Leukemia (Part Three)

Diagnosis

Established based on: anamnesis, clinic, cytology in Optical Microscope of peripheral and central blood (myelogram), cytochemistry, immunophenotype, cytogenetics, and molecular analysis.

The most commonly used classifications: FAB (French-American-British scheme) which is based on clinic, cytology, and cytochemistry and is the most frequently used in our conditions, and WHO 2008 which is based on FAB criteria + the latest data on immunophenotype, cytogenetics, molecular analyses. The most significant difference between the two classifications is:

FAB classification > 30 % tumor cells in BMA (AREB-t 20-30 %) and WHO classification > 20 % blasts.

LA Treatment

Supportive therapy for PPC insufficiency.

1. Insertion of a central venous catheter for the administration of chemotherapy, antibiotics, blood, blood products, for intravenous feeding, for taking analyses, etc.
2. Prevention of vomiting. Primperan, chlorpromazine, promethazine, dexamethasone, lorazepam, and the most potent anti-5-HT3 (Kytril, Zofran) are used.
3. For anemia, erythrocyte measures are given.
4. Treatment and prevention of hemorrhage. Platelet Measures are given (especially when the number of platelets is less than 20,000 mm3). Coagulation factors, Fresh Frozen Plasma, and in cases of microthromboses from DIC, heparin is given. In cases of hemorrhage from fibrinolysis, EACA, Tranexamic Acid is given.
5. Allopurinol for hyperuricemia.
6. Prophylaxis and treatment of infections.
7. Neutropenia resulting from PPC deficiency, from the replacement of leukocytes by leukemic cells, and from intensive cytotoxic therapy makes the patient very susceptible to infections, especially when the number of neutrophils is less than 1,000 mm3 and even more so when this number is less than 500 mm3. Neutrophils remain at these values for a period of two weeks or more. The most common infections are bacterial, viral, fungal, protozoal. Often, a septic condition appears.

Infection Prophylaxis

The patient should be isolated in sterile rooms, with air filters to prevent infections coming from air spores. The Gastro-Intestinal Apparatus should be sterilized by giving antibiotics and antifungal orally. The mouth and skin should be cleaned with antiseptics. Regular cultures should be taken from the throat, mouth, nose, urine, feces, sputum, catheter sites, from the axillary region, perianal, etc.

Treatment of Infections

Temperature is the primary sign that an infection is present. Immediately take an antibiogram from the above-mentioned sites. Perform blood culture. Examine the lungs. Since neutrophils are missing, pus (abscess) does not form and the infection is difficult to localize. Immediately start broad-spectrum antibiotics and when the antibiogram response is received, adjust them. Antibiotics will continue for three days after the temperature drops, if there is no response, treatment with antifungals and/or antivirals should be done.

Treatment of Malignant Hematologies. Factors to consider:

Activity

• Short-term (response to treatment, quality of response).
• Long-term (PFS, OS).

Toxicity (of different grades impacting the dose and continuation of treatment)

• Hematologic (myelosuppression).
• Non-hematologic (neurotoxicity, immunosuppression, hepatotoxicity, etc).

Late Complications

• Myelodysplasia.
• Myeloproliferative Syndrome.
• Secondary non-hematologic Tumors.