Flashcards in Leukemia and lymphoma Deck (44):
1
Major concerns with leukemic patient falling ill suddenly
1. Infection
2. Bleeding
3. Hyperviscocity
4. Tumor lysis
5. Disseminated intravascular coagulation: malignancy, sepsis, trauma, obstetric
Non-specific confusion
a. Take blood culture
b. exclude hypoglycemia
c. UEC, LFT, Ca, clotting screen
d. Consider CNS bleeding->CT/MRI
2
Neutropenic regimen
1. Close liason with microbiologist and hematologist
2. Full barrier nursing. Hand washing.
3. Avoid IM injections->infected hematoma
4. Look for infection->mouth, axilla, perineum, IV site. Take swabs
5. Check: FBC, PLTs, INR, UEC, LFTs
6. Take cultures, urine, sputum, stool
7. CXR
8. Wash perineum after defecation
9. Oral hygeine
10. TPR obs 4 hourly
11. High calorie diet
12. Vases with roses pose a pseudomonas risk
13. Antibiotics: if febrile >38/toxic= septicemia, piperacillin+tazobactam + ceftriaxone
3
What is tumor lysis syndrome, electrolyte changes, risk+, prevention
1. Massive cell destruction= hyperkalemia, hyperuricemia, renal impairment
2. Risk + if +LDH, +Cr, +urate, +WCC
3. Prevention with high fluids, allopurinol pre cytotoxics
4
Management of DIC
1. Identify cause
2. Replace PLTS, cryoprecipitate (replacing fibrinogen), FFP to replace coagulation
5
What is ALL, associations and epidemioloy, CNS
1. Malignancy of lymphoid, either T/B cell
2. Arrested maturation, proliferation of Blast cells
3. Most commonly malignancy of childhood, rare in adults
4. CNS involvement is common
6
Classification systems in ALL
1. Morphological: L1, 2, 3
2. Immunological: Precursor B, T ALL, B ALL
3. Cytogenetic: Philaedelphia has poor prognosis
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Signs and symptoms of ALL
1. Marrow failure=
Anemia
Bleeding
Infection
2. Infiltration
Hepato/splenomegaly
Lymphadenopathy
Orchidoplexy
CNS->CN palsies, menningism
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Common infections in ALL
1. Mouth
2. Skin
3. Perianal
4. Lung
5. Pneumocystis
9
Investigations in ALL
1. FBC, peripheral blood smear w/ blasts, +WCC
2. CT/CXR for mediastinal
3. LP for CNS involvement
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Management of ALL
1. Educate and motivate
2. Supportive
Transfusions, IV fluids, allopurinol
Hickman line for IV access
3. Infections: neutropenia regime. IV antibiotics->co-trimoxazole to prevent Pneumocystsis, antivirals, antifungals
4. Chemotherapy
National trials
a. Remission induction
b. Consolidation
c. CNS prophylaxis
d. Maintenance for 2 years
5. Bone marrow transplant
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Where is relapse common in ALL
1. Blood
2. Testes
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Prognosis: cure rates, poor prognostics
1. 70-90% cure in children, 40% in adults
2. Prognostics
Male
Adult
Philadelphia: BCR:ABL translocation of 9:22
CNS
Anemic
+WCC
Minimal residual disease
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What is AML, incidence, asssociations
1. Acute myeloid leukemia
2. Most common leukemia in adults
3. Associated with radiation, MDS, Downs syndrome
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Morphological classification of AML
1. AML with recurrent genetic abnormalities
2. AML with multi-lineage dysplasia
3. AML therapy related
4. AML other
5. Acute leukemia of ambiguous lineage
15
Is CNS involvement in AML, what about gums
1. CNS involvement is rare
2. Finding of gum hypertrophy
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What findings on smear is diagnostic of AML
Auer rods
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How is AML diagnosed
1. Immunophenotyping, molecular methods
2. Cytogenetic analysis
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Pitfalls in AML complication recognition
1. AML itself causes fever
2. Common organisms present oddly
3. Few antibodies are made
4. Rare organisms (fungi)
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Treatment for AML
1. Supportive as for ALL
2. Chemotherapy
3. Bone marrow transplant
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Prognosis in AML
1. 60% long term survival
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What is CML, epidemiology, Philadelphia chromosome, symptoms
1. Proliferation of myeloid cells, 15% leukemia
2. Most common in 40-60, rare in childhood
3. Ph xsome most common abnormality
4. Fatigue, weight loss, gout, fever, sweats, bleeding, abdominal discomfort
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Signs in CML and investigations
1. +Liver/spleen, anemia, bruising
2. ++WBC, +BEN, anemia, PLT
3. +Urate, +B12.
4. Hypercellular BM
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Natural history in CML
1. Survival 5-6 years
2. Chronic (months)->accelerated (+sympT, +spleen)->blast transformation
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Treatment in CML
1. Chemotherapy->Imatinib specific BCR:ABL tyrosine kinase inhibitor
2. Hydroxycarbamide
3. Dasatinib
4. Stem cell transplant
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What is hallmark of CLL, epidemiology, rai staging
1. Most common leukemia, arrested B cells->+proliferation
2. Rai stage
0= Lymphocytosis >13yr survival
1= +lymphadenopathy 8yr survival
2= +spleno/hepatomegaly 5yr
3= +anemia 2 yr survival
4= +thrombocytopenia 1 yr survival
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Typical presentation in CLL
1. Asymptomatic
2. Surprising finding on routine blood tests
3. Enlarged, non-tender rubbery nodes, +spleen/liver
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Investigations and complications in CLL
1. +Lymphocytes
2. Autoimmune hemolysis
3. Marrow infiltration->anemia, neutropenia, thrombocytopenia
Complications
1. Autoimmune hemolysis
2. Marrow failure
3. +Infection due to hypogammaglobulinemia
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Management in CLL
1. Fldarabine + cyclophosphamide
2. Steroids in autoimmune hemolysis
3. Radiotherapy to relive lymphadenopathy/splenomegaly
4. Supportive
5. Stem cell transplant
29
Prognosis in CLL`
1. One third never progress
2. One third will progress in time
3. One third are actively progressing
30
What is lymphoma
1. Malignant proliferation of lymphocytes within lymph nodes, but can be in peripheral blood and infiltrate organs
31
Characteristic cell of hodgkins lymphoma
Reed-Sternberg
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Epidemiology of HL and risk associations
1. Young and elderly
2. More common in males
3. Risk + if affected sibling, EBV, SLE, post transfusion, Westernisation and obesity
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Symptoms of HL
1. Enlarged, non tender, rubbery superficial LN->cervical, axillary, inguinal
2. Weight loss, night sweats, pruritus
3. Mass effect from mediastinal mass->SVC obstruction/bronchial
4. Alcohol induced LN pain
34
Signs of HL
1. Weight loss, cachexia
2. Hepato-splenoM
35
Investigations in HL
1. FBC->anemia and low PLT
2. UEC, LFTs, LDH, Urate (cell turnover)->baseline prior to therapy commencement
3. ESR ++
4. CXR->mediastinal mass
5. PET-CT, LP
6. Contrast CT N, chest, abdomen/pelvis (for staging)
7. Excisional LN biopsy
8. Immunohistochemistry
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Staging in HL
1. Confined single LN region
2. 2+ nodal areas on same side of diaphragm
3. Nodes on both sides of the diaphragm
4. Spread beyond the LN->liver or bone marrow
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Management
1. Chemotherapy ABVD
Adriamycin
Bleomycin
Vinblastine
Dacarbazine
2. Radiotherapy
38
General risks in radiotherapy
1. Increased risk of secondary malignancies->solid
2. IHD
3. Hypothyroidism
4. Lung fibrosis
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Classification of HL
1. Nodular sclerosing
2. Mixed cellularity
3. Lymphocyte rich
4. Lymphocyte depleted
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Causes of NHL
1. Congenital immunodeficiency
2. Acquired immunodeficiency
3. HIV infection
4. Infection->HTCLV-1, EBV, H pylori
5. Environmental toxins
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Is NHL just LN
No, can occur at other lymphoid tissue->MALT
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Signs and symptoms of NHL
1. Nodal disease
2. Superficial lymphadenopath
3. Extranodal: oropharynx, skin, bone, gut, CNS, lung
4. Fever, night sweats, weight loss
5. Pancytopenia: anemia, infection, bleeding
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Investigations in NHL
1. FBC->anemia and low PLT
2. UEC, LFTs, LDH, Urate (cell turnover)->baseline prior to therapy commencement
3. ESR ++
4. CXR, LP
5. PET-CT
6. Contrast CT N, chest, abdomen/pelvis (for staging)
7. Excisional LN biopsy
8. Immunohistochemistry
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