Leukemia's and lymphomas Flashcards Preview

Yr 3 - December lectures 2018 > Leukemia's and lymphomas > Flashcards

Flashcards in Leukemia's and lymphomas Deck (36)
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1

Case 1:
- 48 yr old fire safety officer
- 4 days fatigue and breathlessness
- 1 day easy bruising
- O/E pale, bruising and purpura around ankles
What are the differential diagnoses?

differentials of purpura:
- thrombocytopenia (low platelets)
- vasculitis
- drugs e.g. steroids
- senile purpura i.e age related

2

What are the differential diagnoses of thrombocytopenia and how do they occur?

Peripheral consumption of platelets = autoimmune destruction (ITP), splenic pooling, infection, active thrombosis

Reduced production = drug-induced marrow suppression, primary marrow failure (rare), marrow infiltration: primary or secondary

3

Case 1 :
on investigation : low Hb, high WCC, low platelets
- abnormal cells = blast
- bone marrow aspirate = immature cells (blasts, red cell precursor, eosinophil precursor)
What is the diagnosis?

acute leukemia = blasts >20%

4

What is the definition of acute leukemia?

rapid clonal hematopoietic stem cell disorder resulting in accumulation of immature precursors in the bone marrow

5

What other urgent investigations need to be carried out in newly diagnosed acute leukaemia?

1) coagulation screen = risk of life threatening DIC
2) blood group and antibody screen
3) biochemistry = check renal and liver function, calcium, phosphate, magnesium, CRP, uric acid
4) microbiology = blood and urine cultures
5) radiology = consider CXR
6) also consider ECG and echocardiogram

6

How does acute leukemia present?

1) marrow failure
- anaemia, SOB, fatigue, headaches, palpitations, leucopenia, infections, mouth ulcers, bleeding, bruising, thrombocytopenia purpura
2) hyper viscosity due to leucocytosis (due to very high production of blast cells being pumped out)
- headaches, SOB, visual blurring with venous engorgment and retinal hemorrhages, confusion
3) leukemia infiltrations
- swollen gums, skin lesion 'chloromas', hepatosplenomegaly

7

What are the different types of acute leukemia?

1) acute myeloid leukemia
- may show no obvious differentiation (poorly differentiated)
- may show features of differentiation (neutrophils, monocytic, erythroid, megakaryocytic)

2) acute lymphoblastic leukemia
- b cell and t cell

3) mixed lineage (rare)

8

How do you identify which type of acute leukemia ?

1) what do the blasts look like? (auer rod= AML)
2) what molecule are expressed on the cell surface and in the cytoplasm? 2 techniques:
- cytochemistry
- immunophenotyping

9

How is immunophenotyping carried out?

using a flow cytometer
- a flow cytometer can determine what molecules a cell is expressing on its surface and in its cytoplasm
- it can therefore distinguish between myeloid and lymphoid blasts
- it uses fluorescent labelled antibodies

10

What are typical myeloid markers?

CD13, 33, 117, MPO

11

What are typical lymphoid markers?

CD10, 19, 79a, TdT

12

What are the causes of acute leukemia?

previous chemo/toxins
- alkylating agents (long latency)
- topoisomerase II inhibitors (short latency)
- benzene exposure
radiation exposure
inherited predisposition
down syndrome and acute megakaryoblastic leukemia
other hematological disorders
- myelodysplasia
- myeloproliferative condition

13

What is the prognosis for patients with acute leukemia?

overall cure rate of AML in 18-60 yr olds is 40%
without treatment life expectancy is only weeks to months
identified prognostic factors
- age (outcome poorer as age increases)
- presenting WCC (worse with higher counts)
- response to chemo
- cytogenetics at presentation

14

What cytogenetic combination tends to respond well to treatment, medium risk and poor risk ?

reciprocal translocation in DF's cells involving chromosomes 8 and 21 = good risk

medium risk = usually normal cytogenetics

poor risk = often very complex cytogenetic changes

15

What is the treatment for acute leukemia?

4 courses of intravenous chemotherapy (2 induction and 2 consolidation)
- one course is typically=> 5-10 days of chemotherapy and then 2-3 weeks of neutropenia often complicated by neutropenic sepsis => marrow recovery
- each course is 4-6 weeks

if poor risk cytogenetics consider bone marrow transplant as course 3 or 4
e.g daunorubicin and ara-c cytarabine

16

What are the treatment side effects?

bone marrow suppression (anaemia, neutropenia, thrombocytopenia)
tumor lysis syndrome
hair loss
N+V
profound fatigue
chemotherapy induced tissue damage: heart, lungs, brain, GI mucosa (mucositis)
increased risk of secondary malignancy
death

17

What supportive treatment is offered?

blood and platelet transfusions
antibiotics and antifungals
antiemetics
nutrition
psychological support
this care has improved over the years

18

What is a hickman line?

its a venous access which is a line going into the right side of the head and up the neck

= reduces infection rates
A Hickman line is a central venous catheter most often used for the administration of chemotherapy or other medications, as well as for the withdrawal of blood for analysis
insertion involves two incisions, one at the jugular vein or another nearby vein or groove, and one on the thoracic wall. At the former incision site, a tunnel is created from there through to the latter incision site, and the catheter is pushed through this tunnel until it "exits" the latter incision

19

What impact does being elderly have on AML?

increasing age results in:
- increased incidence of AML
- reduced tolerance to chemo
- greater proportion of poor risk cytogenetics
- greater proportion of chemo-resistant disease
IV combo chemo is often not indicated in elderly
options are then low dose chemo, supportive care and palliative care
life expectancy is of the order of weeks to months (not years)
work on going to develop better tolerated treatments for the elderly

20

CASE 2:
- 6 year old
- 1 week hx aches in lower limbs
- pale and non-specifically unwell
- HB 6.5, WCC 30 and plt 25
- abnormal cells on blood film

What is the potential diagnosis and the presentation?

Childhood ALL = most common childhood cancer, can affect adults and the prognosis is worsE
- marrow failure = anaemia, infections, purpura / bleeding
- bone pains = 'off legs', limping

21

On immunophenotyping what markers are positive of acute lymphoblastic leukemia?

CD10, CD19, CD79a, TdT

22

What cytogenetics are common in ALL?

hyperdiploid = >50 chromosomes
e.g. 56 chromosomes = confers good prognosis possibly due to increased sensitivity to chemotherapeutic agents

23

What are poor prognostic factor in childhood ALL?

High WCC at presentation
infant or adolescent
specific cytogenetic abnormalities
slow response to chemo
high minimal residual disease levels at end of induction

overall cure rate = 70-80%

24

What is the treatment for childhood ALL?

ALL treatment is very long and complicated
- induction (steroids and vinca alkaloid)
- consolidation / intensification
- CNS prophylaxis (chemo or radio)
- maintenance
total length in girls is 2 years and boys is 3 years
survival rates = 90-95%

25

CASE 3
- 40 yr old
- 8 week hx of neck lumps
- 6 week drenching night sweats
- O/E cervical lymphadenopathy

What is the differential diagnosis?

Lymphoma
- malignancy of the lymphatic system
lymphatic tissue is a key component of your immune system, WCC and antibodies circulate in the lymph fluid to lymph nodes or glands

26

What are some common presentations of hodgkins lymphoma?

cervical lymphadenopathy
large anterior mediastinal mass
left hilar lymphadenopathy
left pleural effusion

27

What is a histological diagnosis of hodgkins lymphoma?

reed sternberg cells - found on biopsy

28

What are the different stages of lymphoma?

stage one - lumps in one area
stage two - lumps in 2 areas on the same side of diaphragm
stage three - more than 2 areas of lumps on either side of the diaphragm
stage four - disseminated disease affecting other organs

29

What is the treatment for hodgkins lymphoma?

localized disease
- short course of chemo (2-4 cycles) - local radiotherapy, 90% cure
advanced disease (stage 3-4)
- 6 cycles chemo and 80% chance of survival

drugs: doxorubicin, bleomycin, vinblastin, dacarbazine

30

CASE 4
- 64 year old
- enlarged lymph nodes both axillae and sees her GP
- O/E modest cervical and axillary lymphadenopathy and splenomegaly
- referred for lymph node biopsy

What is the differential diagnosis?

non-hodgkins lymphoma - diffuse large b cell lymphoma, follicular lymphoma (most common)