Leukemia Flashcards by Mario Luna

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.

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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%.

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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

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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

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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

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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

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Leukemia

Identify the FAB classification:

undifferentiated AML

M0, M1

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Leukemia

Identify the FAB classification:

acute myeloid leukemia

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Leukemia

Identify the FAB classification:

acute promyelocytic leukemia

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Leukemia

Identify the FAB classification:

acute myelomonocytic leukemia with eosinophilia

M4Eo

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Leukemia

Identify the FAB classification:

acute monocytic leukemia

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Leukemia

Identify the FAB classification:

acute erythroblastic leukemia

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Leukemia

Identify the FAB classification:

acute megakaryocitic leukemia

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Leukemia

Characteristic cell seen in AML

Auer rods

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Leukemia

AML stains positively for

myeloperoxidase or monocyte-associated esterases.

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Leukemia

How much blasts in the blood or marrow is required to confirm a diagnosis of AML?

20% (WHO classification)

30% (older FAB criteria)

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Leukemia

This antigen is expressed in about 85% of ALL.

CALLA, CD10

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Leukemia

Chromosomal abnormalities are more common in pediatric than in adult population.

TRUE or FALSE?

False

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Leukemia

What is the translocation in Philadelphia chromosome?

t(9;22) BCR/ABL

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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.

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Leukemia

In, ALL, hyperdiploidy (>51 chromosomes per gene) confers a favorable prognosis.

TRUE or FALSE?

depends.

yes in pediatric
no in adults

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Leukemia

In, ALL, hypodiploidy (<45 chromosomes per gene) confers a favorable prognosis.

TRUE or FALSE?

False

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Leukemia

B-Cell ALL

identify standard-risk population

1-10 years
<50,000uL presenting WBC count
no CNS involvement

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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.