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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

7

Signs and symptoms of ALL

1. Marrow failure=
Anemia
Bleeding
Infection
2. Infiltration
Hepato/splenomegaly
Lymphadenopathy
Orchidoplexy
CNS->CN palsies, menningism

8

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

10

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

11

Where is relapse common in ALL

1. Blood
2. Testes

12

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

13

What is AML, incidence, asssociations

1. Acute myeloid leukemia
2. Most common leukemia in adults
3. Associated with radiation, MDS, Downs syndrome

14

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

16

What findings on smear is diagnostic of AML

Auer rods

17

How is AML diagnosed

1. Immunophenotyping, molecular methods
2. Cytogenetic analysis

18

Pitfalls in AML complication recognition

1. AML itself causes fever
2. Common organisms present oddly
3. Few antibodies are made
4. Rare organisms (fungi)

19

Treatment for AML

1. Supportive as for ALL
2. Chemotherapy
3. Bone marrow transplant

20

Prognosis in AML

1. 60% long term survival

21

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

22

Signs in CML and investigations

1. +Liver/spleen, anemia, bruising
2. ++WBC, +BEN, anemia, PLT
3. +Urate, +B12.
4. Hypercellular BM

23

Natural history in CML

1. Survival 5-6 years
2. Chronic (months)->accelerated (+sympT, +spleen)->blast transformation

24

Treatment in CML

1. Chemotherapy->Imatinib specific BCR:ABL tyrosine kinase inhibitor
2. Hydroxycarbamide
3. Dasatinib
4. Stem cell transplant

25

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

26

Typical presentation in CLL

1. Asymptomatic
2. Surprising finding on routine blood tests
3. Enlarged, non-tender rubbery nodes, +spleen/liver

27

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

28

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

32

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

33

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

36

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

37

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

39

Classification of HL

1. Nodular sclerosing
2. Mixed cellularity
3. Lymphocyte rich
4. Lymphocyte depleted

40

Causes of NHL

1. Congenital immunodeficiency
2. Acquired immunodeficiency
3. HIV infection
4. Infection->HTCLV-1, EBV, H pylori
5. Environmental toxins

41

Is NHL just LN

No, can occur at other lymphoid tissue->MALT

42

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

43

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

44

Chemotherapy regime in high grade NHL

RCHOP
Rituximab
Cyclophosphamide
Hydroxydaunorubicin
Vincristin (Oncovin)
Prednisolone