Leukemia Flashcards by Leslie Mancini

leukemia

definition

Leukemia is a malignancy of the blood
Increased production and proliferation of abnormal leukocytes and leukocyte precursors in the bone marrow and in circulating blood

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lines of leukemia

Myelogenous leukemias arise from the granulocyte
(neutrophils, eosinophils, basophils and monocytes), erythrocytes and platelets.
Acute Myeloid Leukemia (AML) and Chronic Myeloid Leukemia (CML)
Lymphocytic leukemias involve the lymphocyte lineage
T and B lymphocytes.
Acute Lymphocytic Leukemia (ALL) and Chronic Lymphocytic Leukemia (CLL)

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leukemia

patho

Uncontrolled/dysfunctional multiplication of one or more types of leukocytes, resulting in the presence of undifferentiated, immature, nonfunctional cells in the bone marrow.

Malignant transformation occurs at different levels of cell differentiation

Acute leukemias
High proportion of immature and nonfunctional cells
Blast cells

Chronic leukemias
Higher proportion of mature cells
Some of these cells have reduced function

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Acute vs chronic leukemia

Acute leukemias
High proportion of immature and nonfunctional cells
Blast cells

Chronic leukemias
Higher proportion of mature cells
Some of these cells have reduced function

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Sub-types of Leukemia

chronic leukemias tend to have leukocytosis (increase in leukocytes)

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Chronic Lymphocytic Leukemia (CLL)

General

aka small lymphocytic lymphoma (SLL)

CLL/SLL is considered one disease with different manifestations
CLL = disease primarily manifesting in the blood
SLL = disease involvement primarily nodal

Characterized by the progressive accumulation of a population of small mature B lymphoctyes

Most common form of adult leukemia
Median age of diagnosis is 70
CLL has a strong familial predisposition
No definitive causative factors are associated with CLL

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CLL/SLL

Clinical manifestations & Physical Examination

Asymptomatic (with incidental findings on a CBC)
Fatigue
Dyspnea on exertion
Increased incidence of infections
Lymphadenopathy
Splenomegaly
“B” symptoms – Fevers, night sweats, weight loss
Appetite loss
Unusual bruising/bleeding

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CLL/SLL

Workup/Diagnosis

CBC with differential
Leukocytosis
Lymphocytosis (high)
Anemia
Thrombocytopenia
Peripheral smear – “smudge cells” - classic for CLL
Hypogammaglobulinemia
Flow cytometry immunophenotyping
Increased number of circulating lymphocytes that are monoclonal B cells expressing CD5 antigen
Cytogenetic studies (FISH, etc.)
Lymph node biopsy
CT scans
+/- bone marrow biopsy

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CLL

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CLL

factors to consider for Tx

May develop
Autoimmune hemolytic anemia
Autoimmune thrombocytopenia
Initiation of therapy dependent on several factors
Lymphocyte doubling time- looking at CBCs to see how fast WBC count doubles.
Disease stage
Age
Comorbidities
Symptoms
ACFatigue
Symptomatic lymphadenopathy
Therapy goal in most patients is palliation

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CLL

Early stage
Observation

Targeted biologics- not chemo
Anti-CD20 agent (Rituximab{Rituxan}, Obinutuzumab{Gazyva}) + one of the following:
Tyrosine kinase inhibitor:
Ibrutinib (Imbruvica)
BCL-2 targeted agent:
Venetoclax (Venclexta)

Curative therapy (allogeneic transplant) is reserved for younger patients with aggressive symptomatic disease

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Ibrutinib (Imbruvica)

general

BTK Inhibitor
Inhibits Bruton tyrosine kinase leading to inhibition of malignant B cell proliferation

Dosing: 420mg PO daily
Caution with CYP3A inhibitors

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Ibrutinib (Imbruvica)

Side effects

Side effects:
Lymphocytosis (increases by 2-3x before it goes down)
HTN
Cardiac arrhythmias
Rash
Infections
Bleeding risk in conjunction with Warfarin (Coumadin)

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Venetoclax (Venclexta)

general

BCL-2 Inhibitor
Inhibits B-cell lymphoma 2 protein leading to restoration of apoptosis
Dosing: 400mg PO daily (slow titration to max dosing)

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Venetoclax (Venclexta)

side effects

Side Effects:
Tumor lysis syndrome
May need hospitalization for first cycle
Neutropenia
Infection

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Tumor Lysis Syndrome

general and clin man

Risk in hematologic and rapidly proliferating solid tumor malignancies
Caused by rapid release of cellular contents

With impaired breakdown:
Hyperuricemia
Acute kidney injury
Hyperkalemia
Hyperphosphatemia

Clinical manifestations
Nausea/vomiting
Seizures
Arrhythmias
Death

tumor lysis syndrome

Prevention
Baseline uric acid level

Allopurinol 100mg PO daily-TID starting before chemotherapy initiation
Inhibits xanthine oxidase (prevents conversion to uric acid)

Rasburicase IV weight dosing IV x 7 days
Converts uric acid to allantoin, inactive metabolite easily renally excreted
Avoid with G6PD deficiency

Aggressive IV hydration

Chronic Myeloid Leukemia (CML)

general

Malignancy driven by the BCR-ABL-1 gene product (active tyrosine kinase)
Translocation between the long arms of chromosomes 9 and 22
Philadelphia Chromosome (Ph)
15% of all cases of leukemia
Median age at diagnosis is 55yrs
No familial associations
Usually a primary leukemia

CML

Clin man

Typically asymptomatic with incidental findings on a CBC
Fatigue, malaise
Weight loss
Early satiety
LUQ pain
Bone pain
Night sweats
Thrombotic or vasoocculsive events
Splenomegaly (20-70%)

CML

phases

90% of patients present in the indolent or chronic phase
Chronic phase
Accelerated phase
Blastic phase

CML

signs of turning into acute (AML)

Signs of transformation to AML
Leukocytosis resistant to therapy
Increasing anemia
Increasing blasts
Constitutional symptoms

CML

CBC with differential
Leukocytosis (10-500) :
Left shift with many neutrophils
Bands
Myelocytes
Blasts
Elevated basophils

Thrombocytosis
Anemia in 1/3 of patients
CMP
Uric acid
Bone marrow biopsy with cytogenetic analysis
FISH testing (identifies % of Ph chromosome)
PCR for BCR-ABL gene

CML

Response to treatment is gauged by quantitative PCR levels
Tyrosine Kinase Inhibitor (TKI) therapy
Imatinib (Gleevec) 1st drug
30% reach major molecular response in 1 yr
Nilotinib (Tasigna)
71% MMR in 1 yr

Allogeneic transplant if fails TKI or in accelerated/blast phase

Leukopheresis
Symptoms from hyperleukocytosis
Total leukemia blood cell count greater than 50 x 109/L (50,000/microL) or 100 x 109/L (100,000/microL)
Symptoms of decreased tissue perfusion
Medical emergency!

Side effects of TKIs

Drug rashes
QTc prolongation
Edema
Cytopenias
Diarrhea

# Acute Lymphocytic Leukemia (ALL) general

Malignancy defined by the proliferation and accumulation of clonal blast cells (B- or T- lymphocyte progenitor) in the marrow Most common in **children** Median age at diagnosis: 15 57.2% < 20 at age of diagnosis 26.8% of cases are ≥45 at age of diagnosis 11% diagnosed at age ≥ 65yrs 75%-80% of acute leukemias in children Risk factors: Age >70 Exposure to chemo or radiation therapy Genetic disorders Down’s syndrome rare = neurofibromatosis, Klinefelter, Fanconi, etc. **Philadelphia chromosome and BCR-ABL1 fusion*

# ALL clin man

Presentation can be highly variable **Approx 50% patients present with fever** Fatigue and lethargy **> 25% of patients (esp. young children) may have a limp from bone pain or arthralgia** Arthralgia and bone pain less severe in adults Occasionally, life-threatening infection or bleeding Lymphoblasts can accumulate in various extramedullary sites Meninges, testes, thymus, liver, spleen, and lymph nodes

# ALL Labs/ Dx

CBC with differential, Anemia, neutropenia, and thrombocytopenia common **(All cell lines will be down)** Blasts (90% of patients have circulating blasts at diagnosis) CMP LDH Correlates with tumor burden Uric acid, phosphorus, calcium, (tumor lysis syndrome), coagulation studies Bone marrow biopsy (>20% lymphoblasts) Lumbar puncture Leukemic blasts can be identified in as many as 33% of pediatric patients and approx. 5% of adult patients at diagnosis of ALL most of these patients lack neurologic symptoms Echocardiogram Cardiac risks from chemotherapy

# ALL Chemo phases

Treatment consists of three standard phases: **Induction Consolidation Maintenance**

#ALL Tx

**Needs CNS-directed therapy** In adult ALL, long-term disease-free survival rates: 35 to 50% with chemotherapy alone 45 to 60% with allogeneic transplantation Most relapses typically occur during treatment or within the first 2 years after completion CAR-T therapy is improving survival

# ALL CAR-T therapy

* Chimeric antigen receptor T cells * A newer immunotherapy for relapsed refractory ALL in age <25yrs, also some types of lymphomas (in adults) * Patient’s own T cells are removed and genetically modified to express a receptor programmed to fight against specific cells (in this case those that express CD19, present on the B cell precursor in ALL) * T cells are infected using a virus carrying a specific CAR * The modified T cells are then infused back into the patient * Response rates up to 90% Unfortunately, frequent relapses

# Acute Myeloid Leukemia (AML) epidemiology and eti

Malignancy characterized by infiltration of bone marrow, blood, and other tissues by proliferative, clonal, undifferentiated cells (myeloid origin) Incidence increases with age Median age at diagnosis: 65 Risk factors: Benzene exposure Smoking Exposure to petroleum products, paint, embalming fluids, ethylene dioxide, herbicides, pesticides Certain genetic syndromes Prior chemotherapy Underlying bone marrow disorder

# AML Clin Man

Fatigue, weakness Anorexia Weight loss Fever (10%) Easy bleeding/bruising (5%) Occasionally bone pain Splenomegaly, Hepatomegaly Lymphadenopathy Sternal tenderness

# AML Workup/Dx

CBC with differential Anemia Thrombocytopenia Mild leukocytosis or leukopenia CMP, LDH, uric acid, phosphorus, coagulation studies Peripheral smear **Auer rods** on the peripheral smear Bone marrow biopsy (20% blasts) Flow cytometry Cytogenetic analyses (karyotype +/- FISH), Molecular analyses, HLA typing These studies are essential because of the prognostic value specific mutations hold +/- brain imaging +/- Lumbar puncture Echocardiogram

# Subtypes of AML Acute Promyelocytic Leukemia (APL)

Subtype of AML that must be quickly recognized and promptly treated Disseminated Intravascular Coagulation Significant GI bleeding, intrapulmonary hemorrhage, ICH Treatment can rapidly reduce DIC complications **ATRA (all-trans retinoic acid) + ATO (arsenic trioxide)** Without treatment, APL has median survival of < 1month With modern therapy, APL is associated with the highest cure rates

# AML Tx and complications

Treatment consists of Induction chemotherapy (to induce remission) Consolidation Transplant or some form of maintenance therapy Chemotherapy treatment has similar complications/risks as in ALL