Acute Lymphoblastic Leukemia

Question. Write short note on leukemia.

Answer. Leukemia is defied as clone of malignant cells derived from myeloid or lymphoid stem cells.

Etiology Of Leukemia

• Genetic factors such as familial, identical twins, congenital disorders.
• Environmental factors, i.e. atomic radiation and pollution Ionizing radiations
• Retroviruses
• Chemical agents, i.e. alkylating agents, cytotoxic drugs.

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Types Of Leukemias

Acute Leukemia

• Acute lymphoblastic leukemia
• Acute myeloid leukemia

Chronic Leukemia

• Chronic lymphatic leukemia
• Chronic myeloid leukemia.

Clinical Features Of Leukemia

• Anemia
• Fatigue and lethargy
• Fever
• Bone and joint pain
• Combination of pallor, petechiae or purpura is present.
• Mucus membrane is bleeding
• Hepatomegaly, splenomegaly and renomegaly is present.
• There is tenderness over other bones.

Investigations Of Leukemia

• Bone marrow picture shows hypercellular reaction is present with premature and primitive cells.
• There is presence of biochemical changes with presence of
• Philadelphia chromosome.
• Peripheral blood fim show normocytic normochromic picture with an abundance of neutrophil, myelocyte,metamyelocyte.
  White cell counts are elevated

Treatment Of Leukemia

• Chemotherapy, bone marrow transplantation or both should be done.
• New regimes are derived regularly and are tailored to specifi illness
• Treatment is given in several phases, with a period of induction chemotherapy to induce remission followed by maintenance and consolidation phases.
• This multiphase treatment is designed for further deplete malignant cells from bone marrow to achieve complete cure.

Question. Briefl describe Acute Leukemia.
Or
Describe the etiology, clinical features and management of acute leukemia.

Answer. Acute leukemia is defied as an uncontrolled growth of immature hemopoietic cells at the exposure normal marrow tissue.

Etiology Of Acute Leukemia

• Radiation: Association between radiation­induced genetic damage to the hemopoietic progenitors and development of myelodysplasia and acute leukemia is seen after nuclear disease.
• Chemical and drugs: Chronic benzene exposure and use of cytotoxic and immunosuppressive agents.
• Oncogens and cytogenic abnormalities
• Genetic factors, i.e. genetic disorders such as Down’s syndrome, Klinefelter’s syndrome, etc.
• Viruses: Infection by human lymphotrophic virus (HTLV­1).

Clinical Features Of Acute Leukemia

• Symptoms due to anemia, i.e. tiredness, weakness and marked pallor.
• Hemorrhagic manifestation: Petechiae, bleeding from gums and nose, persistent bleeding after tooth extraction.
• Infection: It causes infective lesions of mouth and throat, i.e.
  ulceration of mouth and pharynx, herpes simplex infection of face and infection of respiratory tract such as bronchitis and pneumonia.
• Symptoms of cellular hyperviscosity
• There are tissue deposits of leukemic cells causing gum hypertrophy which is common in myelomonocytic and monocytic variety of AML.
• Lymphadenopathy and splenomegaly are common in acute lymphoid leukemia.
• Signs of organ infitration are present, i.e.
• CNS: Meningeal involvement occurs in children with acute lymphocytic leukemia.
• Skin: Bluish nodules or dusky red patches are present.
• Kidneys: Presence of kidney failure.
• Other sites: Testes, ovary, liver, gut and serous membranes such as pleura and peritoneum.
• Bone pain are present i.e. tenderness of sternum, osteolytic bone lesions and pathologic fractures may occur.
• Constitutional symptoms, i.e. fever, malaise and prostration.
• Roth’s spot, i.e. presence of white central retinal hemorrhages in acute myeloid leukemia

Management Of Acute Leukemia

Chemotherapy Of Acute Leukemia

• Induction phase: Initial high dose chemotherapy in order to reduce leukemic cells below the levels of morphogenic detection

Treatment Regimen for Acute Lymphoblastic Leukemia

• Vincristine 1.4 mg/m2 IV weekly for 4 weeks.
• Prednisolone 60 mg/day for 4 weeks.
• L- Asparaginase 50–200 ku/kg IV for 4 weeks.
• Daunorubicin 30 mg/m2 IV daily for two weeks.

Treatment Regimen for Acute Myeloid Leukemia

• Daunorubicin IV alternate days 3 doses.
• Cytosine arabinoside IV BD for 10 days
• Thioguanine oral BD for 10 days.
• In this, blood transfusion and platelet transfusion are required.
• CNS prophylaxis: Intra thecal methotrexate is given in acute lymphoblastic leukemia
• Consolidation: Another dose of chemotherapy to reduce leukemic burden

In Acute Lymphoblastic Leukemia

• IV daunorubicin
• IV cytosine arabinoside
• IV Etoposide
• Methotrexate, 6 thioguinine
• Dexamethasone

In Acute Myloid Leukemia

• High dose IV Cytosine arabinoside is given
• Maintenance: Low dose chemotherapy for 18 months to 2 years

In Acute Lymphoblastic Leukemia

• Oral Prednisolone
• IV Vincristine
• Oral 6 mercaptopurine
• Oral Methotrexate

In Acute Myeloid Leukemia

Post remission therapy is given, i.e. myeloablative therapy followed by bone marrow transplantation in relapse or those with high­risk chromosomal changes.

Bone marrow transplantation Of Acute Leukemia

In Acute Lymphoblastic Leukemia
Allogenic bone marrow transplantation is an option in acute lymphocytic leukemia patients entering first remission who have an HLA identical sibling, provided the sibling is fi and is less than 55 years.

In Acute Myeloid Leukemia
In adult patient­high dose chemotherapy with autologus transplantation of hemopoietic stem cells derived from peripheral blood or bone marrow can be done.

Supportive Care Of Acute Leukemia

• Hemoglobin level should not allow falling below 8 g/dL by transfusing 4 units of packed RBCs. This is done to avoid anemia.
• If bleeding is present, then there is transfusion of pooled or single donor platelets.
• Good nursing, prophylactic gastrointestinal tract decontamination, antibiotics and attntion to flid balance are given to prevent infections.
• If disseminated intravascular coagulation is present, then firinogen replacement, platelet transfusion twice daily and anticoagulants are given.
• Pneumocystis jiroveci pneumonia is a risk during the treatment of acute lymphocytic leukemia maintenance therapy.
• Hyperuricemia is prevented by adequate hydration and pretreatment with allopurinol which should be continued till peripheral blood is cleared of blast cells.