Leukemia

Leukemia presentation for MSc nursing students

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2. LEUKEMIA PRESENTED BY : Ms. Zuricka Da Costa M.Sc. (N) I year 5/7/2020 2

3. OBJECTIVES Definition of Leukemia Incidence of Leukemia Etiology & Risk factors of Leukemia Classification of Leukemia Pathophysiology of Leukemia Diagnostic evaluation of Leukemia Management of Leukemia Complications 5/7/2020 3

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5. LEUKEMIA The word Leukemia comes from the Greek word leukos which means "white" and aima which means "blood". 5/7/2020 5

6. DEFINITION Leukemia is a progressive, malignant disease of the blood forming organs, marked by distorted proliferation and development of leukocytes and their precursors in the blood and bone marrow. -National Cancer Institute 5/7/2020 6

7. INCIDENCE About 3- 4 percent in 1,00,000 population in India. Affects approximately 9 times more in adults than in children. 5/7/2020 7

8. ANATOMY AND PHYSIOLOGY 5/7/2020 8

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10. ETIOLOGY AND RISK FACTORS The exact cause is unknown. Gender Age Family history Genetic disorders Smoking tobacco Exposures (radiation or chemicals) Previous cancer treatment Viral cause 5/7/2020 10

11. CLASSIFICATION According to nature of disease Acute leukemia Chronic leukemia According to type of blood cell affected Acute lymphocytic leukemia Acute myelogenous leukemia Chronic lymphocytic leukemia Chronic myelogenous leukemia 5/7/2020 11

12. CLASSIFICATION cont. According to nature of disease Acute leukemia Chronic leukemia 5/7/2020 12

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14. ACUTE LEUKEMIA Characterized by clonal proliferation of immature hematopoietic cells. It develops after malignant transformation of a single type of immature hematopoietic cells Cellular replication and expansion of that malignant clone. 5/7/2020 14

15. ACUTE LEUKEMIA - Clinical manifestations Low white blood cell count Infections Tiredness Shortness of breath Pale skin Sweating usually at night Fever Bone and joint aches 5/7/2020 15

16. CHRONIC LEUKEMIA In chronic leukemia, the leukemia cells come from mature cells Distinguished by excessive build up relatively mature but still abnormal WBC. Takes months to years to progress. Shows no symptoms initially. 5/7/2020 16

17. CHRONIC LEUKEMIA- Clinical manifestations Malaise Weight loss Loss of appetite Fever Night sweats Anaemia Infections Bleeding (nosebleed) Enlarged lymph nodes Pain or feeling of fullness in upper left abdomen. 5/7/2020 17

18. ACCORDING TO TYPE OF BLOOD CELL AFFECTED 5/7/2020 18

19. ACCORDING TO TYPE OF BLOOD CELL AFFECTED CONT. 5/7/2020 19

20. ACUTE LYMPHOCYTIC LEUKEMIA (ALL) Most common type of leukemia in children, and accounts for 20% of leukemia case in adults. Here immature small lymphocytes proliferate in bone marrow : most are of B- cell origin. 5/7/2020 20

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22. ALL- CLINICAL MANIFESTATION Fever Pale skin Bleeding Anorexia, weight loss Fatigue Weakness 5/7/2020 22

23. ALL- CLINICAL MANIFESTATION Bone , joint and abdominal pain Generalized lymphadenopathy Infection Hepatosplenomegaly Headache Mouth sores Increased ICP 5/7/2020 23

24. ALL- DIAGNOSTIC FINDINGS Low RBC count, Hb , Hct , low platelet count. Low, or high WBC count, high LDH Transverse lines of rarefaction at ends of metaphysis of long bones on X-rays. Hypercellular bone-marrow with lymphoblast. Presence of Philadelphia chromosomes (20-25% cases). 5/7/2020 24

25. ALL- TREATMENT Chemotherapy is the mainstay of treatment It is the use of potent drugs or chemicals, often in combinations or intervals, to kill or damage cancer cells in the body. 5/7/2020 25

26. ALL- TREATMENT CONT. Prophylactic treatment of the CNS, intrathecal administration and/or cerebrospinal radiation to eradicate leukemic cells. Diet having high protein and fibre. Drink adequate Fluid Avoid infection and injury. 5/7/2020 26

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28. ACUTE MYELOGENOUS LEUKEMIA (AML) This type represents only 1/4 th of all leukemia's , in which 80% of this type in adults. It is characterized by uncontrolled proliferation of myeloblasts in the bone marrow. Its onset is often abrupt and dramatic. Increases in incidence with advancing age after 60yr. 5/7/2020 28

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30. AML- CLINICAL MANIFESTATION Fatigue and weakness Headache Mouth sores Anaemia Bleeding Fever Infection Sternal tenderness Gingival hyperplasia Mild hepatosplenomegaly 5/7/2020 30

31. AML- DIAGNOSTIC FINDINGS Low RBC count, Hb , Hct , Low platelet count Low to high WBC count with myeloblasts . High LDH. Hypercellular bone marrow with myeloblasts . 5/7/2020 31

32. AML- TREATMENT Same treatment as ALL. Common chemotherapy agent for induction of AML includes cytarabine and an antitumor antibiotic such as mitoxantrone . Fluid therapy (2000-3000ml/day) 5/7/2020 32

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35. CHRONIC LYMPHOCYTIC LEUKEMIA (CLL) It is most common type in adults. It is characterized by production and accumulation of functionally inactive but long- lived, small, mature- appearing lymphocytes. The type of lymphocytes involved is usually B- cell and it may infiltrate other organ like bone marrow, spleen and liver. 5/7/2020 35

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37. CLL- CLINICAL MANIFESTATIONS Chronic fatigue Anorexia Splenomegaly & lymphadenopathy Hepatomegaly Fever Night sweats Weight loss Frequent infection 5/7/2020 37

38. CLL- DIAGNOSTIC FINDINGS Mild anemia and thrombocytopenia Total WBC count >100,000 /micro L Increased peripheral lymphocytes and lymphocytes in bone marrow Autoimmune haemolytic anemia Idiopathic thrombocytopenic pupura 5/7/2020 38

39. CLL - TREATMENT Lymphocytic proliferation can be suppressed with cholrambucil , cyclophosphamide and prednisolone . Monoclonal antibody such as campath maybe used. Transfusion therapy to replace RBCs and platelet. Irradiation of painful enlarged lymph nodes. 5/7/2020 39

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42. CHRONIC MYELOGENOUS LEUKEMIA (CML) It is caused by excessive development of mature neoplastic granulocytes in the bone marrow. The excess neoplastic granulocytes move into peripheral blood in massive number and ultimately infiltrate the liver & spleen. It increases in incidence with advancing age. 5/7/2020 42

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44. CML- CLINICAL MANIFESTATION Usually no initial symptoms Fatigue and weakness Fever Sternal tenderness Weight loss Joint pain, bone pain Massive splenomegaly Increase in sweating 5/7/2020 44

45. CML – DIAGNOSTIC FINDINGS Low RBC’s count, Hb , Hct . High platelet count initially but later count decreases. Increased banded neutrophills and myeloblasts and often basophils Normal number of lymphocytes. Normal or low number of monocytes . Nucleated red cells Presence of Philadelphia chromosomes in 90% 0f patients 5/7/2020 45

46. Philadelphia chromosome. 5/7/2020 46

47. CML- TREATMENT It can be treated with drug like imatinib or dasatinib Combination chemotherapy includes prednisolone , vincristine or methotrexate . Imatinib and other tyrosine kinase inhibitor target the BCR –ABL protein that is present in nearly all patient with CML. Take measures to prevent infection Promote safety 5/7/2020 47

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49. PATHOPHYSIOLOGY 5/7/2020 49

50. CLINICAL MANIFESTATION 5/7/2020 50

51. DIAGNOSTIC EVALUATION 5/7/2020 51

52. DIAGNOSTIC EVALUATION Health history Physical examination CBC Lipid profile (lactate dehydrogenase )- elevated Polymerase chain reaction- presence of biomarkers Liver function test- elevated 5/7/2020 52

53. DIAGNOSTIC EVALUATION cont. C reactive protein- elevated { 10 milligram per liter ( mg/L)} Bone marrow aspiration Bone marrow biopsy Cytogenetic Chest X ray - swollen lymph nodes 5/7/2020 53

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55. X-ray Showing swollen lymph nodes 5/7/2020 55

56. MANAGEMENT 5/7/2020 56

57. MANAGEMENT Patient having high levels of WBC Count must start with initial emergent treatment. It includes leukapheresis and hydroxyurea . Chemotherapy is a mainstay for leukemia 5/7/2020 57

58. LEUKAPHERESIS 5/7/2020 58

59. MANAGEMENT cont. Combination therapy should be initiated. Purpose of using multiple drug are: Decrease drug resistance Minimize the drug toxicity to the patient by using multiple drug with varying toxicity Interrupt cell growth at multiple points in the cell cycle. 5/7/2020 59

60. CHEMOTHERAPY It is the use of potent drugs or chemicals, often in combinations or intervals, to kill or damage cancer cells in the body. Normally, healthy cells divide and grow in a controlled pattern. As each cell divides, a replica is produced. Cancer cells, on the other hand, grow uncontrollably and rapidly with no pattern. When a cancer cell comes into contact with a normal cell, the cancer cell takes over and copies itself many times, overburdening the body with cancer cells 5/7/2020 60

61. Chemotherapy cont. All chemotherapy drugs interfere with cancer cells ability to grow or multiply. It attack cancer cells by interacting with the cancer cell's DNA or RNA (genetic makeup). This interaction changes the DNA in such a way that it kills the cancer cell or prevents it from growing or dividing. 5/7/2020 61

62. Other Modes of Attack Hormones  such as prednisone and dexamethasone ( Decadron ) in high doses can kill lymphoma or lymphocytic leukemia cells. Antimitotic drugs  such as vincristine ( Oncovin ) or vinblastine ( Velban ) damage cancer cells by blocking a process called mitosis (cell division), preventing cancer cells from dividing and multiplying. Antibodies  made specifically to attach to cancer cells interfere with a cancer cell's function and kill the cell. Some antibodies are combined with a toxin or radioactive substance. 5/7/2020 62

63. It involves three phases: 5/7/2020 63

64. Induction Therapy The first phase of treatment is induction therapy. Its goal is to "induce" remission (when no evidence of the disease is left). Specifically, induction therapy for leukemia attempts to: Kill as many leukemic cells as possible with chemotherapy Get healthy blood cell counts back to normal Get rid of all signs of the disease for an extended time 5/7/2020 64

65. Post induction or post remission therapy After induction therapy is complete and the patient is in remission, another phase of treatment is needed called “post-remission therapy,” or “consolidation therapy.”  This second phase of treatment is used to destroy any stray leukemic cells not found by blood or marrow tests. Without post-remission therapy, the leukemia will likely return . This phase usually lasts several months. 5/7/2020 65

66. Maintenance therapy The maintenance phase is the final phase of treatment that lasts for two to three years. It's used to kill any remaining cells that could cause a recurrence.  It is a treatment with low doses of same drug as in induction phase given every 3-4 week. 5/7/2020 66

67. Side effects Chemo drugs can affect some normal cells in the body, which can lead to side effects. The side effects of chemo depend on the type and dose of drugs given and the length of time they are taken. Common side effects can include: Hair loss Mouth sores Loss of appetite Nausea and vomiting Diarrhea or constipation 5/7/2020 67

68. Side effects cont. Chemo drugs also affect the normal cells in bone marrow, which can lower blood cell counts. This can lead to: Increased risk of infections (from having too few normal white blood cells) Easy bruising or bleeding (from having too few blood platelets) Fatigue and shortness of breath (from having too few red blood cells) 5/7/2020 68

69. MANAGEMENT cont. The other options are : Watchful waiting Corticosteroids Radiation therapy Immunotherapy Biological therapy Targeted therapy 5/7/2020 69

70. RADIATION THERAPY Radiation therapy (also called radiotherapy) uses high-energy rays to kill leukemia cells. This type of therapy takes place 5 days a week for several weeks. 5/7/2020 70

71. BIOLOGICAL THERAPY Biological therapy for leukemia is treatment that improves the body's natural defences against the disease. One type of biological therapy is a substance called a monoclonal antibody. It's given by IV infusion The side effects of biological therapy differ with the types of substances used, and from person to person. It commonly cause a rash or swelling where the drug is injected. They also may cause a headache, muscle aches, a fever, or weakness. 5/7/2020 71

72. TARGETED THERAPY Targeted therapies use drugs that block the growth of leukemia cells. For example, a targeted therapy may block the action of an abnormal protein that stimulates the growth of leukemia cells. Side effects include swelling, bloating, and sudden weight gain. Targeted therapy can also cause anaemia, nausea, vomiting, diarrhoea, muscle cramps, or a rash. 5/7/2020 72

73. MANAGEMENT cont. HEMATOPOIETIC STEM CELL TRANSPLANTATION Any procedure where hematopoietic stem cells of any donor and any source are given to a recipient with intention of repopulating/replacing the hematopoietic system in total or in part. 5/7/2020 73

74. Hematopoietic stem cell transplantation- Types of transplant cont. Autologous (your own cells) Allogeneic cells from another person Sibling Unrelated Donor Parent or relative or source: Umbilical cord 5/7/2020 74

75. AUTOGENIC HEMATOPOIETIC STEM CELL TRANSPLANTATION 5/7/2020 75

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77. SUPPORTIVE CARE INFECTIONS ANEMIA AND BLEEDING DENTAL PROBLEMS Diet and management Symptomatic management Discharge and home care– physical, psychological, economic, spiritual necessary Continuation of medications on dicharge Folow up Sign and symptoms to inform if occurs on discharge Prevention of infections - instructions 5/7/2020 77

78. MANAGEMENT cont . NURSING MANAGEMENT Obtain health history, focusing on fatigue, weight loss, night sweats, and activity intolerance. Assess for signs of bleeding & infection. Evaluate splenomegaly , lymphodenopathy & hepatomegaly . Examine patient for abnormal breathing sounds, skin lesions. Inspect the patient for the sign of infection & the incidence of frequency of infection. 5/7/2020 78

79. MANAGEMENT cont. NURSING DIAGNOSIS: Risk for infection related inadequate secondary defences: alteration in mature WBCs Acute pain related to enlarged lymph nodes as evidenced by pain score level Activity intolerance related to generalised weakness as verbalized by patient. Risk for deficit fluid volume related to haemorrhage, vomiting . 5/7/2020 79

80. COMPLICATION Infection Multiorgan dysfunction Bleeding Thrombophlebitis DIC Leukostasis 5/7/2020 80

81. ACUTE MYELOID LUEKEMIA: Advancement in diagnosis and treatment This article reviewed the latest developments related to the diagnosis and treatment of AML. Current chemotherapy agents have limited therapeutic efficacy, with an approximate 50–70% complete remission (CR) rate after induction and with only 20–30% of patients achieving long-term disease-free survival. 5/7/2020 81

82. Through an extensive search they found out new therapies like Tyrosine kinase 3 inhibitors, immunotherapy, cellular therapy is the newer trend to treat luekemia . A major task for medical workers is to improve the survival of AML patients while minimizing treatment-related toxicity. These therapy and gene sequencing techniques should set the basis for next-generation diagnostic methods. Further, target therapy should be the focus of future clinical research in the exploration of therapeutic possibilities. 5/7/2020 82

83. Drug Duo a  Weapon Against a Common Leukemia Dr. Tait Shanafelt , professor of medicine at Stanford University A two-drug combo helps patients with a common form of leukemia survive longer than the current standard of care, a new clinical trial finds. The phase 3 trial of more than 500 U.S. patients with chronic lymphocytic leukemia (CLL) found that a combination of rituximab and ibrutinib extended patient survival. 5/7/2020 83

84. Specifically, 89.4% of the patients who received the experimental drug combination did not have any progression of their leukemia about three years after treatment, compared with 72.9% of those who received the traditional chemotherapy combination. As to overall survival, regardless of whether the disease had progressed or not, the trial found that three years after treatment, 98.8% of patients who received the two-drug combination were alive, compared with 91.5% of those who received the traditional treatment. 5/7/2020 84

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