Leukemia

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History
 first described by anatomist and surgeon 
Alfred-Armand-Louis-Marie Velpeau in
1827.
 more complete description was given by
pathologist Rudolf Virchow in 1845.
 Virchow called the condition Leukämie in 
German, which he formed from the two 
Greek words leukos (λευκός), meaning
"white", and haima (αἷμα), meaning "blood".

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 Around ten years after Virchow's findings,
pathologist Franz Ernst Christian Neumann
found that one deceased leukemia patient's
bone marrow was colored "dirty green-
yellow" as opposed to the normal red. This
finding allowed Neumann to conclude that a
bone marrow problem was responsible for
the abnormal blood of leukemia patients.

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 By 1900 leukemia was viewed as a family of
diseases as opposed to a single disease.
 By 1947 Boston pathologist Sidney Farber
 believed from past experiments that
aminopterin, a folic acid mimic, could
potentially cure leukemia in children. The
majority of the children with ALL who
were tested showed signs of improvement in
their bone marrow, but none of them were
actually cured. This, however, led to
further experiments.
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 In 1962, researchers Emil J. Freireich, Jr.
and Emil Frei III used combination
chemotherapy to attempt to cure leukemia.
The tests were successful with some patients
surviving long after the tests.

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Leukemia
 is a group of cancers that usually begin in the 
bone marrow and result in high numbers of
abnormal white blood cells.
 blasts or leukemia cells
 Leukemias and lymphomas both belong to a
broader group of tumors that affect the blood,
bone marrow, and lymphoid system, known as 
tumors of the hematopoietic and lymphoid tiss
ues
.
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Leukemia
Etiology and Pathophysiology
Different kinds of leukemia are believed to
have different causes:
•inherited and environmental (non-
inherited)

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Risk factors include:
 Smoking
 ionizing radiation
 some chemicals (such as benzene)
 prior chemotherapy, and 
 Down syndrome
 Family history
 Viruses
 Immunologic deficiencies

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Leukemia
General classification
Acute Leukemia
•Characterized by rapid increase in
immature white blood cells.
•Immediate treatment is required.
•Most common forms of leukemia in
children.

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Chronic
•Characterized by the excessive buildup of
relatively mature, but still abnormal, white
blood cells.
•Monitored for some time before treatment
to ensure maximum effectiveness of the
therapy.
•Mostly occurs in older people, but can occur
in any age groups.

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Leukemia
Classification
According to kind of blood cell affected:

•Lymphoblastic or lymphocytic
leukemias

•Myeloid or myelogenous leukemias

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Lymphoblastic or 
lymphocytic leukemias

 the cancerous change takes place in a

type of marrow cell that normally goes
on to form lymphocytes, which are
infection-fighting immune system cells.

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Myeloid or 
myelogenous leukemias
 the cancerous change takes place in a 
type of marrow cell that normally goes
on to form red blood cells, some other
types of white cells, and platelets.

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 Four major kinds of leukemia

Cell type Acute Chronic

Acute lymphoblastic leukem Chronic lymphocytic leuke

Lymphocytic leukemia ia mia
(or "lymphoblastic")
(ALL) (CLL)

Myelogenous leukemia Acute myelogenous leukemi Chronic myelogenous leuke

("myeloid" or a mia
"nonlymphocytic")
(AML or myeloblastic) (CML)

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Specific types
 Acute lymphoblastic leukemia (ALL) is the
most common type of leukemia in young
children. It also affects adults, especially
those 65 and older. Standard treatments
involve chemotherapy and radiotherapy.
The survival rates vary by age: 85% in
children and 50% in adults. 

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 Chronic lymphocytic leukemia (CLL) most
often affects adults over the age of 55. It
sometimes occurs in younger adults, but it
almost never affects children. Two-thirds of
affected people are men. The five-year
survival rate is 75%. It is incurable, but
there are many effective treatments. One
subtype is B-cell prolymphocytic leukemia, a
more aggressive disease.

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 Acute myelogenous leukemia (AML) occurs
more commonly in adults than in children, and
more commonly in men than women. It is
treated with chemotherapy. The five-year
survival rate is 40%, except for APL (Acute
Promyelocytic Leukemia), which has a survival
rate greater than 90%. Subtypes of AML
include acute promyelocytic leukemia, 
acute myeloblastic leukemia, and 
acute megakaryoblastic leukemia

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 Chronic myelogenous leukemia (CML) occurs
mainly in adults; a very small number of
children also develop this disease. It is treated
with imatinib (Gleevec in United States,
Glivec in Europe) or other drugs. The five-
year survival rate is 90%. One subtype is 
chronic myelomonocytic leukemia.

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 Hairy cell leukemia (HCL) is sometimes
considered a subset of chronic lymphocytic
leukemia, but does not fit neatly into this
category. About 80% of affected people are
adult men. No cases in children have been
reported. HCL is incurable but easily
treatable. Survival is 96% to 100% at ten
years.

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 T-cell prolymphocytic leukemia (T-PLL) is
a very rare and aggressive leukemia
affecting adults; somewhat more men than
women are diagnosed with this disease.
Despite its overall rarity, it is the most
common type of mature T cell leukemia;
nearly all other leukemias involve B cells. It
is difficult to treat, and the median survival
is measured in months.

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 Large granular lymphocytic leukemia may
involve either T-cells or NK cells; like hairy
cell leukemia, which involves solely B cells,
it is a rare and indolent (not aggressive)
leukemia.

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 Adult T-cell leukemia is caused by 
human T-lymphotropic virus (HTLV), a
virus similar to HIV. Like HIV, HTLV
infects CD4+ T-cells and replicates within
them; however, unlike HIV, it does not
destroy them. Instead, HTLV
"immortalizes" the infected T-cells, giving
them the ability to proliferate abnormally.
Human T-cell lymphotropic virus types I
and II (HTLV-I/II) are endemic in certain
areas of the world.

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Acute Myelogenous Leukemia
(AML)
 Leukemia characterized by proliferation of myeloid
tissue (as of the bone marrow and spleen) and an
abnormal increase in the number of granulocytes,
myelocytes, and myeloblasts in the circulating blood
 One fourth of all leukemias
– 85% of the acute leukemias in adults
 Abrupt, dramatic onset
– Serious infections, abnormal bleeding
 Uncontrolled proliferation of myeloblasts
– Hyperplasia of bone marrow and spleen

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Acute Lymphocytic Leukemia
(ALL)
 Most common type of leukemia in
children
 15% of acute leukemia in adults
 Immature lymphocytes proliferate in the
bone marrow

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Acute Lymphocytic Leukemia
 Signs and symptoms may appear
abruptly
– Fever, bleeding
 Insidious with progressive

– Weakness, fatigue
 Central nervous system manifestations

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Chronic Myelogenous Leukemia
(CML)
 Excessive development of mature
neoplastic granulocytes in the bone
marrow
– Move into the peripheral blood in
massive numbers
– Ultimately infiltrate the liver and
spleen

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Chronic Myelogenous Leukemia
 Philadelphia chromosome
– The chromosome abnormality that
causes chronic myeloid leukemia
(CML) (9 &22)
– Genetic marker
 Chronic, stable phase followed by acute,
aggressive (blastic) phase
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Chronic Lymphocytic Leukemia
(CLL)
 Production and accumulation of
functionally inactive but long-lived,
mature-appearing lymphocytes
 B cell involvement
 Lymph node enlargement is noticeable
throughout the body
– ↑ incidence of infection

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Chronic Lymphocytic Leukemia
 Complications from early-stage CLL is
rare
– May develop as the disease advances
– Pain, paralysis from enlarged lymph
nodes causing pressure

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Hairy Cell Leukemia
 2% of all adult leukemias
 Usually in males > 40 years old
 Chronic disease of lymphoproliferation

– B lymphocytes that infiltrate the bone

marrow and liver

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Hairy Cell Leukemia
 Cells have a “hairy” appearance
 Symptoms from
– Splenomegaly, pancytopenia, infection,
vasculitis
 Treatment
– alpha-interferon, pentostatin,
cladribine

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Unclassified Leukemias
 Subtype cannot be identified
 Malignant leukemic cells may have
– Lymphoid, myeloid, or mixed
characteristics
 Frequently these patients do not respond
well to treatment
– Poor prognosis

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Leukemia
Clinical Manifestations

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Leukemia
Clinical Manifestations
 Relate to problems caused by
– Leukemic cells infiltrate patient’s
organs
• Splenomegaly
• Hepatomegaly
• Lymphadenopathy
• Bone pain, meningeal irritation, oral
lesions (chloromas)

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Leukemia
Diagnostic Studies
 Diagnosis is usually based on
repeated complete blood counts and
a bone marrow examination 
 lymph node biopsy can be performed to
diagnose certain types of leukemia in
certain situations.

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 blood chemistry tests can be used to
determine the degree of liver and kidney
damage or the effects of chemotherapy on
the patient
 X-ray, MRI, or ultrasound- These can
potentially view leukemia's effects on such
body parts as bones (X-ray), the brain
(MRI), or the kidneys, spleen, and liver
(ultrasound)
 CT scans are used to check lymph nodes in
the chest, though this is rarely done.
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Leukemia
Collaborative Care
 Goal is to attain remission (when there is no
longer evidence of cancer cells in the body)
 Chemotherapeutic treatment
– Induction therapy
• Attempt to induce or bring remission
• Seeks to destroy leukemic cells in the tissues,
peripheral blood, bone marrow
• Patient may become critically ill
– Provide psychological support as well

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What is remission?
The main aim of treatment for acute lymphoblastic leukaemia is
to give a remission. This means that the abnormal, immature
white cells or blasts can no longer be detected in your blood or
bone marrow, and normal bone marrow has developed again.
 However, once you are in remission there may still be a very
small number of abnormal lymphoblasts left. To destroy
these, your doctor may prescribe maintenance or continuation
chemotherapy which may last for several years. These drugs
are mainly taken as tablets and you will need to have regular
check-ups to monitor their effect. Very specialised blood tests
to find particular proteins present on the surface of the
leukaemia cells can show if any leukaemia cells are still
present in the body.
 For many people with acute lymphoblastic leukaemia the
remission lasts indefinitely and the person is said to be cured.

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Leukemia
Collaborative Care
 Chemotherapeutic treatment (cont.)
• High-dose therapy
• May be given after induction therapy
• Same drugs at higher doses and/or other
drugs

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Leukemia
Collaborative Care
 Chemotherapeutic treatment (cont.)
– Consolidation therapy
• Started after remission is achieved
• Purpose is to eliminate remaining
leukemic cells that may not be evident
– Maintenance therapy
• Lower doses of the same drug

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Leukemia
Chemotherapy Regimens
 Combination chemotherapy
– Mainstay treatment
– 3 purposes
• ↓ drug resistance
• ↓ drug toxicity to the patient by using
multiple drugs with varying toxicities
• Interrupt cell growth at multiple points in
the cell cycle

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Leukemia - Bone Marrow and Stem
Cell Transplantation
 Goal
– Totally eliminate leukemic cells from
the body using combinations of
chemotherapy with or without total
body irradiation

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Leukemia - Bone Marrow and Stem
Cell Transplantation
 Eradicates patient’s hematopoietic stem cells
 Replaced with those of an HLA-matched
(Human Leukocyte Antigen)
• Sibling (is a brother or a sister; that is, any
person who shares at least one of the same
parents )
• Volunteer
• Identical twin
• Patient’s own stem cells removed before

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Nursing Management
Planning
 Overall goals
– Understand and cooperate with the
treatment plan
– Experience minimal side effects and
complications of disease and treatment
– Feel hopeful and supported during the
periods of treatment, relapse, and
remission
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Nursing Management
 Many physical and psychological needs
– Evokes great fear
• Family also needs help
 Balance demanding technical needs with
a humanistic, caring approach

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 Nursing Management
 Patient empowered by knowledge of the
disease and treatment can have a more
positive outlook and improved quality of
life
 Nurses face special challenges when
meeting the intense psychosocial needs of
a patient with leukemia

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Nursing Management
 Ongoing care is necessary to monitor for
signs and symptoms of disease control or
relapse
 Teach patient and significant other
– Diligence in disease management
– Need for follow-up care
– When to seek medical attention

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Nursing Management
 Goals of rehabilitation
– Manage
• Physical
• Psychosocial
• Social
• Spiritual
• Delayed effects
– Support groups
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Nursing Management
Evaluation
 Cope effectively with diagnosis,
treatment regimen, and prognosis
 Attain and maintain adequate nutrition
 Experience no complications
 Feel comfortable and supported

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BEST WISHES

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