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Please read this section first The HPCSA and the Med Tech Society have confirmed that this clinical case study, plus your routine review of your EQA reports from Thistle QA, should be documented as a “Journal Club” activity. This means that you must record those attending for CEU purposes. Thistle will not issue a certificate to cover these activities, nor send out “correct” answers to the CEU questions at the end of this case study.

The Thistle QA CEU No is: MTS 18/059

Each attendee should claim ONE CEU point for completing this Quality Control Journal Club exercise, and retain a copy of the relevant Thistle QA Participation Certificate as proof of registration on a Thistle QA EQA.

DIFFERENTIAL SLIDES LEGEND

CYCLE 51 SLIDE 3

Acute lymphoblastic (ALL)

Acute lymphoblastic leukemia (ALL) is a cancer of the lymphoid line of blood cells characterized by the development of large numbers of immature lymphocytes. Most cases occur due to an unknown reason. Genetic risk factors may include Down syndrome, Li-Fraumeni syndrome, or neurofibromatosis type 1. Environment risk factors may include significant radiation exposure or prior chemotherapy.

Signs and Symptoms

Initial symptoms can be nonspecific, particularly in children. Over 50% of children with leukemia had one or more of five features: a liver one can feel (64%), a spleen one can feel (61%), pale complexion (54%), (53%), and bruising (52%). Additionally, recurrent infections, feeling tired, arm or leg pain, and enlarged lymph nodes can be prominent features. The B symptoms, such as fever, night sweats, and weight loss, are often present as well. The of ALL are variable and include

 Generalized weakness and feeling tired

 Anemia

 Dizziness

 Headache, vomiting, lethargy, nuchal rigidity, or cranial nerve palsies(CNS involvement)

 Frequent or unexplained fever and infection

 Weight loss and/or loss of appetite

 Excessive and unexplained bruising

 Bone pain, joint pain (caused by the spread of "blast" cells to the surface of the bone or into the joint from the marrow cavity)

 Breathlessness

 Enlarged lymph nodes, liver and/or spleen

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 Pitting edema (swelling) in the lower limbs and/or abdomen

 Petechiae, which are tiny red spots or lines in the skin due to low platelet levels

 Testicular enlargement

 Mediastinal mass

Diagnosis

Diagnosing ALL begins with a thorough medical history, physical examination, complete blood count, and blood smears. While many symptoms of ALL can be found in common illnesses, persistent or unexplained symptoms raise suspicion of cancer. Because many features on the medical history and exam are not specific to ALL, further testing is often needed. A large number of white blood cells and lymphoblasts in the circulating blood can be suspicious for ALL because they indicate a rapid production of lymphoid cells in the marrow. The higher these numbers typically points to a worse prognosis. While white blood cell counts at initial presentation can vary significantly, circulating lymphoblast cells are seen on peripheral blood smears in the majority of cases.

A bone marrow biopsy provides conclusive proof of ALL, typically with >20% of all cells being leukemic lymphoblasts .A lumbar puncture (also known as a spinal tap) can determine whether the spinal column and brain have been invaded.

Pathological examination, cytogenetics (in particular the presence of Philadelphia chromosome), and immunophenotyping establish whether the leukemic cells are myeloblastic (neutrophils, eosinophils, or basophils) or lymphoblastic (B lymphocytes or T lymphocytes).

Figure 1: Lymphoblasts from a Bone marrow aspirate smear from a person with ALL.

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Treatment

Possible treatments for acute leukemia include chemotherapy, steroids, radiation therapy, intensive combined treatments (including bone marrow or stem cell transplants), and/or growth factors.

Chemotherapy Chemotherapy is the main treatment for acute lymphoplastic leukaemia (ALL). Get an overview of the phases of treatment and what to expect. Chemotherapy uses anti-cancer (cytotoxic) drugs to destroy cancer cells. The drugs circulate throughout the body in the bloodstream.

Steroids Steroids are substances made naturally in your body. Doctors use artificial steroids as medicines. Treatment for acute lymphoblastic leukaemia (ALL) works better when you take steroids with the chemotherapy drugs.

Radiation Therapy Radiotherapy means the use of radiation, usually x-rays, to treat cancer cells. The aim of the treatment is to help kill off leukaemia cells in the bone marrow.

Growth Factors Growth factors are natural substances that stimulate the bone marrow to make blood cells. Some growth factors are used during chemotherapy treatment and they increase the number of white blood cells and stem cells in the blood.

References

1. https://en.wikipedia.org/wiki/Acute_lymphoblastic_leukemia 2. www.cancerresearchuk.org/about-cancer/acute-lymphoblastic-leukaemia-all

Questions

1. Name three signs and symptoms that occur in patients with ALL. 2. How can ALL be diagnosed? 3. Discuss how ALL can be treated.

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