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42 Cards in this Set
- Front
- Back
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Leukemia
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The general term used to describe a group of malignancies affecting blood and blood forming tissues including:
Bone marrow Lymphatic system Spleen |
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KNOW THIS FOR EXAM!
Leukemia |
Based on:
Cell type -Lymphocytic (lymphoid line) -Myelocytic (myeloid line - bone marrow) Acuity or Chronicity -Acute leukemia-rapid onset, aggressive -Chronic leukemia-gradual onset, indolent |
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Classifications
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Acute lymphocytic leukemia (ALL)
Acute myelogenous leukemia (AML) Chronic lymphocytic leukemia (CLL) Chronic myelogenous leukemia (CML) **cell maturity refers to acute or chronic** |
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Classifications
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Hairy cell leukemia (highly treated with interferon)
Cutaneous t-cell leukemia Unclassified leukemias - subtype can't be identified, or combination of myeloid and lymphoid |
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Causative Factors
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Unknown
? Genetic Predisposition ? Viral implications Not a single causative agent Most likely combination of factors Anemia may be a precursor |
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Potential Risk Factors
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Smoking
Radiation Exposure Genetic factors: Down's Syndrome and Philadelphia Chromosome |
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Clinical Presentation
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Elevated white count
Enlarged liver/spleen Increased metabolism Severe infections Weakness Anemia (patient reports last week they were fine and 1 week later present very sick, look sick and feel lousy). |
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Clinical Presentation
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CNS symptoms: headache, mental status changes
Renal Insufficiency Bone pain (very common complaint) Bruising/bleeding |
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Potential Risk Factors
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Heredity
Viruses Radiotherapy Chemotherapy Exposure to benzenes |
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Diagnostic Studies
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History and Physical Exam
CBC with differential Serum electrolytes Bone marrow biopsy - definitive diagnosis Lumbar puncture - evaluate if CNS disease Biopsy of skin lesions |
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Cancer in the Marrow: Acute Leukemia
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Acute Leukemia
-More common in children than adults -Progresses rapidly -Ineffective, immature WBC's crowd the bone marrow (large number of diseased cells) Signs: Increasing immature may effect all lines Bone Pain |
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Cancer in the Marrow: Chronic Leukemia
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Chronic Leukemia
-Rarely affect people under the age of 20 -Affect men > women typically age 40-50 -Progress slowly -Allows development of normal cells |
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Acute Lymphocytic Leukemia (ALL)
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Rapidly developing immature lymphocytes crowd out normal cells
Presence of the Philadelphia chromosome Poor prognostic factors: WBC > 25,000/mm3 Age over 50 First remission later than 3 weeks |
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Acute Lymphocytic Leukemia (ALL)
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Four treatment phases: (chemotherapy)
Induction-"induce" a remission Intensification Consolidation Maintenance Consider bone marrow transplant if relapse at any point Goal: Complete remission with restoration of hematopoiesis |
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Acute Lymphocytic Leukemia (ALL)
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Induction Phase:
Aggressive, intensive chemotherapy Goal is to eradicate leukemia Prolonged hospitalization with potentially life threatening complications Requires CNS prophylaxis Infection prevention and treatment Nausea management isolation 6 weeks of hospitalization Wait for blood counts to come back up. |
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Acute Lymphocytic Leukemia (ALL)
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Intensification phase:
Several courses of same or different chemotherapy drugs (never single agents) Goal is to continue destruction of leukemic cells (residual cells) Usually briefer hospitalization, recovery before beginning new cycle |
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Acute Lymphocytic Leukemia (ALL)
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Consolidation phase:
Begun after remission achieved Goal: eliminate undetectable disease Less aggressive, spaced out over weeks Usually same drugs used for remission |
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Acute Lymphocytic Leukemia (ALL)
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Maintenance phase:
Goal is to maintain remission, prevent recurrence of leukemic cells Lower doses, same drugs every 3-4 weeks Less toxicity, out-patient, oral and IV May continue for 3-4 years |
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Acute Lymphocytic Leukemia (ALL)
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The role of Bone Marrow Transplant:
Remains controversial Unclear if improves survival period if in remission Many clinical trials currently ongoing Goal is to eradicate the diseased cells |
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Acute Myelogenous Leukemia (AML)
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Represents 25% of all leukemia in adults
85% of acute leukemias in adults Abrupt onset Uncontrolled proliferation of myeloblasts |
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Acute Myelogenous Leukemia (AML)
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Induction therapy:
Induce a remission like ALL Prolonged hospitalization Goal is <5% blasts 10 days after treatment started No routine CNS prophylaxis |
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Prognostic Factors
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Age under 60 years is favorable
Spontaneous cause Remission within one cycle of chemo=good prognosis WBC <10,000/mm3 |
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Acute Myelogenous Leukemia (AML)
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Post Remission Therapy: is required
No further treatment-relapse in 6-8 months Conflicting data re: appropriate treatment Preference is allogeneic BMT If no match, may involve intensive chemo Clients should enroll in clinical trial |
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Acute Myelogenous Leukemia (AML)
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Remission Rates 25-35%
Role of transplant -Allogeneic transplant from matched donors has increased the cure rate to 50-60% -Autologous stem cell transplant benefit is unclear at this time |
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Chronic Lymphocytic Leukemia (CLL)
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Second most common leukemia, often found in routine exam (discovered with CBC)
Difficult decision re: if or when to treat Early disease: may survive >10 years with no treatment Late disease: aggressive, treatment resistant, death in <2 |
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Chronic Lymphocytic Leukemia (CLL)
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Indolent disease
-lymphocytosis -lymphadenopathy -Hepatosplenomegaly -Recurrent infections |
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Chronic Lymphocytic Leukemia (CLL)
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The goal is not cure and is usually delayed
Median survival when treatment begins: 19 months Chemotherapy Radiation therapy Biologic therapy |
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Chromic Myelogenous Leukemia (CML)
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Hallmark: presence of Philadelphia chromosome - diagnostic of CML
Has 3 phases: Chronic Phase: may last 3-5 years, treated with single agent to control WBC count Accelerated Phase: all clients convert, resistant to treatment, death <6 months Blast Phase |
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Chromic Myelogenous Leukemia (CML)
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Chronic Phase: mild symptoms contolled with single agents designed to keep WBC down. Blasts <105
Accelerated Phase: Spleen enlargement, fevers, night sweats, weight loss 10-30% blasts -lasts 6-12 months -less responsive to therapy |
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Chromic Myelogenous Leukemia (CML)
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Blast Phase: transformation to aggressive leukemia >30% blasts
-Therapies -Gleevec -Interferon hydoxurea -Allogeneic stem cell transplant (must be done early) |
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Bone Marrow Transplant (BMT)
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Cure rates increasing with BMT
Even if no cure, some period of remission Allows for very high dose chemotherapy Type of transplant depends on whose marrow is infused Over 15,000 transplants done in US in 2004 and number is growing |
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Disorders treated with Bone Marrow Transplant
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Malignant Diseases:
Leukemias Hodgekin's Disease Non-Hodgekin's Lymphomas Multiple myeloma Mylodysplastic syndrome (MDS) NON-MALIGNANCIES: Sickle cell disease Thalassemia Aplastic anemia Immunodeficiency diseases |
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Types of Transplant
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Allogeneic Bone Marrow Transplant:
Related, usually sibling Unrelated, matched unrelated donor (MUD) from marrow registry Infused marrow from donor who is HLA matched to recipient |
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BMT
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Autologous Bone Marrow Transplant:
Clients receive own bone marrow back Harvested and stored, can use bone marrow or peripherally harvested cells More of a "rescue" than a true transplant |
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BMT
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Syngeneic Bone Marrow Transplant:
Donor is identical twin Has identical HLA typing and is a perfect match |
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Peripheral Stem Cell Transplant (PSCT)
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Peripheral Stem Cell Transplant (PSCT):
Harvest of peripheral stem cells via pheresis Donor is given colony stimulating factor May require several days to obtain adequate number of stem cells Recovery quicker, fewer side effects |
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Bone Marrow Transplant (BMT)
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Proceeded by harsh chemotherapy regimens:
Dental exam Suppress menstruation pharmacologically Permanent vascular device, with multiple lumens(tunneled permanent central venous access) Preferably no/minimal disease |
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BMT Donation
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Done in OR, general anesthesia
Multiple aspirations from iliac crest Takes 1-2 hours Client discharged home with iron supplements and pain medications Marrow replaced in 1-2 weeks |
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Stem Cells
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Cord Blood Stem Cells
Umbilical cord blood is rich in stem cells Disadvantage: low number of stem cells Data: cord blood has been stored for 15 years with no decrease in effectiveness Still new technology; processing fee: $1800 and annual storage fee: $100 |
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Nursing Considerations BMT
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Same for all bone marrow transplants
Countdown Days: Conditioning Day "0": Transplant Day Plus days: Recovery Engraftment |
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The Course of BMT
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Early: First 100 or so days:
Bacterial, viral, fungal infections Anemia, neutropenia, thrombocytopenia Mucous membrane breakdown: mucocytis, esophogitis, stomatitis, rectal fissures Electrolyte imbalances Rejection - Graft vs Host Disease (GVHD) |
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Complications
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Late: Chronic rejection (GVHD)
Respiratory problems: Bronchiolitis obliterans organizing pneumonia (BOOP) Cataracts Decreased maturation (in children and teens) Secondary cancers and infertility |
