Leukaemia Management

Question 1

Who is ALL more common in?

Answer 1

• Paediatric patients
• 0-4 years

Question 2

How is ALL managed?

Answer 2

• Course 1 = 4 week chemo
• Course 2 = 4 week chemo
• Methotrexate weekly for 3 weeks
• Either 4 cycles of chemo followed by maintenance chemo
  OR
• Stem cell transplant
• Decision based on each individual patient, and their repsonse to treatment
• Treatment lasts between about 3 and 5 years

Question 3

What are the stages of chemotherapy in leukaemia?

Answer 3

• Induction: clear blood of leukaemia cells, reduce number of blast cells in the bone marrow to normal
• Consolidation: Given after induction recovery, kills remaining (undetectable leukaemia cells)
• Maintenance: long term and low dose, not used for all leaukaemia types, common in ALL

Question 4

What Chemo drugs are used in AML?

Answer 4

• Cytarabine (cytosine arabinoside or ara-C)
• Anthracycline Drugs
• Daunorubivin (daunomycin), idarubicin, mitoxantrone

Question 5

What Chemo drugs are used in ALL?

Answer 5

Vincristine
Dexamethasone or prednisone
Anthracycline drugs
Doxorubicin (Adriamycin) or daunorubicin etc.

Question 6

What Chemo drugs are used in maintenance?

Answer 6

Methotrexate
6-mercaptopurine (6-MP)
Possibly additional vincristine and prednisone

Question 7

What is Pegaspargase?

Answer 7

• Used as combination therapy
• recommended for use in children, young people and adults
• enzyme derived from e-coli, an asparaginase
• asparagine = amino acid which synthesises proteins, malignant cells cannot produce it.
• Asparagine is essential for cell growth and survival

Question 8

What are the types of stem cell transplant?

Answer 8

-Autologous stem cell transplant
Stem cells harvested from the patient are given back after conditioning regimen of high dose chemotherapy and/or RT

-Allogeneic stem cell transplant:
Same procedure but uses matching donor (relative, unrelated individual, or saved umbilical cord blood)
Needs a successful human leukocyte antigens (HLA) test
Preferable as donor cells non-malignant but hard to match to donors

Question 9

What is TBI?

Answer 9

• Total body irradiation
• can help reduce chance of a transplant rejection
• can kill cancer cells in the body
• Side effects: nausea, diarrhoea, fatigue, mouth sores, skin changes and IMMUNOSUPPRESSION
• Lungs can be shielded to reduce long term issues and to even out the dose

Question 10

What infection control methods are important for TBI treatment?

Answer 10

• protective isolation
• room sterilisation
• clean air
• clean food
• purified water
• removal of plants
• hand washing
• masks to be worn
• Sealed room
• 1 visitor a day, written instructions, stay 1m apart, face mask and a gown

Question 11

How is acute leukaemia Palliation managed?

Answer 11

• Low dose chemo, based on previous responses
• Outpatient based care
• Supportive care, blood transfusions and symptom management

Question 12

What is CLL?

Answer 12

• Chronic leukaemia
• Age related, 40% in 70+ year olds
• 3800 new CLL cases in the UK per day

Question 13

How is CLL staged?

Answer 13

• Binet system
• Stage A, fewer than 3 groups of enlarged lymph nodes and a high WBC count
• Stage B - more than 3 groups of enlarged lymph nodes and a high WBC count
• Stage C - enlarged lymph nodes or spleen, high WBC count, low RBC or platelet count

Question 14

How is CLL managed?

Answer 14

• watchful waiting
• fast developing disease (chemo)
• lymphandenopathy (RT)
• Splenomegaly (surgery or RT)
• Bone marrow transplant is rare but is sometimes used as an intensive option, in low risk, younger patients

Question 15

How is splenomegaly treated with RT?

Answer 15

• Low dose
• 0.5Gy daily fractions to total dose of 6-10Gy
• Dose can be repeated if needed
• Indicated if unsuitable for surgery

Question 16

How is lympadenopathy treated with RT?

Answer 16

• Indicated when poor chemo response
• Some authors have gained results from 4Gy in 2#

Question 17

What is CML?

Answer 17

• Chronic leukaemia
• 25% of cases in those 70+
• significantly lower numbers in females than males

Question 18

What are the phases of CML?

Answer 18

• Chronic phase, 85% patients present in this phase
• Accelerated phase, some signs in blood/bone marrow that patient is moving toward blast crisis
• Blast crisis: behaves like AML, rapid progression and short survival

Question 19

How is CML managed?

Answer 19

• Biological therapy drug - imatinib
• chemotherapy and intensive chemo
• possible bone marrow or stem cell transplant
• RT rarely used but may be used in palliation of symptoms
• Philadelphia chromosome (imatinib)

Question 20

What are soem new types of treatment for leukaemia?

Answer 20

• 2nd generation TKIs
• Continued research into role of new TKIs and optimising usage: an optimal second line therapy. There is an impact on response rate and an impact on overall survival
• Arsenic Trioxide, long usage in chinese medicine
• Minimal side effects
• given over 6 month period
• causes death of leukaemia cells bia morophological changes and DNA fragmentation
• Monoclonal antibodies

Question 21

What is CAR T-cell treatment?

Answer 21

• CAR T-cell therapy
• blood is taken from patients and separated to get T-cells
• T-cells are then genetically engineered using a disarmed virus to produce surface receptors (CARs)
• The receptors then allow T-cells to recognise and attach to a specific protein or antigens on tumour cells `
• The CARs ‘program’ the T-cells to find and destroy cancer cells
• Used for B-Cell ALL patients in case or recurrence or relapse