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Leukaemia. Dr. Maria Krutikov FY1 Tuesday 15 th Nov 2011.  Cancer affecting bone marrow and blood causing uncontrolled proliferation of cells at different stages of proliferation. Lymphocytic vs Myelogenous. Lymphocytic affects lymphoid marrow that form lymphocytes
LeukaemiaDr. Maria Krutikov FY1 Tuesday 15th Nov 2011 Cancer affecting bone marrow and blood causing uncontrolled proliferation of cells at different stages of proliferationLymphocytic vs Myelogenous
  • Lymphocytic affects lymphoid marrow that form lymphocytes
  • Myelogenous affects myeloid marrow that forms red blood cells, platelets and white blood cells
  • Acute vs Chronic
  • Acute causes number of blasts (young immature, non-functional) to increase rapidly and crowd out functional cells in marrow and enter circulation
  • Chronic affects non-functioning mature cells that slowly increase in number and eventually crowd out functional cells
  •  Can develop into ACUTE leukaemia Risk Factors
  • Smoking
  • Radiation exposure
  • Downs syndrome
  • Past chemotherapy
  • Exposure to Hydrocarbons
  • Myelodysplasia
  • Presentation 4 Main Types:
  • Acute Lymphocytic (lymphoblastic) ALL
  • Acute Myelogenous (myeloid) AML
  • Chronic Myelogenous (myeloid) CML
  • Chronic Lymphocytic (lymphoblastic) CLL
  • ALL
  • Most common in children
  • 550 new cases / year (UK)
  • Survival – 85% in children, 35% in adults
  • 30 % have Ph chromosome – poor prognosis
  • Radiotherapy + Chemotherapy +/- stem cell transplant
  • PresentationMarrow failure: Infiltration:AnaemiaHbhepatosplenomegalyInfection – neutropenialymphadenopathyBleeding + orchidomegaly CNS involvement ie. CN palsy, meningismInfection - mouth, perianal, chest, skin, Herpes Zoster, Candida, measles, CMV Treatments
  • Supportive: Transfusion, IV fluids, Allopurinol (prevent tumour lysis), Hickmann line
  • Chemotherapy: different regimens
  • BMT
  • AML
  • More commonly in adults and in men
  • Common complication of chemotherapy
  • 5 year survival – 40%
  • Chemotherapy +/- stem cell transplant
  • Philadelphia chromosome
  • BCR-ABL gene t(9,22) – produce aggressive tyrosine kinase that prevents myelocytes from developing into neutrophils
  • AMLMarrow failure: thrombocytopenia, neutropenia, anaemia, leucostasis (resp distress + altered mental status), DIC - cytokines released that alctivate clotting cascade forming microemboliOrgan infiltration
  • C/O dizziness, SOB, early satiety, petechiae, bruises, gingivitis, bone pain, fever, infection
  • Can cause gout as plasma URATE increases – give allopurinol + hydrate
  • Hyperviscosity – increased risk stroke / MI
  • Auer rods – crystals of coalesced granules
  • Supportive
  • Chemotherapy – long term (5 cycles in 1/52 blocks, induce remission)
  • Tyrosine Kinase inhibitor
  • BMT
  • Acute promyelocytic leukaemia – t(15;17) release of thromboplastin, present w DIC and treated with Vitamin A to switch off the geneCML
  • Uncontrolled clonal proliferation myeloid cells
  • Mainly in adults + males
  • Slow progression -> splenomegaly
  • Philadelphia chromosome in 80%
  • Treated w immunomodulators ie. Imatinib (Glivec)
  • 5 year survival – 90%
  • Chronic + insiduous: weight loss, fatigue, fever, sweats gout features, bleeding, anaemia, bruising, abdo discomfort – hepatosplenomegaly
  • No lymphadenopathy as myeloid do not mature in lymph nodes
  • ↑WCC , ↓Hb, ↑urate and B12
  • Hypercellular bone marrow
  • Use Imatinib (Glivec) or
  • Stem cell transplant CLL
  • Monoclonal proliferation of non-functioning mature B cells
  • Affects adults > 55 years, never children
  • 5 year survival – 75%
  • Incurable
  • Late defect in maturing lymphocyte
  • Very slow progression therefore splenomegaly + hepatomegaly + lymphaenopathy
  • Infection + anaemia + severe sweats, weight loss and anorexia
  • Enlarged rubbery non-tender nodes, lymphatic obstruction, hepatosplenomegaly
  • Autoimmune haemolysis
  • Infection due to decreases IgG esp HZV
  • If present later - ↑WCC as at first WCC have not yet spilled over into blood
  • Treatments NON-CURATIVE
  • Asymptomatic – monitor
  • Chlorambucil
  • Steroids – autoimmune haemolysis
  • Radiotherapy – relieve hepat/splenomegaly
  • Supportive – transfusions, IV human IgG
  • Investigations
  • FBC + haematinics + U+Es + urate
  • Blood film
  • Bone marrow biopsy
  • CXR +/- CT (mediastinal /abdolymphadenopathy)
  • Flow cytometry- looks at antigen exression on cell surface to elicit stage of development of cells involved
  • FISH – fluorescent in situ
  • hybridisation- fluorescently labelled DNATreatments
  • Supportive – transfusions, IgG
  • Radiotherapy
  • Chemotherapy – vaying regimens
  • Biologic agents ie Glivec
  • Prophylactic – Abx
  • Bone marrow transplant – allogenic transplant from HLA matchingdonor
  • Tumour lysis syndrome
  • Rapid cell death on starting chemo can cause rapid rise in URATE, POTASSIUM, PHOSPHATE causing renal failure
  • Need prevention with good hydration and allopurinol 24h before chemo
  • Special considerations
  • Barrier nursing, side room,
  • Avoid IM injections – chance of infected haematoma
  • Avoid PR exams
  • Candida prophylaxis
  • Oral hygiene – hydrogen peroxidase mouthwash
  • Avoid cut flowers - pseudomonas
  • Conclusions
  • Need to consider cells involved to predict symptoms
  • Variety of treatments available with new developments amongst biologic agents
  • Good prognosis in young
  • Should be in differential for PUO, weight loss, fatigue and neutropenia
  • ?
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