Acute Leukemia
Treatment
PREPARATION
1- Acute leukemia should be regarded as an emergency & needs treatment within 48h of Dx
2- Patient should be prepared for treatment to avoid complications
3- Stabilization of patient & ttt of complications4- Taking consent of patient or family
Preparation--steps
1) Adequate hydration i,v fluids 2-3 L/d of glucose water or normal saline
2) Allopurinol 100-200 mg tds to prevent hyperuricemia
3)Correct anemia- Blood Transfusion 4)Psychological preparation of the patient &
family for ttt & complications5) Tell them about the seriousness of disease &
prognosis
Treatment of Complications
Sometimes the patient presents with complications1- Hemorrhage should be stopped – correct
thrombocytopenia by platelet transfusion. Correct hypovolemia.
2- Fever is regarded due to infection. Never regarded due to leukemic process.
Infection due to neutropenia. Usually due to G-ve bacilli such as Klebsiella, Escherichia, Pseudomomnas, Proteus .
Treated after taking samples for C&S don’t wait the results. Give emperically a 3rd generation cephalosporin (Ceftriaxone)+ gentamicin
Persistent fever
Correct antibiotic according to C&SIf feveer persist think of coagulase –ve Staph &
give VancomycinIf fever persisted think of fungal infection & give
amphotericin-B injectionsIf persisted think of viral infections & treat
accordingly
3- DIC
Mostly seen in APL (M3)Give fresh frozen plasma (FFP), Platewlet
concentrate, blood transfusion4- Hyperuricemic nephropathy – it is prevented
better than treated. It causes renal failure treated by dialysis.
5- Tumor lysis syndrome
Manifested as hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia
It is prevented by preparation & adequate hydration
6- Leukostasis
In AML>ALLEspecially with hyperleukocytosis > 50000 Manifested as CNS & Pulmonary manifestationDue to sludging of blasts in microcirculationCNS- confusion, cranial nerve palsies, seizure, , meningitis, comaPulm- tachypnea, dyspnea, pulmonary crackles, bilateral
radiological pulmonary infiltrates, hypoxemiattt – hydroxyurea, cranial irradition
TREATMENT
1- COMBINATION CHEMOTHERAPY2- Supportive therapy3- Targeted therapy4- BMT & Stem cell Transplant
ALL treatment
1- Induction CT UKALL or BFM protocol*Anthracyclin (Daunorubicin, Doxorubicin)- antibiotic
cytotoxic given weekly ----i.v infusion /1hS/E myelosuppression pancytopenia dilated cardiomyopathy,
mucositis*Vincristine i.v diluted bolus weekly– antitubulin agentS/E
PNP senory> motor, extravasation causes severe necrosis of skin & subcut tissues
Not myrlosuppressive*PDN 60-100 mg/dContinurd for 5 weekly doses
2- Postinduction CT
1- Consolidation giving same doses as induction2- Intensification giving high dose CTShould use new non-cross resistant agentsGiving L-Asparaginase that depletes blasts from
asparagine essential amino acid ( especially useful in children)
3- CNS prophylaxis
1- Intrathecal Methotrexate or cytosine arabinoside & hydrocrtisone given weekly
2- Cranial irradiation giving 2400 rad to cranium to prevent CNS relapse
3- High dose methotrexate crosses BBB
4- Maintenance treatment
1- 6mercaptopurine tab daily2- methotrexate tab weeklyContinued for 2-3 yearsReinforcement doses given every 3 months
AML
1- Induction “3+7” protocolDaunorubicin or Doxorubicin i.v infusion over 1h
D1-D3Cytosine arabinoside continuous infusion 12
hourly D1-D7Given monthly until CR
2- Postinduction CT
A- Consolidation giving same dosesB- Intensification High dose CT *No maintenance ttt in AML except M3* No CNS prophylaxis except M4,M5
Targeted therapy
1- Imatinib in Ph +ve ALL2- All-trans-retinoic acid (ATRA) a differentiating
agent used in M3 induction & maintenanceS/E retinoic acid syndrome3- Gemtuzumab/ozagamycin moAb M3* Arsenic trioxide in M3 relapse
Supportive therapy
1- Stimulating factors (G-CSF, GM-CSF) to correct neutropenia in myelosuppression
2- Plat conc keep plat > 20000/µl3- packed RBCs to correct anemia
BMT
1- syngeneic from identical twin2- Autologous from pt during CR (high risk of
relapse, less GVHD)3- Allogeneic from HLA-matched related or un
related donor ( less relapse, Gvleukemia effect, moreGVHD)
Indications
AML – in 2nd CR after 1st relapseALL- in 3rd CR after 2nd relapse
Prognosis
ALL better AMLALL L1 better than L2 better than L3 Children better than adults (2-9y) female better than male T cell worse than B cell worse than PrepreBAML M3 worse in acute stage but better longterm M4 M5 bad M4E better than M4 M7 bad secondary leuk worse than deNovo
Acute Leukemia
Treatment
