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Hematologic Malignancy

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Hematologic Malignancy Hematologic Malignancy Siriraj Cancerอ. นพ. ดร.อาจรบ Registry คูหาภินันทน์ สาขาวิชาโลหิตวิทยา ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ศิริราชพยาบาล มหาวิทยาลัยมหิดล เลือด (Blood) Siriraj Cancer Registry Siriraj Cancer Registry Hematologic Malignancy The leukemias Acute leukemia Chronic leukemia MyeloproliferativeSiriraj Cancer disorders Registry Malignant lymphoma Multiple myeloma and plasma cell dyscrasias Siriraj Cancer Registry Acute leukemia Malignant accumulation of transformed hematopoietic progenitors cells (“blast cells”) Blast cells Self-Sirirajrenewal capability Cancer Registry Limited or no potential for terminal differentiation Bone marrow failure due to leukemic cell infiltration cytopenia Two types Acute myeloid leukemia (AML) [80%] Acute lymphocytic leukemia (ALL) [20%] Siriraj Cancer Registry Siriraj Cancer Registry Epidemiology AML Annual incidence 2-3 : 100000 (USA) Incidence increases with age (median 65 yr) < 1Siriraj : 100000 in Cancer age <30 yr Registry 15 : 100000 with age > 80 yr ALL Annual incidence 1 : 60000 75% patients with age < 15 yr Peak incidence at age 3-5 yr Both types have a slight male predominance CELLULAR ORIGIN OF AML Siriraj Cancer Registry Age-related incidence of AML Siriraj Cancer Registry Incidence of ALL vs AML Siriraj Cancer Registry Etiology of acute leukemia Environmental factors/ clinical conditions Ionizing radiation e.g. atomic bomb survivors Benzene (known to cause AML, MDS, AA) DownSiriraj syndrome Cancer (trisomy 21 Registry) patients Chromosomal breakage disorder (Fanconi anemia, Bloom syndrome) patients Prior MPD or MDS Chemotherapy (CMT) (therapy-related AML) Unknown (most patients) Clinical presentation (1) Bone marrow failure Fatigue/ weakness due to anemia Thrombocytopenic hemorrhage (petechiae and atraumatic ecchymoses) NeutropenicSiriraj infections Cancer (bacteria, Registryfungus) Severe bone pain due to BM infiltration Leukostasis (more common in AML) Stasis of blood flow (cerebral and pulmonary vasculature) when blast count > 50,000/µl Cerebral BF (headache, confusion, visual disturbance, coma, or stroke) Pulmonary BF (dyspnea at rest, tachypnea, inspiratory rales and pulmonary infiltrates Clinical presentation (2) Coagulopathy Disseminated intravascular coagulation (DIC) More common in AML esp acute promyelocytic leukemia and monocytic leukemia PrimarySiriraj fibrinolysis Cancer Registry Extramedullary acute leukemia ALL : adenopathy and splenomegaly, and leukemia meningitis AML (monocytic origin) : extramedullary mass, skin infiltration (leukemia cutis), gingival hypertrophy Clinical presentation (3) Metabolic abnormalities Tumor lysis syndrome esp ALL Hyperuricemia and hyperphosphatemia urate nephopathySiriraj and Cancer nephrocalcinosis Registry Elevated liver transaminases Elevated LDH esp ALL Artifactual hypoglycemia or hypoxia (due to in vitro activity of blast cells after phlebotomy) Siriraj Cancer Registry Gum hypertrophy in M5 Siriraj Cancer Registry Hemorrhage in M3 Siriraj Cancer Registry Leukemia cutis Siriraj Cancer Registry Extramedullary Leukemia in M5 Siriraj Cancer Registry CNS involvement in ALL Siriraj Cancer Registry Diagnosis and Classification Diagnosis of acute leukemia (WHO) Blast count > 20% Blast : large, immature hematopoietic progenitor cellsSiriraj with open Cancerchromatin and Registry single to multiple nucleoli French-American-British (FAB) classification World Health Organization (WHO) classification Siriraj Cancer Registry Acute myelogenous leukemia WHO CLASSIFICATION 1.Acute myeloid leukemia with recurrent genetic abnormalities AML with t(8;21)(q22;q22), (AML1/ETO) AMLSiriraj with abnormal Cancer bm Registry eosinophils and inv(16)(p13q22) or t(16;16)(p13;q22), (CBFβ/MYH11) APL with t(15;17)(q22;q12), (PML/RARα) and variants AML with 11q23 (MLL) abnormalities Acute myelogenous leukemia WHO CLASSIFICATION 2.Acute myeloid leukemia with multilineage dysplasia Following MDS or MDS/MPD Without antecedent MDS or MDS/MPD, but with dysplasia in at least 50% ofSiriraj cells in 2 or moreCancer myeloid lineages Registry 3.Acute myeloid leukemia and myelodysplastic syndromes, therapy related Alkylating agent/radiation–related type : 5,7 abn Topoisomerase II inhibitor–related type (some may be lymphoid) : 11q23 (MLL) Others Acute myelogenous leukemia WHO CLASSIFICATION 4.AML, not otherwise categorized Acute myeloid leukemia, minimally differentiated Acute myeloid leukemia without maturation Acute myeloid leukemia with maturation AcuteSiriraj myelomonocytic Cancer leukemia Registry Acute monoblastic/acute monocytic leukemia Acute erythroid leukemia (erythroid/myeloid and pure erythroleukemia) Acute megakaryoblastic leukemia Acute basophilic leukemia Acute panmyelosis with myelofibrosis Myeloid sarcoma Modalities in diagnosis Cellular morphology (blood/ marrow) Histochemical stain (cytochemistry) AML : myeloperoxidase (MPO), Sudan black B, non-Sirirajspecific esterase Cancer (monocyte) Registry ALL : terminal deoxynucleotidyl transferase (TdT) Immunophenotyping (flow cytometry) Expression of CD antigen on cell surface Cytogenetic and molecular genetic abnormalities Siriraj Cancer Registry Siriraj Cancer Registry Siriraj Cancer Registry Siriraj Cancer Registry Acute lymphoblastic leukemia Siriraj Cancer Registry L1 L2 L3 Siriraj Cancer Registry Siriraj Cancer Registry Siriraj Cancer Registry Flow cytometry Siriraj Cancer Registry Siriraj Cancer Registry N. Gökbuget, D. Hoelzer: Recent approaches in ALL in adults Rev Clin Exp Hematol • vol 6.2 • June 2002 4 Recurring chromosomal abnormalities characteristics of AML Siriraj Cancer Registry Siriraj Cancer Registry Initial Management and Supportive Care (1) Transfusion support for RBC, platelets Management of leukostasis Intravenous hydration and leukapheresis HydroxyureaSiriraj (AL), Cancer high dose Registry steroid (ALL) Avoid RBC transfusion in extreme leukocytosis Induction chemotherapy Management of DIC Replacement with FFP, cryoprecipitate, platelets Initial Management and Supportive Care (2) Management of tumor lysis syndrome IV hydration Urine alkalinization AllopurinolSiriraj administration Cancer Registry Other forms of management Placement of a subcutaneously tunneled central venous catheter (e.g. Hickman catheter) Assessment of cardiac function HLA typing for eligible patient for allogeneic stem cell transplantation Treatment of AML Induction CMT Goal to obtain “complete remission” or “CR” i.e. marrow blast count < 5%, resolution of all signs of leukemicSiriraj infiltrate Cancer Registry 3 + 7 regiment or 3 days of anthracycline drug + 7 days of cytarabine Postremission therapy Consolidation CMT e.g. 2 + 5, HiDAC Autologous or allogeneic stem cell transplanation ยาเคมีบําบัดกล่มแอนทราไซคลินุ / ไซตาราบีน Siriraj Cancer Registry Siriraj Cancer Registry Siriraj Cancer Registry Siriraj Cancer Registry AML 11 trial. Blood 2001;98:1312-20. Treatment of ALL Remarkable success in children Consisting of multiagent CMT Antimetabolite (thioguanine, mercaptopurine, methotrexate)Siriraj Cancer Registry Anthracyclines (daunorubicin, doxorubicin) Glucocorticoids, vincristine, cytarabine, cyclophosphamide, L-asparaginase Epipodophyllotoxins (etoposide, teniposide) 4 Phases of ALL protocol Remission induction 4-5 drugs (anthracycline, glucocorticoids, vincristine) Intensive CMT after attaining CR CNS prophylaxisSiriraj Cancer Registry Cranial irradiation Intrathecal CMT administration Prolonged maintenance CMT Allogeneic HSC transplanation for patient with poor prognosis factors Treatment of APL New differentiating agents All-trans-retinoic acid (ATRA, tretinoin) VitaminSiriraj A analog Cancer Registry Arsenic trioxide (ATO) All-Trans Retinoic Acid (ATRA; Versanoid) Siriraj Cancer Registry Arsenic Trioxide Siriraj Cancer Registry Chronic lymphocytic leukemia (CLL) Most common lymphoid malignancy in the Western hemisphere Increase in normal appearing lymphocytes in peripheral blood (PB) or infiltration of lymphocytes in lymph Sirirajnodes, spleen Cancer or other solidRegistry organs Slowly progressing diseases, considered incurable Many patients lead fairly normal life despite the disease Therapy (if necessary) is generally aimed toward relief of symptoms and improvement of quality of life Siriraj Cancer Registry Chronic lymphocytic Leukemia (B-CLL) Siriraj Cancer Registry Malignant Lymphoma Neoplasm of cells derived from lymphocytes or lymphocyte precursors Manifest primarily as a tumor of lymph nodes or relatedSiriraj organs Cancer (e.g. spleen, Registry liver, other solid tissues) Epidemiology New incidence 60,000 cases/yr NHL (USA) Hodgkin lymphoma ~ one-third of NHL Incidence of NHL arising rapidly and correlatesSiriraj with Cancerages Registry Bimodal age distribution in HL (20-29 yr and 60 yr) Both types have a moderate male predominance Clinical presentation (1) HL spreads in a contiguous fashion and rarely involves mesenteric nodes, CNS, skin, GI tract or Waldeyer ring and rarely presents with grossSiriraj splenomegaly Cancer Registry NHL spreads in an unpredictable fashion due to blood dissemination Fever, night sweats and weight loss (B symptoms) are found in both types; pruritus and pain on alcohol drinking (HL) Clinical presentation (2) . Lymphadenopathy and extranodal masses . Tumor mass effect : gut obstruction, SVC syndrome, neurological deficit . TumorSiriraj cachectic Cancer syndromes Registry : prolonged fever, weight loss, night sweat (B symptoms) . Bone marrow
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