Leukemia
From IDWiki
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