Leukemia: Difference between revisions

Revision as of 15:44, 30 July 2020

Clinical Manifestations

Often cytopenia-related symptoms

Differential Diagnosis

Primary: suspect when multiple lineages affected, significant leukocytosis, lymphadenopathy, splenomegaly
Secondary
- Acute infection (30-50%)
- Chronic inflammation
- Stress (MI, surgery, burn) (30-50%)
- Steroids
- Pregnancy
- Cigarette smoking

Investigations

Urgent blood film review to r/o APL

Management

Acute

Rule out DIC (especially seen in APL)

Tumour lysis syndrome

2 or more: hyperkalemia, hyperphosphatemia, hypocalcemia, hyperuricemia
Causes acute kidney injury, seizures, arrhythmias
Hydration with normal saline (don't supplement electrolytes), target urine output of 80-100 mL/m²/h
Rasburicase to get rid of uric acid (may need to call Nephrology)
Treat hyperkalemia
Do NOT treat hypocalcemia

Leukostasis

More common in AML than any other
Lungs and brain most commonly affected
Cytoreduction
- Induction chemotherapy as soon as possilble
- Overnight, give hydroxyurea 2g q6h
  - Can develop tumour lysis syndrome
- No evidence for leukopheresis

Suspected APL

Consult Hematology overnight
Start ATRA 45mg/m² divided BID
Beware differentiation syndrome, with fever, effusion, dyspnea, hypotension; treated with steroids
Beware DIC
- Follow q6h bloodwork
- Transfuse platelets ≥ 30
- Cryoprecipitate to keep fibrinogen ≥ 1.5 (regardless of bleeding)
- Plasma to keep INR < 1.5
- AVOID tranexamic acid

Chronic

AML

Induction with 3+7: 3 days of daunorubicin and 7 days of cytarabine, includes about a month as inpatient
BM to confirm induction, then consolidation
- Low risk: 2-3 more cycles of same
- High/poor risk: 1-2 more cycles, then alloSCT

APL

ATRA + arsenic trioxide

ALL

Dana-Farber protocol
2+ years of chemo + steroids
For Philadelphia positive disease, add imatinib

@@ Line 1: / Line 1: @@
-== Differential Diagnosis ==
+== Clinical Manifestations ==
+*Often cytopenia-related symptoms
-* Primary: suspect when multiple lineages affected, significant leukocytosis, lymphadenopathy, splenomegaly
-* Secondary
-** Acute infection (30-50s)
-** Chronic inflammation
-** Stress (MI, surgery, burn) (30-50)
-** Steroids
-** Pregnancy
-** Cigarette smoking
+==Differential Diagnosis==
-== Clinical Manifestations ==
+*Primary: suspect when multiple lineages affected, significant [[leukocytosis]], [[lymphadenopathy]], [[splenomegaly]]
+*Secondary
+**Acute infection (30-50%)
+**Chronic inflammation
+**Stress (MI, surgery, burn) (30-50%)
+**Steroids
+**Pregnancy
+**Cigarette smoking
+==Investigations==
+*Urgent blood film review to r/o [[APL]]
+==Management==
+===Acute===
+*Rule out [[DIC]] (especially seen in [[APL]])
+==== [[Tumour lysis syndrome]] ====
+*2 or more: [[hyperkalemia]], [[hyperphosphatemia]], [[hypocalcemia]], [[hyperuricemia]]
+*Causes [[acute kidney injury]], [[Seizure|seizures]], [[Arrhythmia|arrhythmias]]
+*Hydration with normal saline (don't supplement electrolytes), target urine output of 80-100 mL/m<sup>2</sup>/h
+*[[Rasburicase]] to get rid of uric acid (may need to call Nephrology)
+*Treat [[hyperkalemia]]
+*Do NOT treat [[hypocalcemia]]
+==== [[Leukostasis]] ====
+*More common in [[AML]] than any other
+*Lungs and brain most commonly affected
+*Cytoreduction
+**Induction chemotherapy as soon as possilble
+**Overnight, give [[hydroxyurea]] 2g q6h
+***Can develop tumour lysis syndrome
+**No evidence for [[leukopheresis]]
+==== Suspected [[APL]] ====
+*Consult Hematology overnight
-* History
+*Start [[ATRA]] 45mg/m<sup>2</sup> divided BID
-** Often cytopenia-related symptoms
+*Beware differentiation syndrome, with fever, effusion, dyspnea, hypotension; treated with steroids
-* Signs &amp; Symptoms
+*Beware [[DIC]]
+**Follow q6h bloodwork
+**Transfuse platelets ≥ 30
+**[[Cryoprecipitate]] to keep [[fibrinogen]] ≥ 1.5 (regardless of bleeding)
+**[[Plasma]] to keep INR &lt; 1.5
+**AVOID [[tranexamic acid]]
+===Chronic===
-== Investigations ==
+==== AML ====
-* Labs
-** Urgent blood film review to r/o APL
-* Imaging
-* Other
+*Induction with 3+7: 3 days of daunorubicin and 7 days of cytarabine, includes about a month as inpatient
-== Management ==
+*BM to confirm induction, then consolidation
+**Low risk: 2-3 more cycles of same
+**High/poor risk: 1-2 more cycles, then alloSCT
-=== Acute ===
+==== APL ====
+*ATRA + arsenic trioxide
-* DIC (especially seen in APL)
-* Tumour lysis syndrome
-** 2 or more: hyperkalemia, hyperphsphatemia, hypocalcemia, hyperuricemia
-** causes renal dysfunction, seizures, arrhythmias
-** Hydration with IVNS (don't supplement electrolytes), target urine output of 80-100 mL/m2/h
-** Rasburicase to get rid of uric acid (may need to call nephrology)
-** Treat hyperkalemia
-** Do NOT treat hypocalcemia
-* Leukostasis (in AML more than any other)
-** Lungs and brain most commonly affected
-** Cytoreduction
-*** Induction chemotherapy as soon as possilble
-*** Overnight, give hydroxyurea 2g q6h
-**** Can develop tumour lysis syndrome
-*** No evidence for leukopheresis
-* APL is suspected
-** Consult heme/onc overnight
-** Start ATRA 45mg/m2 divided BID
-** Beware differentiation syndrome, with fever, effusion, dyspnea, hypotension; treated with steroids
-** Beware DIC
-*** Follow q6h bloodwork
-*** Transfuse platelets ≥ 30
-*** Cryoprecipitate to keep fibrinogen ≥ 1.5 (regardless of bleeding)
-*** Plasmia to keep INR &lt; 1.5
-*** AVOID tranexamic acid
-=== Chronic ===
+==== ALL ====
+*Dana-Farber protocol
-* AML
+*2+ years of chemo + steroids
-** Induction with 3+7: 3 days of daunorubicin and 7 days of cytarabine, includes about a month as inpatient
+*For Philadelphia positive disease, add imatinib
-** BM to confirm induction, then consolidation
-*** Low risk: 2-3 more cycles of same
-*** High/poor risk: 1-2 more cycles, then alloSCT
-* APL
-** ATRA + arsenic trioxide
-* ALL
-** Dana-Farber protocol
-** 2+ years of chemo + steroids
-** For Philadelphia positive disease, add imatinib
 [[Category:Hematology]]