Leukemias Flashcards
Acute lymphocytic leukemia (ALL) definition
MAlignancy that causes hematopoietic progenitor cells to lose their ability to mature normally and differentiate
cells proliferate in uncontrolled fashion and ultimately replace normal bone marrow leading to decreased production of normal RBC, WBC, and platelets
Incidence/predisposing factors
- no clear cause, greater incidence with benzene and petroleum product exposure
- more common in European descent
- cause of 80% of childhood cancers, peak age 3-7 years, and 20% of adult cancers peak age 60
- most common cancer and leading cause of death in children under 15
- survivors of ALL at risk for late sequelae of secondary brain tumors
- childhood survivors at greater risk for reduced growth, learning disabilities, and osteoporotic fxs later in life
S&S of ALL
sudden onset of acute illness for days or weeks, fever, anorexia, fatigue, bone/joint pain, sob, gum hypertrophy and bleeding, nose bleeds, chest pain, pale, purpura, petechiae, lymphadenopathy, stomatitis, hepatosplenomegaly, bone tenderness ESPECIALLY sternum and tibia
lab hallmark of ALL
pancytopenia with circulating blasts, blast cells on 90 % of smears
Bone marrow in ALL
usually hypercellular, diagnosis requires that more than 30% of cells are blasts,
ALL blood work
decrease in RBCs, hemoglobin, hematocrit, and platelets, elevated urea (azotemia), terminal deoxynucleotidyl transferase present in 95% of cases
test needed confirm ALL diagnosis
bone marrow biopsy
cytogenic studies for ALL
- Hyperdiploid states: more favorable prognosis
- Philadelphia (pH) chromosome t(9,22) and (4/11): unfavorable prognosis
Bone marrow stains for ALL (4)
Periodic acid sschiff: positive
Terminal deoxynucleotidyl transferase: Positive
Sudan black: negative
Myeloperoxidase: negative
Tests to consider for ALL
chromosome analysis, multiparametric flow cytometry (relapse prediction), molecular genetic studies, lumbar puncture
Manamagent for ALL
- hematology/oncolgy consult
- supportive tx or eradication of mass
- stem cell transplant is goal (cures not common except in children
ALL survival rates
25% remain disease free, 5 year survival w/o aggressive tx
35-40% remain disease free, 5 year survival with aggressive tx
supportive care for ph positive ALL patients
- tyrosine kinase inhibitor will be induction therapy:
- transfusion of RBCs and platelets
- hydration
- aggressive antibiotic therapy for infection
- allopurinol to prevent renal damage and hyperuricemia BEFORE chemo
- acetazolamide to make urine alkaline
Before chemo what do you for uremic ALL patients
start dialysis
Chemotherapy phases for ALL
Divide into 3 phases:
Remission Induction
Post remission therapy consolidation
CNS prophylaxis
Remission induction therapy for ALL
- Initial tx: combo chemo and TKI if ph positive or clinical trial
- TKIs: *vincristine, prednisone, cyclophosphamide, doxorubicin, dexamethasone, cytarabine, methotrexate, imatinib, dasatinib
- intrathecal methotrexate with 1 asparaginase in ; intrathecal methotrexate + cytarabine + corticosteroids
- maintenance therapy is 6 mercaptopurine and methotrexate
Post remission ALL
- Short courses of further chemo given
- daily 6-mercaptopurine, weekly methotrexate, TKIs in Ph positive patients with nelarabine preferred in refractory t cell ALL
CNS prophylaxis in ALL
intrathecal methotrexate alone or in combination with radiation
**CNS relapse much higher in ALL than AML
When to consider bone marrow transplant for ALL
at time of 1st relapse or 2nd remission
Acute Myeloid Leukemia (AML) definition
- malignancy of hematopoietic progenitor cells
- similar to AML, but distinguished by morphologic examination and cytochemistry that differentiates myeloblasts from lymphoblasts
Classifications of AML (4)
- AML with recurrent genetic abnormalities
- AML with multilineage dysplasia
- Therapy related AML
- AML not otherwise categorized
Bone marrow or peripheral blood blast % needed to diagnosis AML
20%
Incidence/predisposing factors
- no clear cause
- increased incidence in patients with chromosomal abnormalities, especially Down syndrome
- Predominant type of acute leukemia in adults: 80% in adults over 20
- incidence increases with age: median 67 years old
- increased incidence of DIC
S&S of AML
bleeding, SOB, bruising, fever, anorexia, weight loss, HA, bone and joint pain, bone tenderness (sternum and tibia), exposure to petrochemicals and/or ionizing radiation, lymphadenopathy, hepatosplenomegaly, stomatitis, gingival hypertrophy, purpura, petechiae, overt bleeding, infection
labs in AML
- pancytopenia, anemia,
- low RBCs, hgb, hct, and platelets
- mild thrombocytopenia
- granules in blast cells
- Auer rods
- Myeloblasts
- butyrate esterase
Why are AML patients prone to DIC
elevated PT, PTT, fibrin degredation products, and d dimer, decreased fibrinogen
prognosis findings with Immunophenotyping in AML
Favorable: t(8,21), t(15,17), and inv(16)(p13,q22)
Unfavorable: monosomy 5 and 7 and complex abnormalities
Bone marrow stain results in AML
Sudan black: positive
Myeloperoxidase: positive
main AML tx
- hematology/oncology consult
- chemo, radiation, stem cell transplant, targeted immune therapy
AML supportive tx
- transfuse of RBCs and platelets
- hydration
- aggressive antibiotic therapy for infection
- acetazolamide, to create alkaline urine
- allopurinol, to prevent hyperuricemia and renal damage
Remission induction combo chemotherapy AML
- dose intensive cytarabine
- cytarabine and daunorubicin
- cytarabine and idarubicin
- cytarabine and daunorubcin and thioguanine/cladribine
- mitoxantrone and etopside, cytarabine and daunorubicin and 5-azacytidine
- treat CNS leukemia with intrathecal cytarabine or methotrexate
Consolidative and maintenance therapy for AML
- cytarabine based combo if tolerated
- mitoxantrone and daunorubicin
- mitoxantrone and idarubicin
- high dose ARA-C
- M3 subtype initiated with retinoic acid then use above meds
When to use bone marrow transplant in AML
consider at time of 1st relapse or second remission (salvage therapy), Consider after induction therapy and each surveillance visit or change of tx visit
Chronic Lymphocytic Leukemia (CLL) definition
chronic leukemia with abnormal b lymphoctyes, generalized lymphadenopathy
if blood and bone marrow involvement its call CLL
in those with enlarge lymph nodes, its called small lymphocytic lymphoma
CLL incidence/predisposing factors
-most common leukemia in adults, especially elderly. 90% of patients are >50 years old, median age 65
- slow progressing dz, origin unknkown
- 1st degree relatives are 3 x more likely to get CLL
- more common in russian and eastren european jewish descent
- more common in farmers, men
- associated with warm antibody autoimmune hemolytic anemia
- median survival 6 years
S&S of CLL
- asymptomatic
- fatigue, malaise, lethargy, anorexia, progressive weight loss, early satiety, lymph node enlargement (painless), pain or feeling of fullness below the ribs
- fever is RARE
- strong reaction to insect bites
- lymphadenopathy: usually cervical, supraclavicular, and axillary; usualy mobile and nontender with rubbery feel
- hepatosplnomegaly
Hallmark lab finding for CLL
Lymphocytosis
minimal level >5000
usual range 40,000-150,000
lymphocytes are 75% to 98% of circulating cells
peripheral smear findings for CLL
smudge cells
immunoglobulins in CLL
hypogammaglobinemia
-IgG, IgA, IgM levels are low
lymphocytes specific to CLL
B lymphocyte lineage marker CD19 with T lymphocye marker CD5
Bone marrow results CLL
more than 30% lymphocytes seen
focal or diffuse infiltration
extent of marrow infiltration correlates with severity of disease
Rai system stages (5)
Stage 0: lymphocytosis only Stage 1: lymphocytosis plus lymphadenopathy Stage 2: organomegaly Stage 3: anemia Stage 4: thrombocytopenia
CLL management
consult hematology/oncology
- therapy not initiated until symptoms occur
- chemo given according to staging and presence or absence of deletions at 11 q and 17 p
- chemo combined with targeted therapy drug (usually monoclonal antibody) and/or an immunotherapy
chemotherapy if younger than 70 for CLL
- FCR: fludarabine, cyclophosphamide, rituximab
- FR: fludarabine, rituximab
- PCR: pentostatin, cyclophosphamide, rituximab
- Bendamustine with rituximab
- consider stem cell transplant after induction for those under 65 year
chemo of older than 70 for CLL
chlorambucil and rituximab
bendamustine and rituximab
alemtuzumab
lenalidomide
which med does clinical guidelines say is best for higher response rate and lasting results for CLL
fludarabine
Stages and survival for CLL
Stage 0-1 disease median 10-15 years
Stage 3 and 4 median survival 2 years
Radiation for CLL
usually used for localized nodule masses that are refractory to chemo
Supportive care for CLL
flu shot
pneumo shot q 5 years
avoid live vaccines and zooster
Chronic Myelogenous Leukemia (CML) definition
disorder characterized by myeliod cell production
- abnormal cells overcome and replace normal hematopoiesis
- clonal stem cell disorder
- Philadelphia chromosones in leukemia cells translocated pieces fuse the gene BCR/ABL protein leading to leukemia
Chromosome linked specifically to CML
Philadelphia chromosome
Incidence/predisposing factors CML
- 7-15% of adult leukemias
- primarily disorder of middle age (median age 67)
- radiation exposure increases risk
- atomic bomb survivors have increased incidence 5-10 years after exposure
- unknown cause
- no significant hereditary link
- medican survival rate 3-4 years but may go into remission in 4 years with aggressive tx with TKI
S&S of early CML
insidious onset, fatigue, early satiety, weight loss, diminished exercise tolerance,
S&S of progression of CML
low grade fever, dizziness, irritability, increased sweating/night sweats, abdominal fullness, bone pain, blurred vision, resp distress, splenomegaly, , bone pain/sternal tenderness, hepatomegaly, bleeding and infection with blast crisis
Hallmark lab of CML
WBCs elevated, blasts usually <5%
BCR/ABL gene dectected with use of polymerase chain reaction
Labs of CML
- HGB and HCT normal and decrease with progression
- platelets up at the beginning then drop with progression
- B12 elevated
- LDH and uric acid elevated
- Philadelphia chromosome present
- low to absent leukocyte, less than 22
Management of CML
Hematology/oncology referral
-no therapy until WBC < 200,000 or evidence of priaprism, confusion, DVT, visual blurring, SOB
Best TKI for CML
imatinib for BCR/ABL
If imatinib fails, what is second line for CML
nilotinib or bosutinib
3rd line tx for CML
omacetaxine
Last resort for CML
hematopoietic stem cell transplant
Support therapy for CML
- hydration
- allupurinol (hyperuricemia)
- hydroxyurea or apharesis for leukocytosis
- TKI
- hydroxyurea, anti aggregants, anagrelide, or apharesis for thrombocytosis
Treatment length and intervals for CML
Treatment with TKI at month 3 and 6, then every 6 months after that
Drug that alter therapeutic effects of TKIs
drugs that induce or inhibit CYP3A4 (Clarithromycin, telithromycin, nefazodone, itraconazole, ketoconazole, a) and CYP3A5 (Cobicistat) enzyemes
only curative therapy for CML
allogenic bone marrow transplant (from sibling)
BUT there is 40% change of death in the 1st year due to adverse effects of transplant
