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Acute Leukemia PowerPoint Presentation

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Description : for medical students

Tags : Acute lymphocytic leukemia,Acute Leukemia,type of cancer,cancer,blood cancer,acute

Published on : Apr 28, 2023 | Views : 1959 | Downloads : 24

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ACUTE MYELOGENOUS LEUKEMIA-AML ACUTE LYMPHOBLASTIC LEUKEMIA –ALL Mulugeta A.(INTERNIST) ACUTE LEUKEMIAS
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outline Introduction Epidemiology Classification Etiology Pathogenesis Clinical Presentation General Treatment Approach AML ALL
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Introduction Acute Leukemia (AL) is a clonal neoplastic disorder characterized by the proliferation & accumulation of immature and malignantly transformed cells in the BM and PB. The abnormal cells replace the normal BM tissue. The result is abnormal /insufficient hematopoiesis. Anemia Thrombocytopenia Leukocytosis/leukopenia Infiltrate other organ tissues
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Introduction... AL is basically one of the two types Acute Myelogenous Leukemia(AML) Acute Lymphoblastic Leukemia(ALL) Other very rare variants of AL Biphenotypic Leukemia Bilineage Leukemia Other rare variant in WHO classification AL can be De novo Secondary/ transformed Distinction b/n AML & ALL should be the first step in the diagnosis and management.
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Epidemiology Rare disease but has huge impact on cancer survival statistics The annual incidence of AML( in Western pop) 3.6 cases/100,000 80% of AL The annual incidence of ALL 1.4 cases/100,000 20% of AL The incidence of AML Increases with age Median age at presentation 60-65yrs
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Epidemiology... The peak incidence of ALL 3-4yrs of age Incidence decreases after 9yrs of age Rare after 40 Sex distribution M:F in AML = 1.3:1 M:F in ALL = 1.5:1 The relative frequency of the 4 leukemias ALL (11%) AML (46%) CLL (29%) CML (14%)
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Classification of AL The classification is based on biological features Clinical feature Morphology based on Wright or Giemsa stain Cytochemical studies Electron Microscope Flowcytometry Cytoplasmic markers Cytogenetic or molecular study Microarray analysis
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Classification of AL... French-American and British(FAB) Based on morphology & cytochemical studies ALL into L1-L3 AML into M0-M7 Immunological classification Specially for ALL into the different stages of B-Cell & T-Cell groups WHO classification For all hematological malignancies Cytogenetic studies included Comprehensive but not applicable in all setting
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Etiology in Acute Leukemias(AL) Most AL sporadic Acquisition of somatic mutation in hematopioetic progenitors Usually not possible to identify a cause Valuable clues from Rare heritable leukemias Cases related to specific environmental exposure Variable latency following exposure to causative agent Genetic Polymorphism
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Etiology in AL... Chemical exposure Benzene Other petroleum products & others Ionizing Radiation Virus HTLV-1 EBV Therapy Related (chemotherapy) Alkylating agents DNA topoisomerase inhibitors Anthracyclins( doxorubicin) Epipodophyllotoxins( etoposide) Autologous stem cell transplantation ? Hematopoietic growth factors
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Etiology in AL... Antecedent Hematological Disorders Myeloproliferative Disorders Myelodysplastic Syndromes(MDS) Paroxysmal Nocturnal Hemoglobinuria (PNH) Familial Leukemias Down’s Syndrome ( trisomy 21) Trisomy 8
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Etiology in AL... Familial Disorders leading to Leukemias Defective DNA repair syndromes Bloom’s Syndrome Fanconi’s Anemia Neurofibromatosis Li-Fraumeni Syndrome Wiskott-Aldrich Syndrome Blackfan-Diamond Syndrome Kostmann’s Syndrome ( Infantile Agranulocytosis)
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Pathogenesis Single cell of origin of AL Leukemic Stem Cell Clonality Like other human malignancies, in AL one or more of the following somatic mutation and genetic abnormalities are involved Oncogene mutations (Proto-oncogenes) Tumor Suppressor gene mutation General Genomic instability Multistep and multicausal
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Pathogenesis... Two –hit hypothesis Mutations giving proliferative& survival advantage The next impairing differentiation The two models for the explanation of heterogeneous groups in AL Transformation at one of the several developmental stages Transformation within the primitive multipotent progenitor cells Specific or recurrent genetic abnormalities leading to certain leukemia types
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Clinical Features of AL AL presents acutely Exception- transformed/secondary AL In general patients manifest signs & symptoms related to Abnormalities of the 3 blood cell lines Infiltration of organs & tissues Certain features are specific to the AL type Family history of malignancy and history of predisposing factors should be looked for.
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Symptoms of AL Sxs of anemia Sxs of thrombocytopenia Fever High grade due to infections Low grade with systemic sxs due to the AL Sxs due to CNS involvement Seizure, headache, cranial nerves dysfunction Vomiting, blurring of vision, altered mentation Abdominal fullness & other GI sxs due to organomegaly and electrolyte disturbance Oliguria
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Signs of AL Pallor Bleeding Mucocutaneous DIC Fever and other signs of infection accordingly
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Signs ... Signs of tissue or organ infiltration Gingival hyperplasia LAP Hepatosplenomegaly Bone(sternal tenderness) Chloromas Leukemic cutis Cranial nerve palsies Mengeal irritation signs Extramedullary disease Prominent LAP & signs of mediastinal LAP
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Investigation in AL Complete history and physical examination CBC, differential, platelets, ESR, Blood group Serological screening ( HIV, HBV, HCV, CMV...) Examination of peripheral smear BM aspiration & biopsy Morphology Flowcytometry Cytochemical studies Cytogenetic study
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Investigation in AL... CXR Coagulation profile Biochemical tests Liver & renal functions Serum electrolytes Uric acid Serum LDH Serum lysozymes Blood and other specimen for culture
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Investigation in AL... LP CT Scan HLA TYPING Cardiac function ( ECG, ECHO)
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Treatment Requires comprehensive team & good setup Starts with the confirmation of specific AL dx & prognostication. In general has 2 important components Supportive Specific/ Definitive Certain parameters/ goals related to specific therapy Remission ( CR, PR) Survival (leukemia free, overall survival, relapse ) Cure
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Supportive Care Fluid & electrolyte management Blood component therapy Packed red cells transfusion Platelet transfusion Treatment of infection Broad spectrum IV antibiotics( empiric/emergency) culture and other studies Prevention of uric acid nephropathy & tumor lysis syndrome hydration Allopurinol & other agents
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Supportive Care Recombinant growth factors (GM-CSF, G-CSF, EPO, IL-11, Thrombopoietin) Hyperleukocytosis/hyperviscosity, leukostasis Associated with various complications Leukopheresis Emergency irradiation of whole-brain Adminstration of drugs for cytoreduction Hydroxyurea, steriods Early dx & Rx of coagulation abnormality Reverse-barrier ( reverse – isolation)
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Supportive Care Vascular access Birth control and fertility advice Treatment of comorbid conditions Psychosocial support
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Specific Treatment Chemotherapy Specific regimen of the AL types Phases Remission Induction Postremission Hematopoietic Stem Cell Transplantation Allogeneic-SCT Syngeneic-SCT Autologous-SCT Investigational Therapy Clinical trails
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DDX MDS Aplastic Anemia Infectious Mononucleosis ( LAP & atypical lymphocytes) BM failure syndromes & infiltration Severe infection with leukocytosis & shift Aggressive & very aggressive NHL ITP
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GENERAL REMARKS CLASSIFICATION TREATMENT ACUTE MYELOGENOUS LEUKEMIA
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General remarks about AML A complex disease Heterogenous group Phenotypically Genotypically More than 100 recurrent cytogenetic abnormalities. Patients die of leukemia or Rx complication Still a challenge both clinically & in genetic study Certain groups with excellent prognosis
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Classification FAB Based on morphology & cytochemical studies Blast % in the BM for Dx Simple & still in wide clinical use but does not incorporate the recent advances in molecular study WHO Comprehensive Detail molecular and cytogenetic studies Currently not universally applicable
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Specific Rx for AML Chemotherapy Remission induction 7+3 regimen ( cytarabine + daunorubicin/doxorubicin) Alternative ( cytarabin + Idarubicin + etoposide) Elderly patients – modification Double induction Postremission therapy The best regimen not yet settled Consolidation/Intensification chemotherapy Allo-SCT Auto-SCT BM transplantation
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Specific Rx for AML... CNS prophylaxis or Rx M4 & M5 Relapsed and refractory AML Early vs late relapse Treatment of M3(APL) Special entity(t(15;17)) & Favourable outcome All- Trans-Retinoic Acid(ATRA) with other chemo Maintenance therapy Arsenic TriOxide(ATO) Treatment of secondary/ therapy related AML
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GENERAL REMARKS CLASSIFICATION TREATMENT ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)
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General remarks about ALL ALL is a malignant d/s characterized by accumulation of lymphoblasts. Different treatment outcomes in children & adults. Cure rate Children 2/3 Adults 1/3 Reason for poor outcome in adults with ALL High rate of adverse prognosis(Ph-chromosome) high degree of toxicity with the drugs Different pharmacodynamics Much less heterogeneous in general and less common ( 20% of AL) in adults
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Stratification of patient into high- risk & low-risk is required to select therapy More intensive chemotherapy Stem cell transplantation CNS involvement and relapses are the features
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Classification of ALL FAB classification of ALL L1, L2, L3 Based on the morphology of lymphoblasts Less relevant in predicting outcome Immunological classification of ALL Based on cell marker and other studies B or T cell variant with their stage of development Comprehensive Relevant in predicting outcome
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FAB Classification for ALL L1 L2 L3
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Specific Treatment in ALL Chemotherapy Several phases Remission Induction CNS prophylaxis or Treatment Consolidation/Intensification Maintenance Upfront cytoreduction Cyclophosphamide and steriods 75-85% of adults achieve Complete Remission
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Specific Treatment in ALL Consolidation/ Intensification Difference b/n consolidation & intensification Early intensification Maintenance Continues for upto 22months Monthly pulse doses (Dexa + Vincristine) Methotrexate /wk + 6-mercaptopurine/d (orally)
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Specific Treatment in ALL Remission Induction 4-6 weekly cycles with the aim of CR Vincristine + Predinsolone + daunorubicin +/- L-Asparaginase CNS prophylaxis or Treatment Intrathecal(cytarabin,Methotrexate, hydrocortisol) High dose systemic chemo Cranial Irradiation
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Specific Treatment in ALL Stem Cell Transplantation Reserved for relapse or refractory ALL Types Allo-SCT Auto-SCT MUD & NMSCT
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Thank you!