CANCERS OF THE BLOOD

LEUKEMIA AND LYMPHOMA

OBJECTIVES
 Review of
Anatomy and
Physiology:
THE BONE
MARROW

Colleen C. Flores, RN PhD

 LYMPHATIC SYSTEM - transport
lymph, a fluid containing infection-
fighting white blood cells,
throughout the body.

Spleen
1. Fights invading germs in the
blood (the spleen contains
infection-fighting white blood
cells) I
2. Controls the level of blood
cells (white blood cells, red
blood cells and platelets)
3. Filters the blood and removes
any old or damaged red blood
Colleen C. Flores, RN PhD cells.
 TYPES OF BLOOD CANCERS

•LEUKEMIA
•LYMPHOMA
•MYELOMA
 ACUTE LEUKEMIA
rise in the number of white blood cells in your body
that don’t work right
 ACUTE LEUKEMIA
ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) ACUTE MYELOID LEUKEMIA (AML)
• Also called acute lymphocytic leukemia • Also called acute myelocytic
and acute lymphoid leukemia
leukemia and acute
• Affects the blood cells and immune
system
myelogenous leukemia
• Common among children (2-4y/o) • Common among adults
• Classification: B-cell 75%; T-cell 25%
**Type of treatment to receive, and treatment outcome
depend on the ALL subtype and individual risk factors
 RISK FACTORS
• Age
• Infection – EBV, HIV
• Chemicals – benzenes
and pesticides
• Genetics: Trisomy 8 &
21 (AML)
• Race: Whites > Asians
Colleen C. Flores, RN PhD
 ACUTE LEUKEMIA: SIGNS & SYMPTOMS
• ALL
- Insidious Onset - (+) CONCOMITANT INFECTIONS
- May have CNS involvement - (+) CHLOROMAS
- (+) bony pain (EXTRAMEDULLARY)
- Hepatomegaly & - BONE PAIN – LESS SEEN
lymphadenopathy (40% in - BLEEDING EPISODES
pediatric patients) - APPEARS MORE ILL THAN ALL
Colleen C. Flores, RN PhD KIDS
SIGNS AND SYMPTOMS
LEUKEMIA
• BLOOD TESTS
• CBC
• PERIPHERAL BLOOD SMEAR = (+)
AUER RODS FOR AML
• BONE MARROW ASPIRATION & BIOPSY
(BONE CELLULARITY)
• CYTOGENIC ANALYSIS (FISH, RT-
PCR)
• CSF
 Bone marrow aspiration and
biopsy: After a small area of
skin is numbed, a bone
marrow needle is inserted
into the patient’s hip bone.
Samples of blood, bone, and
bone marrow are removed
for examination under a
microscope.
Colleen C. Flores, RN PhD
TREATMENT /
MANAGEMENT
ACUTE LEUKEMIA
 MANAGEMENT: CHEMOTHERAPY
ALL
• INDUCTION • REFRACTORY
➢ Vincristine, doxorubicin, prednisone (dexamethasone) ➢ newer or more intensive doses of chemo
➢ T-cell = cytarabine drugs may be tried
➢ B-cell = cytarabine + methotrexate ➢ HSCT

➢ CNS prophylaxis (adults) intrathecally • RELAPSE

• POST-REMISSION ➢ Brain or spinal fluid
➢ Nalarabine for T-cell
• Consolidation – increase drug doses used in
induction (1-2months); HSCT suggested ➢ MoAbs (Monoclonal Antibody) for B-cell and
Chimeric antigen receptor (CAR) T-cell
• Maintenance – decrease doses (2-3yrs) with
therapy (Kymriah)
methotrexate and 6-MP (6-MERCAPTOPURINE);
➢ HSCT
CNS prophylaxis continued
Monoclonal antibodies are man-made proteins that act like
human antibodies in the immune system. There are 4 different
ways they can be made and are named based on what they are
made of.
•Murine: These are made from mouse proteins and the names of
the treatments end in -omab.
•Chimeric: These proteins are a combination of part mouse and
part human and the names of the treatments end in -ximab.
•Humanized: These are made from small parts of mouse proteins
attached to human proteins and the names of the treatments end
in -zumab
•Human: These are fully human proteins and the names of the
treatments end in -umab.
 MANAGEMENT: CHEMOTHERAPY
• INDUCTION
➢PEDIATRICS
AML
✓7 + 3 REGIMEN (BMA on the 14th day)
✓7+3 = CYTARABINE CONTINUOUSLY FOR 7 DAYS, ALONG WITH SHORT
INFUSIONS OF AN ANTHRACYCLINE ON EACH OF THE FIRST 3 DAYS
✓Fludarabine or etoposide (for patients with poor cardiac function)
➢ ADULTS – aggressive & short-course (6months)
✓ Ara-C (Cytarabine)
• POST-REMISSION
• Consolidation – HiDAC – High Dose Ara-C (for younger patients) , Daunorubicin,
etoposide, mitoxanthrone for older; HSCT
 MANAGEMENT

Colleen C. Flores, RN PhD

Colleen C. Flores, RN PhD
Colleen C. Flores, RN PhD
CHRONIC LEUKEMIA
 CHRONIC LEUKEMIA
CLL
• B-cell CLL - >95% of people with CLL
have the B-cell type
• T-cell prolymphocytic leukemia
• Leukemia cells from these 2 types look
alike, but lab tests can tell the difference
between them (proteins ZAP-70 and
CD38)
CML
• Gets worse slowly
• Philadelphia Chromosome (Ph chromosome =
BCR-ABL)
• The prognosis and treatment options depend
on age, phase of CML, amount of blasts in
the blood or bone marrow, size of the spleen
at diagnosis, patient’s general health
CHRONIC LEUKEMIA: SIGNS AND
SYMPTOMS
• GENERALIZED
LYMPHADENOPATHY
• ANEMIA,
NEUTROPENIA,
THROMBOCYTOPENIA
 CHRONIC PHASE
• In chronic phase CML, fewer than 10% of the cells in the blood and bone marrow
are blast cells; LUQ pain (splenomegaly)

ACCELERATED PHASE
• In accelerated phase CML, 10-19% of the cells in the blood and bone marrow are

CML: Phases blast cells; fever of unknown origin, night sweats, lymphadenopathy, decreased
appetite (weight loss)

and BLASTIC PHASE

• In blastic phase CML, 20% or more of the cells in the blood or bone marrow are
Manifestations blast cells; resembles AML/ALL but patient does not respond to treatment
• Tiredness, fever, and an enlarged spleen occur during this phase = blast crisis

❖ CHRONIC MYELOGENOUS LEUKEMIA CAN RELAPSE (RETURN) AFTER IT HAS BEEN

TREATED.
❖ IN RELAPSED CML, THE NUMBER OF BLAST CELLS INCREASES AFTER A REMISSION.
 MANAGEMENT: CLL
COMMONLY-USED:
1. TARGETED THERAPY - Bruton's tyrosine
kinase (BTK) inhibitors & PI3K inhibitors
2. CHEMOTHERAPY – F.C.R (Fludarabine +
Cyclophosphamide + Rituximab)
3. IMMUNOTHERAPY – Monoclonal antibodies
4. EBRT
5. HSTC
 MANAGEMENT: CML
COMMONLY-USED:
1. TARGETED THERAPY - tyrosine
kinase inhibitors (TKIs)
2. CHEMOTHERAPY - hydroxyurea
3. IMMUNOTHERAPY - Interferons
4. HIGH-DOSE CHEMOTHERAPY with
HSTC
LYMPHOMA
CANCERS OF THE BLOOD
 RISK FACTORS
• FAMILY HISTORY
• INFECTIONS (EBV, HIV)
• AUTOIMMUNE DISORDERS (RA, SLE, etc.)
• CHEMICALS (Pesticides)
• DIET
• SMOKING
X-rays (fluoroscopy) of the lymphatic
vessels.
ABVD – Doxorubcin+ Bleomycin + Vinblastin +
Dacarbazine
BEACOPP - bleomycin, etoposide, doxorubicin,
cyclophosphamide, vincristine, procarbazine,
prednisone/
CHOP - Cyclophosphamide, Doxorubicin,
Vincristine, Prednisone
CVP - Cyclophosphamide, Vincristine, and
Prednisone
SPECIAL TREATMENT
CONSIDERATIONS
CANCERS OF THE BLOOD
 with

Colleen C. Flores, RN PhD

STEM CELL THERAPY
BONE MARROW AND TRANSPLANT
 Recall:
THE BONE
MARROW

Colleen C. Flores, RN PhD

INDICATIONS
• NEOPLASTIC DISORDERS –
Hematologic malignancies
and solid tumors
• NON-NEOPLASTIC
DISORDERS – aplastic
anemia, autoimmune
diseases, inborn errors of
metabolism, Parkinsosn’s, etc.
 GVHD
• IMMUNE-MEDIATED (donor
lymphoid and recipient's
immunity)
• INCIDENCE – 1-2%
• MORTALITY 75%
1.ACUTE - <3MOS
2.CHRONIC - > 3MOS

Colleen C. Flores, RN PhD

QUESTIONS ?