Leukemia

Differential Diagnosis

• 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

Clinical Manifestations

• History
  • Often cytopenia-related symptoms
• Signs & Symptoms

Investigations

• Labs
  • Urgent blood film review to r/o APL
• Imaging
• Other

Management

Acute

• 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 < 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