Acute Leukemia¶
Robert Corty
Background¶
- Hematological malignancy caused by unchecked proliferation of WBC precursors in the bone marrow
- Pt’s with suspected acute leukemia require hospitalization for urgent diagnosis & treatment
- Types:
- AML = Acute Myeloid Leukemia
- APL = Acute Promyelocytic Leukemia defined by translocation (15;17) PML-RARA
- ALL = Acute Lymphocytic Leukemia
- AML = Acute Myeloid Leukemia
- Risk Factors:
- radiation, chemical exposures (e.g benzene), chemotherapy (esp alkylating agents)
- HIV, immunosuppression, smoking
- myeloproliferative disorders, aplastic anemia
Presentation¶
- Leukocytosis, leukemia cutis, gingival hypertrophy, leukostasis
- Functional Leukopenia, often neutropenia: recurrent infections
- Anemia: fatigue, pallor, dyspnea
- Thrombocytopenia: gingival bleeding, epistaxis, petechiae, ecchymoses, menorrhagia
- Extramedullary hematopoiesis: splenomegaly, hepatomegaly, lymphadenopathy
Evaluation¶
- Diagnosis of acute leukemia requires one of the following:
- 20% blasts in peripheral blood
-
20% blasts in bone marrow biopsy
- Any pathognomonic cytogenetic abnormality of t(8;21), inv(16), t(15;17)
- Check for the presence of these time-sensitive conditions.
- DIC – check fibrinogen, PT, PTT, platelets
- TLS – check uric acid, phosphate, K+
- Neutropenic fever – check temp, neutrophil count
- Leukostasis (see below)
- Presumptive APL – promyelocytes on diff, DIC or Auer rods on smear
- Confirm if peripheral flow cytometry ordered/in process
- Use hematology admission order set
- Set RBC and Plt transfusion thresholds
- Order nurse-driven electrolyte repletion
- ECG and TTE to establish pre-chemotherapy cardiac function
- Daily labs: CBC, TLS, DIC
- TLS prophylaxis
Management¶
- Consult hematology
- Discuss chemo plan and order double lumen PICC for reliable access
- If findings suggest APL start ATRA
- Subspecialized lab tests: bone marrow biopsy, cytogenetics, FISH
- Monitor for Common Complications/Emergencies: (see individual
sections)
- TLS, DIC, Febrile Neutropenia, Leukostasis
Additional Information¶
- Obtain blood product consent on admission
- APL Specific findings: promyelocytes on differential or Auer rods on smear
- Differentiation syndrome: promyelocytes differentiate
- Symptoms and signs: fever, SOB, Hypotn, peripheral edema, pleural effusion, AKI
- Diagnosis: No defined criteria. If suspicious, discuss with hematology fellow
- Management: steroids. If critically ill, hold ATRA and ATO and consider hydroxyurea
Leukemia Treatment Overview¶
- General strategy is to use “induction” chemo to try to induce clinicopathologic (as opposed to molecular) “remission”
- Defined as absence of symptoms, normal CBC, and <5% blasts in bone marrow (on day 28)
- Then waiting in hospital until neutrophil count >500 (typically ~3 weeks)
- From there, bone marrow transplant (for high-risk disease) or “consolidation” chemo for normal-risk or low-risk disease
AML Treatment¶
- Induction
- Typical is “7+3” i.e. idrarubicin on days 1-3 and cytarabine on days 1-7
- If therapy-related AML, MDS-related AML, or AML with cytogenetics similar to MDS, use “Vyxeos” which is liposomal daunorubicin and cytarabine on days 1, 3, and 5
- If low-risk dz (t(8;21) or inv(16)), use cytarabine on days 1-7, and 3 days of low-dose daunorubicin + gemtuzumab-ozogamicin
- There are other induction regimens that can be used depending on specific cytogenetics and patient frailty, which is beyond the scope of the handbook
- Consolidation
- Typically “HiDAC”(high-dose Ara-C i.e. cytarabine)
- Generally too toxic for pts with age > 60, so a dose reduction is used
- In the case of relapse, typical treatment is a different high-dose chemo and BMT if possible
- Typically “HiDAC”(high-dose Ara-C i.e. cytarabine)
ALL Treatment¶
- Typical induction is “HyperCVAD” (hyper-fractionated cyclophosphamide, vincristine, doxorubicin (“A” due to trade name Adriamycin), and dexamethasone
- If t(9;22) (known as Philadelphia chromosome), use tyrosine kinase inhibitor (TKI)
- If CD20+, use rituximab
Common Chemotherapy Regimens for Leukemia Encountered as Inpatient¶
Regimen | Components | Use |
---|---|---|
7+3
|
Cytarabine (Ara-C) x 7 d & Anthracycline (e.g. idarubicin x3 d) | AML induction |
Vyxeos | Cytarabine + liposomal daunorubicin | AML-MRC or t-AML |
CLAG-M | Cladribine, cytarabine (Ara-C), Filgrastim (G-CSF), mitoxantrone | AML induction (relapsed/refractory) |
HIDAC | High-dose cytarabine | AML consolidation |
ATRA | All-trans retinoic acid given with arsenic trioxide (ATO) |
APL (APML) |
HyperCVAD/MA | CVAD = Cyclophosphamide, vincristine, doxorubicin, dexamethasone MA = methotrexate/cytarabine (Given as alternating cycles) |
ALL |
R-CHOP | Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone | NHL |
R-EPOCH | Etoposide plus the drugs above (dosing is different) |
NHL |
ABVD | Doxorubicin, bleomycin, vinblastine, dacarbazine | HL |
Last update:
2022-06-25 02:05:01