Hematopoiesis

Immunophenotyping
Leukemia
Treatment of Leukemia :

 Chemotherapy. Chemotherapy is the major form of treatment for leukemia. This drug treatment uses
chemicals to kill leukemia cells.

Depending on the type of leukemia you have, you may receive a single drug or a combination of drugs.
These drugs may come in a pill form, or they may be injected directly into a vein.

 Biological therapy. Biological therapy works by using treatments that help your immune system
recognize and attack leukemia cells.
 Targeted therapy. Targeted therapy uses drugs that attack specific vulnerabilities within your cancer
cells.

For example, the drug imatinib (Gleevec) stops the action of a protein within the leukemia cells of
people with chronic myelogenous leukemia. This can help control the disease.

 Radiation therapy. Radiation therapy uses X-rays or other high-energy beams to damage leukemia
cells and stop their growth. During radiation therapy, you lie on a table while a large machine moves
around you, directing the radiation to precise points on your body.

You may receive radiation in one specific area of your body where there is a collection of leukemia cells,
or you may receive radiation over your whole body. Radiation therapy may be used to prepare for a
stem cell transplant.

 Stem cell transplant. A stem cell transplant is a procedure to replace your diseased bone marrow
with healthy bone marrow.

Before a stem cell transplant, you receive high doses of chemotherapy or radiation therapy to destroy
your diseased bone marrow. Then you receive an infusion of blood-forming stem cells that help to
rebuild your bone marrow.

You may receive stem cells from a donor, or in some cases you may be able to use your own stem cells. A
stem cell transplant is very similar to a bone marrow transplant.
Levels of risk for childhood ALL

Doctors will consider all the prognostic factors for childhood acute lymphoblastic leukemia (ALL) together to
determine a level of risk, or risk classification. The level of risk includes the likelihood that cancer will not
respond, or be resistant, to treatment or that the cancer will come back, or relapse, after treatment.

The level of risk can guide treatment plans for a child with ALL. Doctors use this information to determine if
more or less treatment is needed. This approach ensures that the child is given enough treatment with the least
possible side effects.

The following 2 approaches are used to determine level of risk for childhood ALL.

National Cancer Institute (NCI)/Rome criteria

The National Cancer Institute (NCI)/Rome criteria uses age and white blood cell (WBC) count to determine
risk and predict outcome.

Standard risk

Standard-risk ALL must have both of the following criteria:

 WBC count is less than 50,000 cells/mm3 (50.0 x 109 cells/L)

 the child is between 1 and 9 years old

High risk

High-risk ALL can have either of the following criteria:

 WBC count is greater than 50,000 cells/mm3 (50.0 x 109 cells/L)

 the child is younger than 1 or older than 9 years old

Children’s Oncology Group (COG)

The Children’s Oncology Group (COG) refines the criteria for risk-based treatment, specifically for B-precursor
ALL in children older than 1 year.

Low risk

Low-risk ALL must have all of the following criteria:

 WBC count is less than 50,000 cells/mm3 (50.0 x 109 cells/L)

 the child is 1–9 years old
 favourable genetics (the child has chromosome and gene abnormalities linked with a favourable
prognosis)
 no unfavourable genetics (the child has no chromosome or gene abnormalities linked with an
unfavourable prognosis)
 no blasts in the brain or spinal cord (called the central nervous system, or CNS) and the leukemia hasn’t
spread to the testicles
 day 8 peripheral blood minimal residual disease (MRD) is less than 0.01%
 day 29 bone marrow MRD is low

Average risk

Average-risk ALL must have all of the following criteria:

  WBC count is less than 50,000 cells/mm3 (50.0 x 109 cells /L)
 the child is 1–9 years old
 day 8 peripheral blood MRD greater than or equal to 0.01% with favourable genetics or day 8
peripheral blood MRD is less than 0.1% without favourable genetics
 no unfavourable genetics
 day 29 bone marrow MRD low
 CNS disease is less than CNS-3 and the leukemia hasn’t spread to the testicles

High risk

High-risk ALL may or may not have favourable genetics, has no unfavourable genetics and any of the following
criteria:

 WBC count is greater than 50,000 cells/mm3 (50.0 x 109 cells /L)
 the child is older than 9 and younger than 13 years old
 day 8 peripheral blood MRD is greater than or equal to 1%
 day 29 bone marrow MRD is greater than or equal to 0.01%
 leukemia has spread to the testicles

Very high risk

Very high-risk ALL has any of the following criteria:

 the child is older than 13 years

 unfavourable genetics
 day 29 bone marrow MRD is greater than or equal to 0.01% and one of the following:
o no favourable genetics
o WBC is greater than 50,000 cells/mm3 (50.0 x 109 cells /L)
o the child is older than 9 years

Sumber lain

ALL risk groups

Standard-risk ALL

Your child is considered standard-risk if they have all of the following features:

 they are between age 1 and 10

 they have less than 50,000 white blood cells per cubic millimetre (mm3) of blood when they are
diagnosed
 No blasts in the CSF (CNS 1) or less than 5 blasts in CSF (CNS 2)
 no testicular leukemia
 no unfavorable cytogenetic features
 no steroids were given before diagnosis of leukemia
 a good response to the first phase of chemotherapy (induction), as measured by a bone marrow test on
day 29 with MRD.

High-risk ALL

Your child is considered high risk if they have any of the following features:

 less than age one or older than ten years of age

 more than 50,000 white blood cells/mm3 of blood when they are diagnosed
 More than 5 leukemic cells in the CSF (CNS 3)
  leukemia cells with chromosome changes that are more difficult to treat
 testicular involvement
 steroids given before diagnosis of leukemia.

Very high-risk ALL

Children are considered to have very high-risk ALL based on certain chromosome changes inside their
leukemia cells that make it harder to treat. They may require other special types of medication.

Remission

Definition

Remission of cancer refers to the absence of active disease for a period of at least 1 month. The absence of
active disease does not mean that cancer has been cured or even that there are no detectable signs of cancer.
There are two types of remission:

Complete Remission

Complete remission (or undetectable disease) refers to cancer that has no signs or symptoms, and no evidence
of cancer can be found on a physical exam by a doctor or through radiological tests such as a CT scan, MRI, or
PET scan. 

With complete remission, some doctors use the terminology "NED"—which stands for "no evidence of
disease." A complete remission may also be described as a "complete response."

Partial Remission

The term partial remission refers to cancer that is still detectable but has decreased in size (or in the number of
cancerous cells as in leukemia.) This may also be described as a tumor that is "controlled" or with the term
stable disease. One type of partial remission is called a partial response.  A partial response is a remission in
which there is at least a 50 percent reduction in the size of a tumor, which persists for at least 1 month.

While remission can mean the same thing as a complete response or stable disease, depending on the type, the
term remission is used more often with blood related cancers such as leukemias and lymphomas and the terms
stable disease or no evidence of disease are used more often when describing the response of solid tumors
(such as lung cancer, breast cancer, or colon cancer) to treatment.

Spontaneous Remission

On rare occasions, however, cancer may go into remission without any treatment directed at cancer. This
uncommon occurrence is referred to as the spontaneous remission of cancer.

Spontaneous remissions often occur when someone with cancer has been fighting an infection, and it's thought
that the bodies immune system, in this case, fights off cancer. This idea, in fact, is the basis for the newer types
of cancer treatments referred to as cancer immunotherapy.

Most remissions occur after cancer has been treated with surgery, chemotherapy, radiation therapy, or one of
the newer treatments such as a targeted therapy or immunotherapy.
Myeloproliferative Disease