrent infections (organ specific)
25
What would indicate that CLL may be active in a patient? [3]
**The onset of the classic “B symptoms” is a sign that the CLL may be active**. The symptoms include:
* Frequent, severe night sweats
* Unexplained weight loss >10% of body weight in the previous 6 months
* High fever in the absence of any infections (>38°C)
26
Describe how you would investigate for CLL [4]
**FBC**:
- **Presence of excess lymphocytes** on full blood count that are found to be clonal
**PBS**:
- indicated to confirm lymphocytosis
- presence of **smudge cells** *artefacts from lymphocytes damaged during the slide preparation because of the fragile nature of these cells.*
**Immunophenotyping**:
- shows the characteristic clonal B lymphocytes expressing **CD5 and CD23 antigens.**
- detect **deletion of TP53 gene**
27
Describe the staging criteria for CLL (there are two)
**Binet staging** - used more in the UK
* **Stage A**: < 3 lymphoid sites
* **Stage B**: ≥ 3 lymphoid sites
* **Stage C**: presence of anaemia ( < 100 g/L) and/or thrombocytopaenia (< 100 x10^9/L)
**Rai staging**
* **Stage 0 (lymphocytosis)**: 25% at initial diagnosis
* **Stage I-II** (lymphocytosis + lymphadenopathy + organomegaly): 50% at initial diagnosis
* **Stage III-IV** (lymphocytosis + anaemia or thrombocytopaenia +/- lymphadenopathy/ organomegaly): 25% at initial diagnosis
28
Why might you perfom a Direct antiglobulin test (coombs test) with a query CLL patient? [1]
It should be done in all anaemic patients and before commencing therapy to **identify autoimmune-related haemolytic anaemias.**
29
What does NICE recomennd for CLL patients who are **previously untreated and without TP53 mutations** [3]
**Fludarabine, cyclophosphamide and rituximab (FCR)**
30
What is the treatment advised by NICE for the first-line treatment of CLL (Binet stage B or C) in patients for whom FCR chemotherapy is not appropriate? [1]
Chemotherapy with **bendamustine** is advised by NICE as an option for the first-line treatment of CLL (Binet stage B or C) in patients for whom FCR chemotherapy is not appropriate.
31
For patients with FCR or bendamustine-based therapy unsuitable, what treatment does NICE recommend? [2]
For adults with FCR or bendamustine-based therapy unsuitable, NICE recommends **obinutuzumab** in combination with **chlorambucil** as an option.
32
What is the treatment NICE rec. for patients with TP53 deletion/mutation have a poor prognosis even after first line FCR combined chemotherapy? [1]
Patients with TP53 deletion/mutation have a poor prognosis even after first line FCR combined chemotherapy. In such cases, chemo agents like **ibrutinib** can be used.
33
**[]** is a monoclonal antibody which has also been shown to be effective in TP53 mutations.
**Alemtuzumab** is a monoclonal antibody which has also been shown to be effective in TP53 mutations.
34
**[]** is the dominant clinical feature among the complication in CLL, which should be treated with **[]**.
**Auto‐immune cytopenia** is the dominant clinical feature among the complication in CLL, which should be treated with **corticosteroids**.
35
[] provides the best opportunity of achieving long‐term disease‐free survival for patients with high‐risk CLL, including those with TP53 abnormalities.
**Allogeneic stem‐cell transplantation** provides the best opportunity of achieving long‐term disease‐free survival for patients with high‐risk CLL, including those with TP53 abnormalities.
It is a potential option in patients who fail chemotherapy and BCR inhibitor therapy or those with TP53 mutations that do not respond to treatment or relapse. In addition, it can also be considered in those with Richter transformation
36
Describe potential prophylaxis treatment might give patients with CLL? [4]
**Vaccination**: **influenza**, **pneumococcal** (ensure no contraindication with current therapy)
**Antibiotics for infections**
**Consider intravenous immunoglobulin:** treatment of secondary hypogammaglobulinaemia (i.e. IgG < 5g/L)
**Consider Pneumocystis jirovecii pneumonia (PJP) and herpes zoster prophylaxis**: usually in patients on treatment for relapsed CLL
37
Which chromosome deletion in CLL has bad prognostics? [1]
**Chromosome 17 deletion**
38
Describe the treatment plan for CLL
1. Watch and wait (and vaccinate), until have symptoms or cytopaenias - unless otherwise the CLL is not introducing harm, and giving treatment might cause resistance or harm to patient
2. Small molecules: **Ibrutinib**; **Immunotherapy**
| Lectures
39
Describe the pathophysiology of ALL
Acute lymphoblastic leukaemia (ALL) affects one of the lymphocyte precursor cells, causing acute proliferation of a single type of lymphocyte, usually B-lymphocytes.
The precursor cell acquire specific chromosomal mutations, which leads to uncontrolled proliferation of lymphoblasts and evasion of immune surveillance
As a result, lymphoblasts infiltrate bone marrow and other organs. which restricts hematopoiesis and leads to bone marrow suppression.
40
What is the most common cytogenetic feature seen in ALL?
t(4;11)
t(12;21)
t(9;22)
Hypodiploid karyotype
Hypodiploid karyotype
What is the most common cytogenetic feature seen in ALL?
t(4;11)
**t(12;21)**
t(9;22)
Hypodiploid karyotype
Hypodiploid karyotype
41
ALL is commonly seen in which patient populations? [3]
Those with chromosomal abnormalities:
- **Trisomy 21**
- **Klinefelter's syndrome**
**Fanconi anaemia**
**Monozygotic twins**
42
The most widely accepted classification system of ALL is the WHO classification.
Describe this classification [3]
* B cell lineage (85% of cases)
* T cell lineage (10-15% cases)
* Rare cases of NK cell lineage (<1% of cases)
43
Describe the typical presentation of ALL related to marrow failure [4]
**Recurrent infections:** **neutropaenia**
**Thrombocytopenia**:
* Petechiae
* Nose bleeds
* Bruising
**Anaemia**:
* Fatigue
* Breathlessness
* Angina
* Syncope
44
Describe the typical presentation of ALL related to tissue infiltration [4]
**Lymphadenopathy**
- Persistent
- Painless
- Firm & Rubbery
**Hepatosplenomegaly**
- Can present with anorexia, weight loss or abdomen pain
**Bone pain**
**Mediastinal mass** (may result in SVCO)
**Testicular enlargement**
45
**[]**- an uncommon presentation among those being first diagnosed, but more likely among patients with relapsing ALL (10%)
**Testicular enlargement ( < 1 %)** - an uncommon presentation among those being first diagnosed, but more likely among males with relapsing ALL (10%)
46
Describe the FBC seen in a patient with ALL [3]
**Thrombocytopaenia**
**Anaemic**
**WBC**: low or high
- **Low** indicates lymphoblasts present that have not differentiated as recognisable WBC
- **High** indicates similar enough to WBC to be counted
**U&Es; LDH; uric acid high**
- Due to metabolic abnormalities
- TLS
47
T-cell ALL is rarer than the B-cell form. It is said to typically present in which patient population? [1]
Describe two common presenting symptoms [2]
T-cell ALL is rarer than the B-cell form. It is said to typically present in **adolescent males with lymphadenopathy or a mediastinal mass.**
48
What investigational tests should you perfom to assess for features of disseminated intravascular coagulation (DIC)? [2]
**Coagulation screen** and **DDIMER**
49
What is the definitve diagnostic test for ALL? [1]
**Bone marrow aspiration and biopsy**
- Immunophenotyping is used to identify the lineage.
50
What is the threshold lymphoblast level in a PBS for ALL diagnosis? [1]
The most commonly accepted threshold for diagnosis is when lymphoblasts occupy >20% of bone marrow.
51
What specific information does immunophenotyping help provide with regards to ALL? [1]
Through analysis of the surface antigens, this also determines **whether the lymphoblasts are of B or T cell lineage.**
52
How would you differentiate ALL from Burkitts lymphoma? [2]
Through histology with the characteristic **'starry sky'** appearance of highly proliferative cells with basophilic cytoplasm in BL.
Confirmation of Burkitt's lymphoma involves identification of a **mature germinal centre immunophenotype** and cytogenetic features specific to Burkitt lymphoma cells
53
How would you differentiate ALL from AML based off which parts of the body are implicated [2]
ALL has a predisposition for **testicular**, and **CNS involvement**
AML has a predisposition to involve **skin and gums or other mucous membranes**
Confirm AML through the presence of **myeloid features** and **antigens** and **absence of any lymphoid antigens.**
54
Describe the overall goals of the different phases of ALL treatment [4]
**Pre-treatment & supportive therapy phase**
* Treating any infection, metabolic complication and if indicated giving a transfusion to stabilise the patient.
**Induction chemotherapy**
- goal to eradicate the presence of leukaemic cells to < 5% of blasts and to restore normal haematopoiesis.
**Consolidation**:
- Prevent the growth of leukaemia from any residual cells (known as a minimal residual disease (**MRD**)) and to prevent the development of drug resistance, by using numerous agents with multiple mechanisms of action.
**Maintenance therapy**
- prevent relapse
55
Desribe how the **pre-treatment & supportive therapy phase** of ALL is performed [4]
For roughly 5-7 daysL
* **Corticosteroids** with or without another drug
* **Hydration**
* **Allopurinol**
* **CNS** **prophylaxis** is given intrathecally
*This pre-phase helps reduce the risk of TLS*
56
Desribe how the **induction chemotherapyphase** of ALL is performed [1]
The selection of chemotherapy is dependent on a multitude of factors including age, Philadelphia chromosome status and the presence of CNS disease. Those with CNS disease require intrathecal chemotherapy and prophylactic therapy may be used in those without to reduce the risk of CNS relapse.
57
Describe the regime usually used for maintenance therapy fr ALL
**daily 6-mercaptopurine** and **weekly methotrexate**
*though there is considerable variation.*
58
Describe the regime usually used for consolidation therapy fr ALL
*the goal is to prevent the growth of leukaemia from any residual cells (known as a minimal residual disease (MRD)) and to prevent the development of drug resistance, by using numerous agents with multiple mechanisms of action.*
For those who don't achieve a complete remission following induction, termed high-risk cases, ESMO guidelines advise **allogeneic haematopoietic cell transplantation** leads to better outcomes.
59
Describe 4 complications of ALL [4]
**Tumour lysis syndrome**:
- significant metabolic disturbances arising from the rapid breakdown of malignant cells, normally after therapy has been initiated. It should be anticipated and when appropriate prophylaxis may be given with close monitoring and HDU/ITU availability if needed.
**Neutropenic sepsis**:
- characterised by fever and neutrophils < 0.5 (or expected to fall below 0.5). A medical emergency requiring early identification and management.
**SVCO**:
- patients may present with features of superior vena cava obstruction (e.g. dyspnea, facial swelling, cough) secondary to a mediastinal mass.
**Chemotherapy side-effects:**
- depends on the therapy and intensity, can be early (e.g. mucositis, nausea and vomiting, hair loss) or late (e.g. cardiomyopathy, secondary malignancies)
60
Describe the genetic pathophysiology of CML [3]
presence of the **BCR-ABL fusion gene:**
- results from a reciprocal translocation between **chromosomes 9 and 22**
- known as the **Philadelphia (Ph) chromosome**
- BCR-ABL fusion protein drives **uncontrolled cell growth and proliferation, leading to CML.**
61
Describe the typical presentation of CML [+]
* **Fatigue/lethargy**
* **Night sweats**
* **Weight loss**
* **Splenomegaly**
* **Generalised lymphadenopathy**
* Symptoms and signs of **anaemia**
* **Altered mental state**: due to leucostasis
* Signs secondary to **hyperviscosity**: a cerebrovascular events; priparism; opthalmic complications
62
How do you diagose CML? [2]
**Cytogenetics**:
- **identification of Ph chromosome** (95%)
- Ph chromosome is not identified on cytogenetics in around 5%. In these patients **fluorescent in situ hybridisation (FISH)**
63
What findings for CML would you find on a FBC? [3]
**Leucocytosis**, typically 20-60 * 109 /L
- The differential may demonstrate increased cell numbers from the myeloid lineage of leucocytes.
**Thrombocytosis or thrombocytopenia** may occur
**Anaemia** is a common finding, often **normochromic and normocytic**, but depending on haematinics, other abnormalities e.g. microcytic, hypochromic anaemia of iron deficiency may also be found.
64
Describe the different phases of CML [3]
**1. Chronic phase**
- The vast majority (> 85%) present in the chronic phase of disease.
- Clinical features are typically non-specific and include **fatigue, weight loss and night sweats**
**2. Accelerated phase**
- abnormal blast cells **take up a high proportion (10-20%)** of the **bone marrow and blood cells.**
- In the accelerated phase **symptoms** and features become more **apparent** and **severe**:
- **anaemia, thrombocytopenia and immunodeficiency.**
- Disease is more **difficult to treat and outcomes worse.**
**3. Blast crisis**
- This phase resembles an **acute leukaemia with the rapid expansion of blasts**
- **pancytopenia** occurs
- Without treatment survival is typically a few months.
65
Describe the treatment regime for CML in the:
- Chronic phase
- Advanced phase
- B
**Chronic phase**: tyrosine kinase inhibitors
- 1st line: **imatinib**
- **dasatinib**
- **nilotinib**
**Advanced**:
- Ideally all patients should be treated as part of a **clinical trial**
**Blast phase:**
- start / switch a **tyrosine kinase inhibitor** with **induction** **chemotherapy**; followed by **stem cell transplant**
66
a. Regular monitoring of which parameter is crucial for assessing the response to treatment and detecting relapse in CML?
A. Hemoglobin levels
B. Platelet count
C. BCR-ABL transcript levels
D. Liver function tests
a. Regular monitoring of which parameter is crucial for assessing the response to treatment and detecting relapse in CML?
A. Hemoglobin levels
B. Platelet count
**C. BCR-ABL transcript levels**
D. Liver function tests
67
a. What is the characteristic molecular marker for CML?
A. BCR-ABL fusion gene
B. FLT3-ITD mutation
C. JAK2 mutation
D. MPL mutation
a. What is the characteristic molecular marker for CML?
**A. BCR-ABL fusion gene**
B. FLT3-ITD mutation
C. JAK2 mutation
D. MPL mutation
68
Which fusion of chromosomes are common in CML? [1]
Which other type of leukaemia does this sometimes occur in?
| Lecture content
**9:22**
Can also occur in **ALL**
69
What treatment do we give for Philadelphia chromosome - BCR-ABL? [1]
| Lecture
**Imatinib**
70
Which of the following is most associated with smudge cells
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
**Chronic lymphocytic leukaemia**
71
Which of the following is most associated with warm haemolytic anaemia
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Which of the following is most associated with warm haemolytic anaemia
**Chronic lymphocytic leukaemia**
Warm hemolytic anemia is a type of autoimmune hemolytic anemia (AIHA), which is a condition where the body's immune system attacks and destroys its own red blood cells123. Warm hemolytic anemia is caused by IgG antibodies that bind red blood cells at normal body temperature12. The diagnosis is confirmed by the direct antiglobulin (direct Coombs) test1.
72
Which of the following is most associated with Downs syndrome
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Which of the following is most associated with Downs syndrome
Acute myeloid leukaemia
**Acute lymphoblastic leukaemia**
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
73
Which of the following is most associated with the Philadelphia chromosome
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Which of the following is most associated with the Philadelphia chromosome
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
**Chronic myeloid leukaemia**
Chronic lymphocytic leukaemia
74
Which of the following is most associated with three phases
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Which of the following is most associated with three phases
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
**Chronic myeloid leukaemia**
Chronic lymphocytic leukaemia
75
Which of the following is most associated with Auer rods
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Which of the following is most associated with Auer rods
**Acute myeloid leukaemia**
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
76
Which of the following is most likely this imaging?
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
**Auer rods**
**Acute myeloid leukaemia**
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
77
Which of the following is most likely to have a transformatong into a rare type of non-Hodgkin lymphoma, usually diffuse large B cell lymphoma?
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
**Chronic lymphocytic leukaemia** = Richter’s transformation
78
What is a key presenting feature of leukaemia? [1]
Describe this feature [1]
One key presenting feature of leukaemia is bleeding under the skin due to **thrombocytopenia**. Bleeding under the skin causes **non-blanching lesions**. These lesions are called different things based on the size of the lesions:
- **Petechiae**
- **Purpura**
- **Eccyhmosis**
79
The NICE guidelines on suspected cancer (2021) recommend a full blood count within 48 hours for patients with suspected leukaemia.
They recommend **children or young people** with **[]** or **[]** are sent for **immediate specialist assessment.**
The NICE guidelines on suspected cancer (2021) recommend a full blood count within 48 hours for patients with suspected leukaemia.
They recommend children or young people with **petechiae** or **hepatosplenomegaly** are sent for immediate specialist assessment.
80
Which of the following is used for the definitive diagnosis of leukaemia?
Full blood count
Blood film
Bone marrow biopsy
CT or PET scans
Lymph node biopsy
**Bone marrow biopsy** - used to analyse the cells in the bone marrow to establish a definitive diagnosis of leukaemia.
81
Which part of the body is a bone marrow biopsy typically taken from for leukaemia diagnosis? [1]
What are the two methods? [2]
**Iliac crest**
**Bone marrow aspiration**
- involves taking a **liquid sample** of cells from **within** the **bone** **marrow**.
**Bone marrow trephine**
- involves taking a **solid** **core** sample of the bone marrow and provides a better assessment of the **cells** and **structure**.
82
Which of the following is most associated with Fanconi anaemia
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
**Acute myeloid leukaemia**
83
Which of the following is most associated with : exposure to certain toxins (e.g. benzene and organochlorine insecticides)
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
Which of the following is most associated with : exposure to certain toxins (e.g. benzene and organochlorine insecticides)
**Acute myeloid leukaemia**
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
84
Which of the following is most associated with : exposure to previous chemotherapy regimens, in particular alkylating agents and topoisomerase-II inhibitors
Acute myeloid leukaemia
Acute lymphoblastic leukaemia
Chronic myeloid leukaemia
Chronic lymphocytic leukaemia
**Acute myeloid leukaemia**
85
Describe 5 risk factors that increase the risk of AML [4]
**Congenital disorders:**
- **Congenital** **neutropenia**
- **Fanconi** **anaemia**
**Radiation exposure**
**Myeloproliferative disorders**:
- **polycythaemia ruby vera**
- **myelofibrosis**
**Previous chemotherapy**:
- Alkylating agents
- topoisomerase-II inhibitors
**Toxins**
- Insecticides
86
Desribe the typical presentation of a patient with AML [8]
Features are largely related to bone marrow failure:
* **anaemia** (fatigue; pallor; angina)
* **fever** (due to infections)
* **splenomegaly** & **hepatomegaly**
* **recurrent** **infections** (neutropenia)
* **thrombocytopenia** (petechiae; nose bleeds; bruising; ecchymosis; gingivial bleeding)
* **bone pain** (sternal discomfort; aching in extremities)
* **leukaemia cutis** (nodular, violaceous lesions on the skin)
* **gingivial hypertrophy**
* **CNS involvement**: headaches; visual changes; nerve palsies
87
State potential features of AML if it has spread and caused tissue involvemment [4]
* **Lymphadenopathy**
* **Hepatosplenomegaly**
* **Bone pain**
* **Gum hypertrophy**
* **Violaceous skin deposits**
* **Testicular enlargement**
88
What investigation mode is required for the diagnosis of AML [1]
What finding would indicate a positive result? [1]
Bone marrow aspirate and biopsy is required for formal diagnosis of AML
**≥ 20% myeloblasts** in the bone marrow confirm the diagnosis
89
**[]** a non-specific marker of increased cell turnover may be raised in leukaemia.
**LDH** a non-specific marker of increased cell turnover may be raised in leukaemia.
90
What is a typical finding on a peripheral blood film for AML? [1]
Auer rods
91
Describe the general management prinicples for AML [2]
Treatment is set up in cycles and organised into **induction** and **consolidation** (and occasionally maintenance) stages.
**Induction**:
- **7+3 GO** - An induction regime consisting of **cytarabine, daunorubicin and gemtuzumab ozogamicin (GO)** (combination therapy)
**Consolidation**:
- **IDAC +/- GO** - A consolidation regime consisting of **intermediate-dose cytarabine (IDAC) +/- gemtuzumab ozogamicin.**
**allogenic haematopoietic stem cell transplantation**
- for patients with unfavourable prognostic factors (unfavourable cytogenetics) or patients who do not achieve remission through chemotherapy
92
How would you differentiate between AML & ALL? [2]
**terminal deoxynucleotidyl transferase (TdT) positive** in ALL
No Auer rods in ALL
93
How would the following change in AML? [5]
- Prothrombin time
- activated partial thromboplastin time (APTT)
- platelet count
- D-dimer concentration
- fibrinogen concentration
How would the following change in AML?
- Prothrombin time: **raised**
- activated partial thromboplastin time (APTT): **raised**
- platelet count: **reduced**
- D-dimer concentration: **elevated**
- fibrinogen concentration: **reduced**
94
AML typically causes cell lysis. What electrolyte abnormalities would occur because of this? [4]
**Hyperphosphatemia, hypocalcemia, hyperkalemia, and hyperuricemia**
95
How would you differentiate between AML & CML? [2]
CML is found with **Philadelphia chromosome**
96
State and describe one of the main complications of AML [5]
**Leukostasis**: excessive number of leukaemic cells, causes **increased blood viscosity.**
The clinical features are:
* Chest pain
* Headache
* Altered mental status
* Priapism
97
What supportive treatment do you give alongside Haematopoietic cell transplantation (HCT)? [5]
**Antibiotic prophylaxis** (broad-spectrum IV antibiotics) for **febrile neutropenia**
**Trimethoprim-sulfamethoxazole** for **pneumocystis** **pneumonia** prophylaxis in **neutropenic patients.**
**Immunisations**
**ondansetron**
**Transfusions** for severe anaemia, thrombocytopenia.
98
TLS cause the release of calcium phosphate crystals. What pathologt can this lead to? [1]
**Acute kidney injury**
99
State the electroylte disturbances seen in TLS [4]
hyperkalemia, hyperphosphatemia, hypocalcemia (secondary to phosphate binding), and hyperuricemia
100
According to NICE, what is the standard induction chemotherapy regimen for adults under 60 years old with AML who are fit for intensive treatment?
a) Azacitidine
b) Decitabine
c) Daunorubicin and Cytarabine
d) Midostaurin
According to NICE, what is the standard induction chemotherapy regimen for adults under 60 years old with AML who are fit for intensive treatment?
a) Azacitidine
b) Decitabine
**c) Daunorubicin and Cytarabine**
d) Midostaurin
101
According to NICE, what is the recommended duration of thromboprophylaxis in AML patients receiving intensive chemotherapy?
a) 7 days
b) 14 days
c) 21 days
d) Until complete remission is achieved
According to NICE, what is the recommended duration of thromboprophylaxis in AML patients receiving intensive chemotherapy?
a) 7 days
**b) 14 days**
c) 21 days
d) Until complete remission is achieved
102
Which cytogenetic abnomarlities in AML have a really poor prognsosis (3% to 10yrs)? [1]
**inversion 3**
103
acute promyelocytic leukaemia (AMPL) can have really bad clotting problems.
This arises from a translocation of which chromosomes? [1]
What medication do we give PML-RARA fusion? [1]
| From lecture
**t(15:17)**
PML-RARA fusion: **give ATRA**
