3rd Year 2nd Semester Medicine 1

L14 Medicine Leukemia

Leukemia
• A group of malignant disorders affecting the blood and blood-forming tissues of
o Bone marrow o Lymph system o Spleen
• Occurs in all age groups
• Results in an accumulation of dysfunctional cells because of a loss of regulation in cell
division
• Fatal if untreated
o Progressive
• Often thought of as a childhood disease
• The number of adults affected with leukemia is 10 times that of children
Etiology and Pathophysiology
• No single causative agent
• Most from a combination of factors
o Genetic and environmental influences
• Associated with the development of leukemia
o Chemical agents o Radiation
o Chemotherapeutic agents o Immunologic deficiencies
o Viruses
Classification
• Acute versus chronic
o Cell maturity
 Acute: clonal proliferation of immature hematopoietic cells (the formation of
blood or blood cells)
 Chronic: mature forms of WBC; onset is more gradual
o Nature of disease onset
• Type of white blood cell (WBC)
o Acute lymphocytic leukemia (ALL)
o Acute myelogenous leukemia (AML)
 Also called acute nonlymphoblastic leukemia (ANLL)
o Chronic myelogenous leukemia (CML)
o Chronic lymphocytic leukemia (CLL)

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3rd Year 2nd Semester Medicine 1

Myelogenous Leukemia
• Leukemia characterized by proliferation of myeloid tissue (as of the bone marrow and
spleen) and an abnormal increase in the number of granulocytes, myelocytes, and
myeloblasts in the circulating blood
• Myeloid tissue is a biologic tissue with the ability to perform haematopoiesis. It is
mainly found as the red bone marrow in bones, and is often synonymous with this.
However, myeloid can also be present in the liver and spleen .
• A myelocyte is a young cell of the granulocytic series, occurring normally in bone
marrow, but not in circulating blood (except when caused by certain diseases).
• Granulocytes are a category of white blood cells characterized by the presence of
granules in their cytoplasm.[1] They are also called polymorphonuclear leukocytes
(PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into
three segments.
• The myeloblast is a unipotent stem cell, which will differentiate into one of the actors of
the granular series.
Acute Myelogenous Leukemia (AML)
• Leukemia characterized by proliferation of myeloid tissue (as of the bone marrow and
spleen) and an abnormal increase in the number of granulocytes, myelocytes, and
myeloblasts in the circulating blood
• One fourth of all leukemias
o 85% of the acute leukemias in adults
• Abrupt, dramatic onset
o Serious infections, abnormal bleeding
• Uncontrolled proliferation of myeloblasts
o Hyperplasia of bone marrow and spleen
Acute Lymphocytic Leukemia (ALL)
• Most common type of leukemia in children
• 15% of acute leukemia in adults
• Immature lymphocytes proliferate in the bone marrow
• Signs and symptoms may appear abruptly
o Fever, bleeding
• Insidious with progressive
o Weakness, fatigue
• Central nervous system manifestations

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3rd Year 2nd Semester Medicine 1

Chronic Myelogenous Leukemia (CML)

• Excessive development of mature neoplastic granulocytes in the bone marrow
o Move into the peripheral blood in massive numbers
o Ultimately infiltrate the liver and spleen
• Philadelphia chromosome
o The chromosome abnormality that causes chronic myeloid leukemia (CML) (9 &22)
o Genetic marker
• Chronic, stable phase followed by acute, aggressive (blastic) phase
Chronic Lymphocytic Leukemia (CLL)
• Production and accumulation of functionally inactive but long-lived, mature-appearing
lymphocytes
• B cell involvement
• Lymph node enlargement is noticeable throughout the body
o ↑ incidence of infection
• Complications from early-stage CLL is rare
o May develop as the disease advances
o Pain, paralysis from enlarged lymph nodes causing pressure
Hairy Cell Leukemia
• 2% of all adult leukemias
• Usually in males > 40 years old
• Chronic disease of lymphoproliferation
o B lymphocytes that infiltrate the bone marrow and liver
• Cells have a “hairy” appearance
• Symptoms from
o Splenomegaly, pancytopenia, infection, vasculitis
• Treatment
o alpha-interferon, pentostatin, cladribine
Unclassified Leukemias
• Subtype cannot be identified
• Malignant leukemic cells may have
o Lymphoid, myeloid, or mixed characteristics
• Frequently these patients do not respond well to treatment
o Poor prognosis

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3rd Year 2nd Semester Medicine 1

Clinical Manifestations
• Relate to problems caused by Bone marrow failure
o Overcrowding by abnormal cells
o Inadequate production of normal marrow elements
o Anemia, thrombocytopenia, ↓ number and function of WBCs
• Relate to problems caused by Leukemic cells infiltrate patient’s organs
o Splenomegaly o Hepatomegaly
o Lymphadenopathy
o Bone pain, meningeal irritation, oral lesions (chloromas)
Diagnostic Studies
• To diagnose and classify
o Peripheral blood evaluation (CBC and blood smear)
o Bone marrow evaluation
• To identify cell subtype and stage
o Morphologic, histochemical, immunologic, and cytogenic methods
Collaborative Care
• Goal is to attain remission (when there is no longer evidence of cancer cells in the body)
• Chemotherapeutic treatment
o Induction therapy
 Attempt to induce or bring remission
 Seeks to destroy leukemic cells in the tissues, peripheral blood, bone marrow
 Patient may become critically ill
 Provide psychological support as well
What is remission?
• The main aim of treatment for acute lymphoblastic leukaemia is to give a remission. This
means that the abnormal, immature white cells or blasts can no longer be detected in your
blood or bone marrow, and normal bone marrow has developed again.
• However, once you are in remission there may still be a very small number of abnormal
lymphoblasts left. To destroy these, your doctor may prescribe maintenance or
continuation chemotherapy which may last for several years. These drugs are mainly
taken as tablets and you will need to have regular check-ups to monitor their effect. Very
specialised blood tests to find particular proteins present on the surface of the leukaemia
cells can show if any leukaemia cells are still present in the body.
• For many people with acute lymphoblastic leukaemia the remission lasts indefinitely and
the person is said to be cured.
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3rd Year 2nd Semester Medicine 1

o Intensification therapy
 High-dose therapy
 May be given after induction therapy
 Same drugs at higher doses and/or other drugs
o Consolidation therapy
 Started after remission is achieved
 Purpose is to eliminate remaining leukemic cells that may not be evident
o Maintenance therapy
 Lower doses of the same drug
• Chemotherapy Regimens
o Combination chemotherapy
 Mainstay treatment
 3 purposes
 ↓ drug resistance
 ↓ drug toxicity to the patient by using multiple drugs with varying toxicities
 Interrupt cell growth at multiple points in the cell cycle
• Bone Marrow and Stem Cell Transplantation
o Goal: Totally eliminate leukemic cells from the body using combinations of
chemotherapy with or without total body irradiation
o Eradicates patient’s hematopoietic stem cells
o Replaced with those of an HLA-matched (Human Leukocyte Antigen)
 Sibling (is a brother or a sister; that is, any person who shares at least one of the
same parents)
 Volunteer
 Identical twin
 Patient’s own stem cells removed before

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3rd Year 2nd Semester Medicine 1

Nursing Management
• Planning
o Overall goals
 Understand and cooperate with the treatment plan
 Experience minimal side effects and complications of disease and treatment
 Feel hopeful and supported during the periods of treatment, relapse, and remission
o Many physical and psychological needs
 Evokes great fear
 Family also needs help
o Balance demanding technical needs with a humanistic, caring approach
o Patient empowered by knowledge of the disease and treatment can have a more
positive outlook and improved quality of life
o Nurses face special challenges when meeting the intense psychosocial needs of a
patient with leukemia
o Ongoing care is necessary to monitor for signs and symptoms of disease control or
relapse
o Teach patient and significant other
 Diligence in disease management
 Need for follow-up care
 When to seek medical attention
o Goals of rehabilitation
 Manage
 Physical  Spiritual
 Psychosocial  Delayed effects
 Social
 Support groups
• Evaluation
o Cope effectively with diagnosis, treatment regimen, and prognosis
o Attain and maintain adequate nutrition
o Experience no complications
o Feel comfortable and supported

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