Leukemia: Difference between revisions
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+ | ==Clinical Manifestations== |
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− | == Differential Diagnosis == |
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+ | *Often cytopenia-related symptoms, including [[anemia]], [[leukopenia]], and [[thrombocytopenia]] |
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− | * Primary: suspect when multiple lineages affected, significant leukocytosis, lymphadenopathy, splenomegaly |
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+ | *May also present with [[DIC]], [[tumour lysis syndrome]], or [[leukostasis]] |
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− | * Secondary |
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− | ** Acute infection (30-50s) |
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− | ** Chronic inflammation |
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− | ** Stress (MI, surgery, burn) (30-50) |
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− | ** Steroids |
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− | ** Pregnancy |
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− | ** Cigarette smoking |
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+ | ==Differential Diagnosis== |
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− | == Clinical Presentation == |
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+ | *Primary: suspect when multiple lineages affected, significant [[leukocytosis]], [[lymphadenopathy]], [[splenomegaly]] |
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− | * History |
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+ | *Secondary |
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− | ** Often cytopenia-related symptoms |
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+ | **Acute infection (30-50%) |
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− | * Signs & Symptoms |
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+ | **Chronic inflammation |
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+ | **Stress (MI, surgery, burn) (30-50%) |
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+ | **Steroids |
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+ | **Pregnancy |
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+ | **Cigarette smoking |
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− | == |
+ | ==Investigations== |
+ | *Urgent blood film review to r/o [[APL]] |
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− | * Labs |
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− | ** Urgent blood film review to r/o APL |
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− | * Imaging |
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− | * Other |
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− | == |
+ | ==Management== |
− | === |
+ | ===Acute=== |
− | * DIC (especially seen in APL) |
+ | *Rule out [[DIC]] (especially seen in [[APL]]) |
− | * Tumour lysis syndrome |
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− | ** 2 or more: hyperkalemia, hyperphsphatemia, hypocalcemia, hyperuricemia |
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− | ** causes renal dysfunction, seizures, arrhythmias |
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− | ** Hydration with IVNS (don't supplement electrolytes), target urine output of 80-100 mL/m2/h |
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− | ** Rasburicase to get rid of uric acid (may need to call nephrology) |
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− | ** Treat hyperkalemia |
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− | ** Do NOT treat hypocalcemia |
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− | * Leukostasis (in AML more than any other) |
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− | ** Lungs and brain most commonly affected |
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− | ** Cytoreduction |
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− | *** Induction chemotherapy as soon as possilble |
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− | *** Overnight, give hydroxyurea 2g q6h |
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− | **** Can develop tumour lysis syndrome |
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− | *** No evidence for leukopheresis |
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− | * APL is suspected |
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− | ** Consult heme/onc overnight |
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− | ** Start ATRA 45mg/m2 divided BID |
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− | ** Beware differentiation syndrome, with fever, effusion, dyspnea, hypotension; treated with steroids |
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− | ** Beware DIC |
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− | *** Follow q6h bloodwork |
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− | *** Transfuse platelets ≥ 30 |
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− | *** Cryoprecipitate to keep fibrinogen ≥ 1.5 (regardless of bleeding) |
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− | *** Plasmia to keep INR < 1.5 |
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− | *** AVOID tranexamic acid |
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− | === |
+ | ====[[Tumour lysis syndrome]]==== |
+ | *2 or more: [[hyperkalemia]], [[hyperphosphatemia]], [[hypocalcemia]], [[hyperuricemia]] |
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− | * AML |
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+ | *Causes [[acute kidney injury]], [[Seizure|seizures]], [[Arrhythmia|arrhythmias]] |
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− | ** Induction with 3+7: 3 days of daunorubicin and 7 days of cytarabine, includes about a month as inpatient |
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+ | *Hydration with normal saline (don't supplement electrolytes), target urine output of 80-100 mL/m<sup>2</sup>/h |
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− | ** BM to confirm induction, then consolidation |
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+ | *[[Rasburicase]] to get rid of uric acid (may need to call Nephrology) |
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− | *** Low risk: 2-3 more cycles of same |
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+ | *Treat [[hyperkalemia]] |
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− | *** High/poor risk: 1-2 more cycles, then alloSCT |
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+ | *Do NOT treat [[hypocalcemia]] |
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− | * APL |
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+ | |||
− | ** ATRA + arsenic trioxide |
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+ | ====[[Leukostasis]]==== |
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− | * ALL |
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+ | |||
− | ** Dana-Farber protocol |
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+ | *More common in [[AML]] than any other |
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− | ** 2+ years of chemo + steroids |
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+ | *Lungs and brain most commonly affected |
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− | ** For Philadelphia positive disease, add imatinib |
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+ | *Cytoreduction |
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+ | **Induction chemotherapy as soon as possilble |
||
+ | **Overnight, give [[hydroxyurea]] 2g q6h |
||
+ | ***Can develop tumour lysis syndrome |
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+ | **No evidence for [[leukopheresis]] |
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+ | |||
+ | ====Suspected [[APL]]==== |
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+ | |||
+ | *Consult Hematology overnight |
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+ | *Start [[ATRA]] 45mg/m<sup>2</sup> divided BID |
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+ | *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 |
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+ | **AVOID [[tranexamic acid]] |
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+ | |||
+ | ===Chronic=== |
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+ | |||
+ | ====AML==== |
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+ | |||
+ | *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==== |
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+ | |||
+ | *ATRA + arsenic trioxide |
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+ | |||
+ | ====ALL==== |
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+ | |||
+ | *Dana-Farber protocol |
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+ | *2+ years of chemo + steroids |
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+ | *For Philadelphia positive disease, add imatinib |
||
[[Category:Hematology]] |
[[Category:Hematology]] |
Latest revision as of 11:47, 30 July 2020
Clinical Manifestations
- Often cytopenia-related symptoms, including anemia, leukopenia, and thrombocytopenia
- May also present with DIC, tumour lysis syndrome, or leukostasis
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
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