The Leukaemias FAR TOO MANY CELLS FAR TOO
- Slides: 60
The Leukaemias - FAR TOO MANY CELLS; FAR TOO MANY VOWELS - toby m robins
Leukaemia may be Acute or Chronic
and it may be Lymphoblastic Myeloid or
Put that all together and you get Acute lymphoblastic leukaemia Acute myeloid leukaemia Chronic lymphoblastic leukaemia Chronic myeloid leukaemia
For each, we will briefly cover • • Definition Epidemiology Aetiology Pathogenesis Clinical features Investigations Management Prognosis
but first What exactly IS leukaemia?
Leukaemia is Production
of abnormal WBCs
at an excessive rate
+/- reduced destruction
i. e. it is malignancy of the leukocytes
and it is clonal - ie all the malignant cells have a recent common ancestor
it is classified according to 1. the dominant cell type and 2. the duration from onset to death
Chronic leukaemia Untreated, exceeds one year (with gradual onset of symptoms)
Acute leukaemia Untreated, death ensues within a few months
The acute ones ALL (acute lymphoblastic leukaemia) AML (acute myeloid leukaemia)
firstly Acute Myeloid Leukaemia
Definition of AML Neoplastic proliferation of myeloid blast cells
Myeloid blast cells explained Mature blood cells are derived originally from pluripotent stem cells
Meyloid blast cells explained Pluripotent stem cells then divide and M differentiate either into L myeloid stem cells or lymphoid stem cells
Myeloid blast cells explained Lymphoid stem cells make lymphocytes Myeloid stem cells make all the other blood cells
SEW
There’s more than ONE kind of AML • Morphologically, there are seven and a half: – M 1 = undifferentiated blast cells – M 2 = myeloblastic – M 3 = promyelocytic – M 4 = myelomonocytic – M 4 eo = myelomonocytic with dysplastic eosinophils – M 5 = monocytic – M 6 = erythroleukaemia
Epidemiology 70 -year-old, male, Eastern European Jews
Aetiology ?
Aetiology • All implicated have been – Heredity – Radiation – Mutagenic drugs – Chemical & other occupational exposures – secondary to previous chronic leukaemia or myelodysplasia
Clinical features • Symptoms and signs are a result of 3 things: – 1. Marrow failure – 2. Leukaemic infiltration of tissues – 3. Consitutional upset
Symptoms relating to marrow failure • Infection • Bleeding or easy bruising • symptoms of anaemia - shortness of breath, etc
Symptoms relating to leukaemic infiltration • Symptoms of a mass lesion (rarer, since leukaemias by definition tend not to form masses) – bone – breast, uterus, ovary – cranial or spinal dura – GI tract – lung or mediastinum – prostate
Symptoms relating to constitutional upset • • • Malaise Fatigue Weakness Fever or sweats Anorexia or weight loss Non-specific cough
Signs relating to marrow failure • Evidence of infection • Signs of anaemia • Purpura or signs of bruising/bleeding – including retinal haemorrhages
Signs relating to leukaemic infiltration • • • Hepatosplenomegaly Lymphadenopathy Sternal tenderness Thymic mass Gingival hypertrophy
Signs relating to constitutional upset • Fever
Investigations • • • FBC Blood film U&Es LFTs coagulation (especially for the DIC of M 3) • Bone marrow examination • cell markers and molecular studies (eg
FBC • Anaemia • Neutropenia • Thrombocytopenia
Blood film • Blast cells that contain – granules – Auer rods
U&Es, LFTs • The following are occasionally increased – calcium – urea – LFTs
Bone marrow examination • Blast cells constituting > 20% of the bone marrow cells is diagnostic
Cell markers, molecular studies • Flow cytometry (immunophenotyping) may aid in morphological (ie appearance-based) diagnosis and may add further prognostic information • Karyotyping, FISH, and PCR may confirm diagnosis (eg acute promyelocytic leukamia; =M 3), + may add information not otherwise
Management includes • Intensive chemotherapy • Bone marrow transplant • Supportive care
Chemotherapy • Divided into 3 phases – 1. Remission induction – 2. Remission consolidation – 3. Remission maintenance
1. Chemotherapy for remission induction • Complete remission (CR) – full recovery of haematopoiesis, with – blasts accounting for < 5% of bone marrow cells • Involves mainly – anthracyclines – cytosine arabinoside
Why have they chosen these drugs? • Anthracyclines – because AML is like cycling a “myel” and a half with anthrax • Cytosine arabinoside – think “sight-o-seen arabocide” – because some (ignorant, misinformed, prejudiced) people because think an Arab that comes within a “myel” radius should be shot on sight
2. Chemotherapy for remission consolidation • Involves similar chemotherapy to that of remission induction
3. Chemotherapy for remission maintenance • Treatment is continued for 2 years in ALL, but for a much shorter time in AML
Bone marrow transplant (BMT) • Suitable marrow may be – allogeneic (from histocompatible siblings or unrelated donors) – syngeneic (from an identical twin) – autologous
BMT continued • Used increasingly as a form of consolidation • Use depends on the pt’s age – the elderly develop more complications
BMT continued • Marrow is infused intravenously to “rescue” the pt from otherwise supralethal chemoradiotherapy • Enables destruction of (almost) all leukaemic cells and the entire immune system with eg cyclophosphamide plus total body irradiation
Why use cyclophosphamide? • ‘cause you midas well make phossels out of all those nasty leukaemia cells in one foul swoop (cycle) A FOUL SWOOP
BMT continued • To reduce graft vs host effect – cyclosporin +/– methotrexate • Complications – graft vs host disease – infections (commonly CMV) – veno-occlusive disease – relapse of leukaemia
Supportive treatment • Blood transfusion for anaemia • Platelet transfusion for thrombocytopenic bleeding • Prompt antibiotic treatment, and prevention, of infections • Hygeine
Prognosis • 70% achieve complete remission lasting (on average) 12 months • Long-term survival (~ 50%)
Secondly Acute Lymphoblastic Leukaemia
Definition Neoplastic proliferation of lymphoblasts
Types of ALL • Common – phenotypically pre-B lymphocytes – 75% of cases • T-cell • B-cell • Null-cell
Aetiology as for AML
Epidemiology (Common ALL) • 4 -year-olds
Epidemiology (T-cell ALL) • Adolesce nt males
Clinical features as for AML
Investigations • As for AML • Blood film shows – small blasts with – a high nuclear-cytoplasmic ratio
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