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Prognosis And Treatment Therapies In Acute Leukemia And An Overview On Lymphoblastic Leukemia
An Acute Leukemic Patient
Prognosis Of Acute Leukemia
Leukemia is invariably fatal if untreated. Modern treatment has helped in prolonging life in the vast majority of cases of acute leukemias and in about 10% of cases to bring about cure. Best results are obtained in acute lymphatic leukemia in children. At present, research is on going to evolve newer modalities for diagnosis and treatment and the results are bound to improve further in the future.
The favourable prognostic factors
- Initial leucocyte count below 20,000/cmm
- Platelet count above 100,000/cmm
- Absence of organomegaly, meaning, lymph nodes, spleen and liver are impalpable
- Null cell (common ALL) leukemia
- Absence of complications
- Absence of mediastinal lymphadenopathy in acute lymphatic leukemia
- Younger age groups, and
- Institution of proper therapy from the beginning
The unfavourable prognostic factors
- Older age groups
- Initial leucocyte count above 20,000/cmm
- Thrombocytopenia below 100,000/cmm
- Presence of complications
- T-cell acute lymphatic leukemia, and
- Presence of mediastinal lymph nodes in lymphatic leukemia.
Cases which fall in the poor-prognosis group are given more intensive induction regimen using a larger number of drugs.
Administering Drugs In Leukemic Patients
Drugs used for the treatment of acute leukemias
Antimetabolites: Methotrexate, cytosine arabinoside, 6-mercaptopurin and 6-thioguanine
Antimitotic drugs: Vincristine
Antibiotics: Doxorubicin and Rubidazone
Alkylating agent: Cyclophosphamide
Other supportive treatments
Other supportive measures include red cell transfusions for anemia, platelet transfusions for hemorrhage and whole blood to correct blood loss. Hyperuricemia may lead to correct blood loss. Hyperuricemia may lead to secondary gout and renal failure during treatment. Prompt use of allopurinol 100 mg thrice daily orally during the initial phases of treatment helps in keeping the uric acid levels normal. Adequate hydration and maintenance of urine output of at least two liters daily help in avoiding uric acid nephropathy.
Young Girl With Acute Lymphoblastic Leukemia
Lymphoblastic Leukemia (ALL)
This type of leukemia which is most common in children, arises lymphoid tissue. About 75% cases are null cell type, 20-25% T cell type and a few are B cell type. Maximum incidence is in the first two decades. There is also a peak in the fourth and fifth decades. Male to female ratio is 2:1.
The presenting features are fever, pallor, lymphadenopathy and bleeding tendencies. Ophthalmoscopic examination reveals pallor of the optic disc, venous engorgement, hemorrhages and exudates. Vitreous hemorrhage and subconjunctival hemorrhage may occur in severe cases. Some cases present with neurological involvement. These take the form of meningitis, cranial nerve palsies, focal neurological deficits, convulsions or coma. About 20% present with arthralgias and arthritis resembling rheumatic or rheumatoid arthritis. Moderate lymphadenopathy, especially the posterior cervical and mediastinal groups, mild hepatosplenomegaly (spleen 2-5 cm), and pallor are detectable on physical examination. Bone involvement is more common. T cell leukemia is more serious since it is less responsive to therapy. It is characterized by higher total leucocyte count and enlargement of mediastinal lymph nodes.
Receiving Leukemia Treatment
Laboratory Findings And Treatment
There is normocytic normochromic anemia. Total leucocyte count is moderately elevated (20-30,000/cmm) but sometimes, it may go up to 100-200,000/cmm. Lymphoblasts may be from 5 to 95% of the total. Platelets are reduced. Bone marrow shows infiltration by lymphoblasts.
Remission is induced by a combination of vincristine, prednisolone and L-asparaginase given in repeated courses. About 80-90% of children and 60-70% of adults respond to this regimen and achieve complete remission. In the poor prognosis group, Adriamycin in a dose of 30 mg/m2 per week may be added. Remission is consolidated by giving 1 or 2 doses of the drugs used in the induction regimen.
Total number of courses
1- 1.5 mg/m2
7 days interval
daily X 5 days
Methotrexate in a dose of 15 mg/m2 as a single weekly dose and 6-mercaptopurine in a total dose of 600 mg/m2/week divided into daily doses are given orally. Vincristine 1.5 mg/m2 is given intravenously every month. Maintenance therapy has to be continued for 3-5 years. Neuroprophylaxis is started on achieving remission. If overt neuroleukemia exists on admission, treatment for this is also given simultaneously along with the inducing regimen.
Flow Chart for the Management of ALL
This is just a simple summary of the protocols or patterned guidlines to follow when managing an acute lymphoblastic leukemic patient. Induction of remission- Consolidation, Neuroprophylaxis and intrathecal drugs- Cranial irradiation- Maintenance.
© 2014 Funom Theophilus Makama