Leukemia Flashcards
Leukemia
Which has a better cure rate?
Adult ALL vs. pediatric ALL
pediatric
Childhood ALL can now be cured in 80% to 89% of cases, with initial
remissions generally occurring in about 90%.
In adults, initial remission rates
are generally equally high, but cure rates are only in the 30% to 45% range.
Leukemia
Which has a better cure rate?
Pediratric ALL vs. pediatric AML
ALL
In
contrast to the situation in pediatric ALL, pediatric acute myeloid leukemia
(AML) generally fairs less well, with 60% cure rates, although this represents a
marked improvement since the 1970s when cure rates were roughly 20%.
Leukemia
This type of leukemia has the ability to progress to a more acute disease in its terminal phase (blast crisis)
CML
chronic myelogenous leukemia
Leukemia
Which of the statments is/are true?
Pathologically, CNS leukemia originates as a perivascular infiltrate along the subpial blood vessels.
As disease progresses, the leukemia infiltrates preferentially into the subarachnoid space as well as into the brain parenchyma.
both
Leukemia
Because
subdural space extends as a sheath along the optic nerve, it is standard to
include the posterior half of the eye globes within cranial radiation fields
TRUE or FALSE?
False.
It’s the subarachnoid not subdural
Leukemia
What is the role of intrathecal chemotherapy in combination with CSI?
- cover spinal subarachnoid space
2. allows spine to be treated with a lower RT dose
Leukemia
Identify the FAB classification:
undifferentiated AML
M0, M1
Leukemia
Identify the FAB classification:
acute myeloid leukemia
M2
Leukemia
Identify the FAB classification:
acute promyelocytic leukemia
M3
Leukemia
Identify the FAB classification:
acute myelomonocytic leukemia with eosinophilia
M4Eo
Leukemia
Identify the FAB classification:
acute monocytic leukemia
M5
Leukemia
Identify the FAB classification:
acute erythroblastic leukemia
M6
Leukemia
Identify the FAB classification:
acute megakaryocitic leukemia
M7
Leukemia
Characteristic cell seen in AML
Auer rods
Leukemia
AML stains positively for
myeloperoxidase or monocyte-associated esterases.
Leukemia
How much blasts in the blood or marrow is required to confirm a diagnosis of AML?
20% (WHO classification)
30% (older FAB criteria)
Leukemia
This antigen is expressed in about 85% of ALL.
CALLA, CD10
Leukemia
Chromosomal abnormalities are more common in pediatric than in adult population.
TRUE or FALSE?
False
Leukemia
What is the translocation in Philadelphia chromosome?
t(9;22) BCR/ABL
Leukemia
The Philadelphia chromosome is associated with higher risk of CNS involvement but overall good prognosis
TRUE or FALSE?
False
poorer prognosis in general.
but if you consider TKIs, outcomes are improved.
Leukemia
In, ALL, hyperdiploidy (>51 chromosomes per gene) confers a favorable prognosis.
TRUE or FALSE?
depends.
yes in pediatric
no in adults
Leukemia
In, ALL, hypodiploidy (<45 chromosomes per gene) confers a favorable prognosis.
TRUE or FALSE?
False
Leukemia
B-Cell ALL
identify standard-risk population
1-10 years
<50,000uL presenting WBC count
no CNS involvement
Leukemia
B-Cell ALL
identify standard-low population
standard-risk
(1-10 years
<50,000uL presenting WBC count
no CNS involvement)
+ rapid early response to induction chemotherapy
Leukemia
B-Cell ALL
identify high-risk population
opposite of standard-risk
<1 yr/>10 years
high WBC at presentation >50k uL
+CNS involvement
Leukemia
ALL
CNS-1
no blast cells on CSF cytology
regardless of WBC
Leukemia
ALL
CNS-2
<5 WBC/uL + blast cells in CSF cytology
but negative for Steinherz/Bleyer algorith
Leukemia
ALL
CNS-3
<5 WBC/uL + blast cells in CSF cytology or + cranial nerve palsy
Leukemia
Blasts counts of >50,000/uL are worrisome for ALL as they may cause leukostasis particularly in the vessels of the brain and lung.
TRUE or FALSE?
false.
up to 400k is usually tolerated for ALL.
It should be AML.
lymphoid blasts are less adhesive than myeloid blasts.
Leukemia
What is the classic induction therapy for AML?
anthracycline (d1-3)
ctyarabine x 7d.
Leukemia
What is the treatment for acute promyelocytic leukemia?
ATRA (all trans retinoic acid)
arsenic trioxide
Leukemia
Which statement is false?
Patients younger than age 60 have CR rates of 70% to 80%, whereas older
patients tend to have lower CR rates of 30% to 50%.
Patients who develop
secondary AML following chemotherapy for other cancers have CR rates in the
30% to 50% range.
None
Leukemia
What is the consolidative treatment for AML after remission?
or is therapy still needed?
4 cycles of high-dose ARA-C
or additional cycles of anthracyclines plus conventional dose cytarabine
Leukemia
The role of CNS prophylaxis is not well defined for AML, particularly
because CNS relapse rates are relatively infrequent (at roughly 5% to 10%).
Some studies show no difference in relapse rates with cranial radiation.
What are the characteristics of high-risk patients that may benefit with prophylactic cranial RT?
high WBC count (>40.000/μL) at diagnosis
extramedullary involvement
high-risk APML
mixed phenotype acute
leukemia
or monocytic variants of AML
Leukemia
What is the usual toxicity from ara-C?
neurotoxicity
Leukemia
What is the RT dose for chloroma?
24 Gy / 2 / 12
Leukemia
What are the four components/goals of treatment for ALL?
induction of remission
intensification and/or consolidation
maintenance
CNS prophylaxis
Leukemia
Among high-risk
pediatric patients with ALL, allogeneic hematopoietic stem cell transplantation
was not affected by donor type
However, what is the benefit of using related-donors?
faster engraftment
Leukemia
What are the minimum required drugs for ALL induction therapy?
glucocorticoid
anthracycline
vincristine
L-asparaginase
(L-a VAG)
Leukemia
What is the medication added to anthracycline that serves as a cardioprotectant?
dexrazoxane
Leukemia
What dose was used in the CSI for the studies V and VI from SJCRH that established it as the standard in the 1960s?
24 Gy/15-16 fx
Leukemia
Due to the concerns for myelosuppresion, this trial compared and found equivalence between PCI + IT MTX vs. CSI
SJCRH Study VII
Leukemia
What is the standard maintenance therapy for ALL following PCI + IT MTX that showed the least incidence of treatment-related leukoencephalopathy?
oral MTX + 6-mercaptopurine
SJCRH study VIII
Leukemia
What was the PCI dose in the St. Jude Total XV trial?
none
they eliminated cranial RT
Leukemia
The European BFM-ALL trials reduced the doses of cranial radiation.
What are their dose prescriptions?
12 Gy
for CNS3 24 Gy (BFM90) 18 Gy (BFM95)
Leukemia
Identify patient/disease characteristics that would be considered for cranial RT prophylaxis
for ALL older patients (>10)
T-cell phenotype (especially with WBC over 100k, CNS-2/3)
B-cell with MRD and adverse cytogenetics
for AML
monocytic variant
Leukemia
Unless
otherwise indicated, in a specific treatment protocol, the radiation prescription
for prophylactic cranial radiation to prevent ALL relapse is:
18 Gy in 9 or 10 fractions.
depends on chemo, if BFM chemo is used, it can be 12 Gy.
Leukemia
Richter syndrome is an agressive large B-cell lymphoma occasionally seen from a transformed CLL.
What are the characteristic findings?
asymmetric adenopathy,
splenomegaly,
B symptoms,
and elevated LDH.
Leukemia
What chronic leukemia is characterized by the t(9;22) which results in a BCR-ABL1 fusion protein that leads to leukemic transformation?
CML
Leukemia
Poor prognostic factors in CML
age >60 years
spleen >l0 cm below the costal margin
blasts >3% in blood or marrow
basophilia >7% in blood or marrow
platelets >700,000/μL.
Leukemia
First line targeted agent used in the upfront therapy of CML
Imatinib (Gleevec)
Leukemia
Poor responders to Gleevec, as well as tose with poor prognostic features are given second generation TKIs namely _____ & ______.
dasatinib and nilotinib
Leukemia
What is the RT dose prescription for a palliative RT to CLL patients with massive splenomegaly?
10 to 20 Gy or lower using 25 to 100 cGy per fraction
Leukemia
What is the most important predictor of survival in patients with CLL?
Clinical stage
There
have been many staging systems proposed, but the most widely used are those
modified by Rai et al. and Binet et al., the former used in the United States
and the latter in Europe
Leukemia
What medication is the backbone of CLL treatment?
fludarabine
Leukemia
Identify
This is a selective irreversible inhibitor
of Bruton tyrosine kinase, part of the B-cell receptor signaling cascade has been FDA approved for the upfront treatment of older
patient with CLL based on the results of the RESONATE-2 trial.
This has also been FDA approved for patients with relapsed/refractory CLL and for the upfront treatment of patients with CLL harboring a deletion in the chromosome 17p or a deletion on p53 who have
historically a poor response to traditional chemoimmunotherapy.
Ibrutinib
Leukemia
RT
What is the typical dose prescription for testicular RT?
24 to 26 Gy/1.5-2
4x1 or 2x2 (if with TBI)
Leukemia
RT
What is the typical dose prescription for splenic RT?
4 to 10 Gy (usually no more than 20)
0.25 to 1 per fraction.
titrated to until response is achieved.
