Leukemia

Cytopenia: (reduced number of mature blood cells)

Bone Marrow infiltration:

1° causes – Leukemia

2° - Malignancy

Bone Marrow failure

Aplastic anemia

Immune dysregulation

Hemophagocytic lymphohistiocytosis (HLH)

Long case

The patient complained of symptoms of bone marrow infiltration such as symptoms of

anemia/symptomatic anemia – no symptoms suggestive of heart failure

No symptoms suggestive of bleeding tendencies

Constitutional symptoms: LOW & LOA (previous and current weight)

No bone pain

No abnormal swellings such as lymphadenopathy

No signs of hemolytic anemia such as jaundice, no abnormal abdominal distension

No sick contact with TB patient (since fever, cough)

Anemia: Diet, weaning, breastfed will explain IDA, Iron rich diet.

Social history:

Always try to identify one social problem

Example: who is taking care of the child

Are they a high income earning family

Financial support – occupation, household income

Family support

Mention occupation, both government servants (as chronic illness requires long term
treatment as well as financial commitment)

Mention insurance

Siblings – mention biological siblings- candidate for bone marrow transplant

Tend to get neglected, do they have behavior problems, attention seeking behaviours

Down syndrome – 20x more likely to get leukemia

Immunisation history: up to age, any extra vaccinations given such as pneumococcal/passive

immunization given
MMR vaccine – egg allergies?; MMR vaccine was uneventful

Antenatal period: cord blood storage in cord blood bank

Physical examination

Appearance, height & wt appropriate, which centile

Breathing, resp distress

Colour – leukemic cutis/leukemic infiltration

Dysmorphism

Extra/Paraphernalia

Abdominal examination: hepatosplenomegaly

Lymph nodes: cervical, axillary, inguinal, popliteal, epitrochlear

Testes

Respiratory: mediastinal mass - dullness over retrosternal

SVC obstruction – plethora, facial/UL edema, dilated neck veins

Cardiovascular

Sign of heart failure, gallop rhythm

Neuro
UMN signs – suggestive of leukostasis
GCS
Hemiparesis

Summary: J is a 7 years old boy who is previously well currently presented with recurrent high
grade fever with symptoms of bone marrow infiltration and constitutional symptoms with a
history of abnormal blood count from earlier investigation.

Investigation:

Divide into biochemical & radiological/diagnostic & therapeutic

Full blood count:

↓Hb
↓Plt
↑/↓WCC

MCH
MCV
RDW

Differential count:
↓ANC
Lymphocyte
Monocyte
Reticulocyte
Eosinophils

Peripheral blood film:

Blast
Auer rods in AML

Renal profile:
K
Uric acid -----à tumour lysis syndrome
Ca2+
Phosphate

-LDH

Coagulation profile
DIVC – complication of APML

Blood culture – pt has fever

Bone marrow aspiration & trephine:

Morphology
Immunohistochemistry- myreloperoxidase sudan black
Cytogenetics: Ph Chr/BCR ABL gene

Immunophenotyping (flow cytometry) to look at cell surface antigens

Eg: CD3, CD20, CD34, CD117

Radiological
CXR : mediastinal mass
CT brain – stroke

Prognosticate:

1. Patient – Age <1yo and >10yo, Male

2. Disease characteristics –
↑WCC>50
ALL/AML (ALL worst than AML)
T cell or B cell (T cell poorer prognosis)
Mixed (mixed poorer prognosis)

3. Cytogenetics:
structural – BCR/ABL gene or Ph Chr
MLL rearrangements
Numeric : hypopolyploidy vs hyperpolyploidy
 Hypopolyploidy have poorer prognosis because chemotherapy targets RAPIDLY dividing
cells, hypopolyploidy – slower..

Treatment response
Day 8 prenisolone factor?
MRD:minimal residual disease

Treatment

CHEMOTHERAPY, know groups and examples

-anti metabolite
-name
-common side effects

cyclophosphamide
SE: haemorrhagic cystitis

Arthracycline/doxorubicin
SE: cardiomyopathy

Cisplatin/Platinum based drugs

SE: hearing, ototoxicity

Induction ---- Consolidation ---- Maintenance

TRANSPLANT.