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Acute Lymphoblastic Leukaemia September 2018

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Acute Lymphoblastic Leukaemia September 2018 Pan-London Haemato-Oncology Clinical Guidelines Acute Leukaemias and Myeloid Neoplasms Part 1: Acute Lymphoblastic Leukaemia September 2018 CONTENTS Contents 1 Introduction ........................................................................................................................... 4 2 Referral Pathways ................................................................................................................ 5 2.1 Children, teenagers and young adults ........................................................................ 6 3 Investigation and Diagnosis .................................................................................................. 7 3.1 Fertility ........................................................................................................................ 7 3.2 Peripheral blood film ................................................................................................... 7 3.3 Bone marrow aspirate ................................................................................................ 8 3.4 Flow cytometry ........................................................................................................... 8 3.5 Cytogenetics ............................................................................................................... 8 3.6 Bone marrow trephine ................................................................................................ 8 3.7 Imaging ....................................................................................................................... 9 3.8 Pathology .................................................................................................................... 9 3.9 Lumbar puncture and CSF examination ..................................................................... 9 3.10 Bone marrow aspiration and trephine (BMAT) ....................................................... 10 4 Patient Information/Support ................................................................................................ 10 5 Treatment ........................................................................................................................... 11 5.1 Initial management considerations ........................................................................... 11 5.2 Clinical trials ............................................................................................................. 12 5.3 Specific therapeutic problems .................................................................................. 12 5.4 Allogeneic stem cell transplantation ......................................................................... 14 5.5 Management of older patients with ALL ................................................................... 14 5.6 Patients not wishing to enter a clinical trial ............................................................... 14 6 Management of Disease and Treatment-related Complications ........................................ 17 6.1 Anaemia ................................................................................................................... 17 6.2 Severe neutropenia .................................................................................................. 17 6.3 Neutropenic sepsis ................................................................................................... 17 6.4 Severe thrombocytopenia ......................................................................................... 18 6.5 Thrombosis/haemostasis .......................................................................................... 18 6.6 Haemostasis and thrombosis ................................................................................... 19 6.7 Hyperleukocytosis/hyperviscosity syndrome ............................................................ 19 6.8 Leukapheresis .......................................................................................................... 19 6.9 Hyperuricaemia and tumour lysis syndrome (TLS) .................................................. 19 1 CONTENTS 6.10 Central nervous system symptoms ........................................................................ 20 6.11 L-asparaginase-related complications .................................................................... 20 7 Supportive Care .................................................................................................................. 21 7.1 Transfusions ............................................................................................................. 21 7.2 Hyperviscosity syndrome .......................................................................................... 21 7.3 Hyperuricaemia ........................................................................................................ 21 7.4 Infection prophylaxis ................................................................................................. 21 7.5 Mouth care ................................................................................................................ 22 7.6 Control of menstruation ............................................................................................ 22 7.7 Breathlessness ......................................................................................................... 23 7.8 Weight loss ............................................................................................................... 23 7.9 Pain .......................................................................................................................... 23 7.10 Complex symptom management ............................................................................ 23 8 End-of-treatment Information .............................................................................................. 24 8.1 Treatment summary and care plan ........................................................................... 24 9 Follow-up Arrangements .................................................................................................... 24 10 Research/Clinical Trials .................................................................................................... 25 11 End-of-life Care ................................................................................................................ 25 12 Data Requirements ........................................................................................................... 25 Annex 1: Acute Leukaemia Patient Pathway ............................................................................ 26 Annex 2: Acute Lymphoid Leukaemia Checklist ...................................................................... 27 Annex 3: Guideline for the Management of Tumour Lysis Syndrome ...................................... 28 Annex 4: Guidelines for Use of Rasburicase in Adult Haematology and Oncology Patients ... 30 Annex 5: Oral Chemotherapy Patient Education Checklist ...................................................... 32 Annex 6: Monitoring of Long-term Survivors of Chemotherapy ................................................ 34 2 CONTENTS Lead authors: Professor Adele Fielding, University College London Hospitals NHS Foundation Trust Dr Eduardo Olavarria, Imperial College Healthcare NHS Trust Disclaimer These guidelines should be read in conjunction with the latest NICE guidance, and all applicable national/international guidance. The prescribing information in these guidelines is for health professionals only. It is not intended to replace consultation with the Haematology Consultant at the patient’s specialist centre. For information on cautions, contra-indications and side effects, refer to the up-to-date prescribing information. While great care has been taken to see that the information in these guidelines is accurate, the user is advised to check the doses and regimens carefully and if there is any uncertainty about the guidance provided, you should discuss your queries with a Haematology Consultant or Senior Pharmacist. No set of guidelines can cover all variations required for specific patient circumstances. It is the responsibility of the healthcare practitioners using them to adapt them for safe use within their institutions and for the individual needs of patients. Contact us The writing cycle for the guidelines will be from May-July each year. If you wish to be part of the writing group, please contact us through the following link: Pan London Blood Cancer (or via [email protected]). If you wish to report errors or omissions that require urgent attention please contact us via the same email addresses. © RM Partners, South East London Accountable Cancer Network, ULCH Cancer Collaborative 2018 3 INTRODUCTION 1 Introduction Acute lymphoblastic leukaemia (ALL) is an uncommon malignant disorder in adults. It represents approximately 15% of all leukaemias in adults. Patients diagnosed with ALL and treated with intensive protocols should be cared for in a British Committee for Standards in Haematology (BCSH) Level 3 haemato-oncology unit which participates in clinical trials for patients with ALL. Treatment for ALL is primarily based around clinical trials, which are quite regimented and driven by well-defined protocols. This guideline does not recapitulate these clinical trials but sets out a general guide to treatment strategies for new and relapsed patients. The main considerations are: ALL is an eminently curable disease in young patients that becomes harder to treat
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