Leukemia

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