Leukaemia

Question 1

What is leukaemia?

Answer 1

Leukaemia is the name for cancer of a particular line of the stem cells in the bone marrow. This causes unregulated production of certain types of blood cells.

Question 2

How can leukaemia be classified?

Give examples of the 4 main types of leukaemia

Answer 2

They can be classified depending on how rapidly they progress (slow= chronic or fast= acute) and the cell line that is affected (myeloid or lymphoid) to make four main types with different characteristics:

• Acute myeloid leukaemia
• Acute lymphoblastic leukaemia
• Chronic myeloid leukaemia
• Chronic lymphocytic leukaemia

There are other rarer and more specialist leukaemias such as acute promyelocytic leukaemia.

Question 3

Briefly describe the pathophysiology of leukaemia

Answer 3

Leukaemia is a form of cancer of the cells in the bone marrow. A genetic mutation in one of the precursor cells in the bone marrow leads to excessive production of a single type of abnormal white blood cell.

The excessive production of a single type of cell can lead to suppression of the other cell lines causing underproduction of other cell types. This results in a pancytopenia, which is a combination of low red blood cells (anaemia), white blood cells (leukopenia) and platelets (thrombocytopenia).

Question 4

What is pancytopenia?

Answer 4

Pancytopenia is a combination of low red blood cells (anaemia), white blood cells (leukopenia) and platelets (thrombocytopenia).

Question 5

Which leukaemias affect the following age groups:

• Under 5 and over 45
• Under 55
• Under 65
• Over 75

Note: ALL CeLLmates have CoMmon AMbitions

Answer 5

You can use the mnemonic “ALL CeLLmates have CoMmon AMbitions” to remember the progressive ages of the different leukaemia from 45-75 in steps of 10 years. Remember that ALL (the first in the mnemonic) most commonly affects children under 5 years.

• Under 5 and over 45: acute lymphoblastic leukaemia (ALL)
• Over 55: chronic lymphocytic leukaemia (CeLLmates)
• Over 65: chronic myeloid leukaemia (CoMmon)
• Over 75: acute myeloid leukaemia (AMbitions)

Question 6

How does leukaemia present?

Answer 6

The presentation of leukaemia is quite non-specific. If leukaemia appears on your list of differentials then get an urgent full blood count. Some typical features are:

• Fatigue
• Fever
• Failure to thrive (children)
• Pallor due to anaemia
• Petechiae and abnormal bruising due to thrombocytopenia
• Abnormal bleeding
• Lymphadenopathy
• Hepatosplenomegaly

Question 7

What causes brusing and petechiae in leukaemia?

Answer 7

This is caused by thrombocytopenia (low platelets).

Question 8

What differentials should be considered for petechiae in myeloma

Answer 8

It is important to be aware of the differential diagnoses for this type of non-blanching rash. Don’t ever forget non-accidental injury (abuse) as a differential, particularly in children and vulnerable adults.

• Leukaemia
• Meningococcal septicaemia
• Vasculitis
• Henoch-Schonlein Purpura (HSP)
• Idiopathic Thrombocytopenia Purpura (ITP)
• Non-accidental injury

Question 9

What is the initial diagnostic test for leukaemia?

Answer 9

Full blood count is the initial investigation. NICE recommend a full blood count within 48 hours for patients with suspected leukaemia. Children or young adults with ptechiae or hepatosplenomegaly should be referred immediately to the hospital.

Question 10

What test is used for the definitive diagnosis of leukaemia?

Answer 10

Bone marrow biopsy can be used to analyse the cells in the bone marrow. This is the main investigation for establishing a definitive diagnosis of leukaemia.

Question 11

Other than FBC and bone marrow biopsy, what tests should be investigated in leukaemia?

Answer 11

Blood film, lactate dehydrogenase (LDH), chest xray, lymph node biopsy, lumbar puncture and CT, MRI and PET scans.

Question 12

Why investigate using blood films?

Answer 12

Blood film can be used to look for abnormal cells and inclusions.

Question 13

What investigate using lactate dehydrogenase (LDH)?

Answer 13

Lactate dehydrogenase (LDH) is a blood test that is often raised in leukaemia but is not specific to leukaemia. It can be raised in other cancers and many non-cancerous diseases.

Question 14

Why investigate using chest xray?

Answer 14

Chest xray may show infection or mediastinal lymphadenopathy.

Question 15

Why investigate using lymph node biopsy?

Answer 15

Lymph node biopsy can be used to assess lymph node involvement or investigate for lymphoma.

Question 16

Why investigate using lumbar puncture?

Answer 16

Lumbar puncture may be used if there is central nervous system involvement.

Question 17

Why investigate using CT, MRI and PET scans?

Answer 17

CT, MRI and PET scans can be used for staging and assessing for lymphoma and other tumours.

Question 18

Briefly differentiate between bone marrow aspiration, trephine and biopsy

Answer 18

Bone marrow aspiration involves taking a liquid sample full 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.

Bone marrow biopsy is usually taken from the iliac crest. It involves a local anaesthetic and a specialist needle. Samples from bone marrow aspiration can be examined straight away however a trephine sample requires a few days of preparation.

Question 19

Briefly describe acute lymphoblastic leukaemia and its features

Answer 19

Acute lymphoblastic leukaemia is where there is malignant change in one of the lymphocyte precursor cells. It causes acute proliferation of a single type of lymphocyte, usually B-lymphocytes. Excessive proliferation of these cells causes them to replace the other cell types being created in the bone marrow, leading to a pancytopenia.

This is the most common cancer in children and peaks around 2-4 years. It can also affect adults over 45. It is often associated with Downs syndrome.

Blood film shows blast cells.

It is associated with the Philadelphia chromosome (t(9:22) translocation) in 30% of adults and 3-5% of children with ALL.

Question 20

Briefly describe chronic lymphocytic leukaemia and its features

Answer 20

Chronic lymphocytic leukaemia is where there is chronic proliferation of a single type of well differentiated lymphocyte, usually B-lymphocytes. This usually affects adults over 55 years of age. Often it is asymptomatic but it can present with infections, anaemia, bleeding and weight loss. It can cause warm autoimmune haemolytic anaemia.

CLL can transform into high-grade lymphoma. This is called Richter’s transformation.

Blood film shows “smear” or “smudge” cells. These occur during the process of preparing the blood film where aged or fragile white blood cells rupture and leave a smudge on the film.

Question 21

Briefly describe chronic myeloid leukaemia and its features

Answer 21

Chronic myeloid leukaemia has three typical phases: the chronic phase, the accelerated phase and the blast phase. The chronic phase can last around 5 years, is often asymptomatic and patients are diagnosed incidentally with a raised white cell count.

The accelerated phase occurs where the abnormal blast cells take up a high proportion of the cells in the bone marrow and blood (10-20%). In the accelerated phase patients become more symptomatic, develop anaemia and thrombocytopenia and become immunocompromised.

The blast phase follows the accelerated phase and involves an even high proportion of blast cells and blood (>30%). This phase has severe symptoms and pancytopenia. It is often fatal.

The cytogenetic change that is characteristic of CML is the Philadelphia chromosome, which is a translocation of genes between chromosome 9 and 22: it is a t(9:22) translocation.

Question 22

Briefly describe acute myeloid leukaemia and its features

Answer 22

Acute myeloid leukaemia is the most common acute leukaemia in adults. There are many different types of acute myeloid leukaemia all with slightly different cytogenetic differences and differences in presentation.

It can present at any age but normally presents from middle age onwards. It can be the result of a transformation from a myeloproliferative disorder such as polycythaemia ruby vera or myelofibrosis.

A blood film will show a high proportion of blast cells. These blast cells can have rods inside their cytoplasm that are named Auer rods.

Question 23

Which leukaemia is most common leukaemia in children and associated with Down syndrome?

Answer 23

Acute lymphoblastic leukaemia.

Question 24

Which leukaemia is most common in adults overall, associated with warm haemolytic anaemia and Richter’s transformation into lymphoma and smudge/ smear cells?

Answer 24

Chronic lymphocytic leukaemia.

Question 25

Which leukaemia has three phases including a 5 year “asymptomatic chronic phase”and is ssociated with the Philadelphia chromosome?

Answer 25

Chronic myeloid leukaemia.

Question 26

Which leukaemia is most common acute adult leukaemia, can be the result of a transformation from a myeloproliferative disorder and is associated with Auer rods?

Answer 26

Acute myeloid leukaemia.

Question 27

Briefly describe the management of leukaemia

Answer 27

Treatment will be coordinated by an oncology multi-disciplinary team. Leukaemia is primarily treated with chemotherapy and steroids.

Other therapies include:

• Radiotherapy
• Bone marrow transplant
• Surgery

Question 28

What are the complications of chemotherapy?

Answer 28

• Failure
• Stunted growth and development in children
• Infections due to immunodeficiency
• Neurotoxicity
• Infertility
• Secondary malignancy
• Cardiotoxicity
• Tumour lysis syndrome

Question 29

Briefly describe tumour lysis syndrome

Answer 29

Tumour lysis syndrome is caused by the release of uric acid from cells that are being destroyed by chemotherapy. The uric acid can form crystals in the interstitial tissue and tubules of the kidneys and causes acute kidney injury.

Question 30

Briefly describe the treatment and monitoring in tumour lysis syndrome

Answer 30

Allopurinol or rasburicase are used to reduce the high uric acid levels.

Other chemicals such as potassium and phosphate are also released so these need to be monitored and treated appropriately. High phosphate can lead to low calcium, which can have an adverse effect, so calcium is also monitored.