Acute Leukemia
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Adult Acute Lymphoblastic
Leukemia
Adult Acute Myeloid Leukemia
Adult acute lymphoblastic leukemia (ALL) is a type of cancer in which the
bone marrow makes too many lymphocytes (a type of white blood cell).
Adult acute lymphoblastic leukemia (ALL; also called acute lymphocytic
leukemia) is a cancer of the blood and bone marrow. This type of cancer usually
gets worse quickly if it is not treated.
Normally, the bone marrow produces stem cells (immature cells)
that develop into mature blood cells. There are 3 types of mature blood cells:
- Red blood cells that carry oxygen and other materials to all tissues of
the body.
- White blood cells that fight infection and disease.
- Platelets that help prevent bleeding by causing blood clots to form.
In ALL, too many stem cells develop into a type of white blood called lymphocytes.
These lymphocytes may also be called lymphoblasts or leukemic cells. There
are 3 types of lymphocytes:
- B lymphocytes that make antibodies to help fight infection.
- T lymphocytes that help B lymphocytes make the antibodies that help fight
infection.
- Natural killer cells that attack cells with cancer or a virus.
In ALL, the lymphocytes are not able to fight infection very well.
Also, as the number of lymphocytes increases in the blood and bone marrow,
there is less room for healthy white blood cells, red blood cells, and platelets.
This may cause infection, anemia, and easy bleeding. The cancer can also spread
to the central nervous system (brain and spinal cord).
Previous chemotherapy and exposure to radiation may affect the risk of developing
ALL.
Possible risk factors for ALL include the following:
- Being male.
- Being white.
- Being older than 70 years of age.
- Past treatment with chemotherapy or radiation therapy.
- Exposure to atomic bomb radiation.
- Having a certain genetic disorder such as Down syndrome.
Possible signs of adult ALL include fever, feeling tired, and easy bruising
or bleeding.
The early signs of ALL may be similar to the flu or other common
diseases. A doctor should be consulted if any of the following problems occur:
- Weakness or feeling tired.
- Fever.
- Easy bruising or bleeding.
- Petechiae (flat, pinpoint spots under the skin caused by bleeding).
- Shortness of breath.
- Loss of appetite or weight loss.
- Pain in the bones or stomach.
- Pain or feeling of fullness below the ribs.
- Painless lumps in the neck, underarm, stomach, or groin.
These and other symptoms may be caused by adult acute lymphoblastic
leukemia or by other conditions.
Tests that examine the blood and bone marrow are used to detect (find) and
diagnose adult ALL.
The following tests and procedures may be used:
- Physical exam and history: An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or anything
else that seems unusual. A history of the patient's health habits and past
illnesses and treatments will also be taken.
- Complete blood count: A procedure in which a sample of blood is drawn and
checked for the following:
- The number of red blood cells, white blood cells, and platelets.
- The amount of hemoglobin (the protein that carries oxygen) in the red
blood cells.
- The portion of the blood sample made up of red blood cells.
- Peripheral blood smear: A procedure in which a sample of blood is checked
for the presence of blast cells, number and kinds of white blood cells, the
number of platelets, and changes in the shape of blood cells.
- Bone marrow biopsy and aspiration: The removal of a small piece of bone
and bone marrow by inserting a needle into the hipbone or breastbone. A pathologist views
the samples under a microscope to look for abnormal cells.
- Cytogenetic analysis: A test in which the cells in a sample of blood or
bone marrow are looked at under a microscope to find out if there are certain
changes in the chromosomes in the lymphocytes. For example, sometimes in
ALL, part of one chromosome is moved to another chromosome. This is called
the Philadelphia chromosome.
- Immunophenotyping: A test in which the cells in a sample of blood or bone
marrow are looked at under a microscope to find out if malignant (cancerous)
lymphocytes began from the B lymphocytes or the T lymphocytes.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment options
depend on the following:
- The age of the patient.
- Whether the cancer has spread to the brain or spinal cord.
- Whether the Philadelphia chromosome is present.
- Whether the cancer has been treated before or has recurred (come back).
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Once adult ALL
has been diagnosed, tests are done to find out if the cancer has
spread to the central nervous system (brain and spinal cord) or to
other parts of the body.
The extent or spread of cancer is usually described
as stages.
It is important to know whether the leukemia
has spread outside the blood
and bone
marrow in order to plan treatment. The following tests and
procedures may be used to determine if the leukemia has spread:
- Chest
x-ray: An x-ray
of the organs
and bones inside the chest. An x-ray is a type of energy beam that
can go through the body and onto film, making a picture of areas
inside the body.
- Lumbar
puncture: A procedure used to collect cerebrospinal
fluid from the spinal column. This is done by placing a needle
into the spinal column. This procedure is also called an LP or
spinal tap.
- Ultrasound:
A procedure in which high-energy sound waves (ultrasound) are
bounced off internal tissues
or organs in the abdomen
and make echoes. The echoes form a picture of body tissues called
a sonogram.
- CT
scan (CAT scan): A procedure that makes a series of detailed
pictures of the abdomen, taken from different angles. The pictures
are made by a computer linked to an x-ray machine. A dye may be
injected into a vein or swallowed to help the organs or tissues
show up more clearly. This procedure is also called computed
tomography, computerized tomography, or computerized axial
tomography.
There is no
standard staging system for adult ALL.
Untreated adult ALL
The ALL is newly diagnosed and has not been treated
except to relieve symptoms
such as fever, bleeding or pain.
- The complete
blood count is abnormal.
- There are more than 5% blasts
(leukemia cells)
in the bone marrow.
- There are signs and symptoms of
leukemia.
Adult ALL in remission
The ALL has been treated.
- The complete blood count is normal.
- There are less than 5% blasts (leukemia
cells) in the bone marrow.
- There are no signs or symptoms of leukemia
in the brain and spinal
cord or elsewhere in the body.
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Recurrent
adult acute
lymphoblastic leukemia (ALL) is cancer that has recurred (come
back) after going into remission.
The ALL may come back in the blood,
bone
marrow, or other parts of the body.
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There are different types of treatment for patients with adult ALL.
Different types of treatment are available for patients with adult acute
lymphoblastic leukemia (ALL). Some treatments are standard (the currently used
treatment), and some are being tested in clinical trials. A treatment clinical
trial is a research study meant to help improve current treatments or obtain
information on new treatments for patients with cancer. When clinical trials
show that a new treatment is better than the "standard" treatment, the new
treatment may become the standard treatment.
The treatment of adult ALL is done in phases:
- Remission induction therapy: This is the first phase of treatment. Its
purpose is to kill the leukemia cells in the blood and bone marrow. This
puts the leukemia into remission.
- Maintenance therapy: This is the second phase of treatment. It begins once
the leukemia is in remission. The purpose of maintenance therapy is to kill
any remaining leukemia cells that may not be active but could begin to regrow
and cause a relapse. This phase is also called remission continuation therapy.
Treatment called central nervous system (CNS) sanctuary therapy
is usually given during each phase of therapy. Because chemotherapy that is
given by mouth or injected into a vein may not reach leukemia cells in the
CNS (brain and spinal cord), the cells are able to find "sanctuary" (hide)
in the CNS. Intrathecal chemotherapy and radiation therapy are able to reach
leukemia cells in the CNS and are given to kill the leukemia cells and prevent
the cancer from recurring (coming back). CNS sanctuary therapy is also called CNS
prophylaxis.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the
growth of cancer cells, either by killing the cells or by stopping the cells
from dividing. When chemotherapy is taken by mouth or injected into a vein
or muscle, the drugs enter the bloodstream and can reach cancer cells throughout
the body (systemic chemotherapy). When chemotherapy is placed directly into
the spinal column, a body cavity such as the abdomen, or an organ, the drugs
mainly affect cancer cells in those areas. Combination chemotherapy is treatment
using more than one anticancer drug. The way the chemotherapy is given depends
on the type and stage of the cancer being treated.
Intrathecal chemotherapy may be used to treat adult ALL that has
spread, or may spread, to the brain and spinal cord. When used to prevent cancer
from spreading to the brain and spinal cord, it is called central nervous system
(CNS) sanctuary therapy or CNS prophylaxis. Intrathecal chemotherapy is given
in addition to chemotherapy by mouth or vein.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or
other types of radiation to kill cancer cells. There are two types of radiation
therapy. External radiation therapy uses a machine outside the body to send
radiation toward the cancer. Internal radiation therapy uses a radioactive substance
sealed in needles, seeds, wires, or catheters that are placed directly into
or near the cancer. External radiation therapy may be used to treat adult ALL
that has spread, or may spread, to the brain and spinal cord. When used this
way, it is called central nervous system (CNS) sanctuary therapy or CNS prophylaxis.
High-dose chemotherapy with stem cell transplantation
Stem cell transplantation is a method of giving chemotherapy and
replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature
blood cells) are removed from the blood or bone marrow of a donor and are frozen
for storage. After the chemotherapy is completed, the stored stem cells are
thawed and given back to the patient through an infusion. These reinfused stem
cells grow into (and restore) the body's blood cells.
Biologic therapy
Biologic therapy is a treatment that uses the patient's immune
system to fight cancer. Substances made by the body or made in a laboratory
are used to boost, direct, or restore the body's natural defenses against cancer.
This type of cancer treatment is also called biotherapy or immunotherapy.
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Standard treatment of adult acute lymphoblastic leukemia (ALL)
during the remission induction phase includes the following:
- Combination chemotherapy.
- CNS prophylaxis therapy including chemotherapy (intrathecal and/or systemic)
with or without radiation therapy to the brain.
Standard treatment of adult ALL during the maintenance phase includes
the following:
- Combination chemotherapy.
- High-dose chemotherapy with stem cell transplantation.
- CNS prophylaxis therapy including chemotherapy (intrathecal and/or systemic)
with or without radiation therapy to the brain.
Standard treatment of recurrent adult ALL may include the following:
- Combination chemotherapy followed by stem cell transplantation.
- Low-dose radiation therapy as palliative care to relieve symptoms and improve
the quality of life.
- A clinical trial of stem cell transplantation using the patient's own stem
cells.
- A clinical trial of biologic therapy.
- A clinical trial of new chemotherapy drugs.
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General Information About Adult Acute Myeloid Leukemia
Adult acute myeloid leukemia (AML) is a type of cancer in which the bone marrow
makes abnormal myeloblasts (a type of white blood cell), red blood cells, or
platelets.
Adult acute myeloid leukemia (AML) is a cancer of the blood and
bone marrow. This type of cancer usually gets worse quickly if it is not treated.
It is the most common type of acute leukemia in adults. AML is also called
acute myelogenous leukemia, acute myeloblastic leukemia, acute granulocytic
leukemia, and acute nonlymphocytic leukemia.
Normally, the bone marrow produces stem cells (immature cells)
that develop into mature blood cells. There are 3 types of mature blood cells:
- Red blood cells that carry oxygen and other materials to all tissues of
the body.
- White blood cells that fight infection and disease.
- Platelets that help prevent bleeding by causing blood clots to form.
In AML, the stem cells usually develop into a type of immature white
blood cell called myeloblasts (or myeloid blasts). The myeloblasts in AML are abnormal and
do not mature into healthy white blood cells. Sometimes in AML, too many stem
cells develop into abnormal red blood cells or platelets. These abnormal white
blood cells, red blood cells, or platelets are also called leukemia cells or
blasts. Leukemia cells are unable to do their usual work and can build up in
the bone marrow and blood so there is less room for healthy white blood cells,
red blood cells, and platelets. When this happens, infection, anemia, or easy
bleeding may occur. The leukemia cells can spread outside the blood to other
parts of the body, including the central nervous system (brain and spinal cord),
skin, and gums.
The AML subtypes are based on how mature (developed) the cancer
cells are at the time of diagnosis and how different they are from normal cells.
Smoking, previous chemotherapy treatment, and exposure to radiation may affect
the risk of developing adult AML.
Possible risk factors for AML include the following:
- Being male.
- Smoking, especially after age 60.
- Having had treatment with chemotherapy or radiation therapy in the past.
- Having had treatment for childhood acute lymphoblastic leukemia (ALL) in
the past.
- Being exposed to atomic bomb radiation or the chemical benzene.
- Having a history of a blood disorder such as myelodysplastic syndrome.
Possible signs of adult AML include fever, feeling tired, and easy bruising
or bleeding.
The early signs of AML may be like those caused by the flu or other
common diseases. A doctor should be consulted if any of the following problems
occur:
- Fever.
- Shortness of breath.
- Easy bruising or bleeding.
- Petechiae (flat, pinpoint spots under the skin caused by bleeding).
- Weakness or feeling tired.
- Loss of appetite or weight loss.
Tests that examine the blood and bone marrow are used to detect (find) and
diagnose adult AML.
The following tests and procedures may be used:
- Physical exam and history: An exam of the body to check general signs of
health, including checking for signs of disease, such as lumps or anything
else that seems unusual. A history of the patient’s health habits and past
illnesses and treatments will also be taken.
- Complete blood count: A procedure in which a sample of blood is drawn and
checked for the following:
- The number of red blood cells, white blood cells, and platelets.
- The amount of hemoglobin (the protein that carries oxygen) in the red
blood cells.
- The portion of the sample made up of red blood cells.
- Blood chemistry studies: A procedure in which a blood sample is checked
to measure the amounts of certain substances released into the blood by organs and
tissues in the body. An unusual (higher or lower than normal) amount of a
substance can be a sign of disease in the organ or tissue that produces it.
- Peripheral blood smear: A procedure in which a sample of blood is checked
for the presence of blast cells, number and kinds of white blood cells, the
number of platelets, and changes in the shape of blood cells.
- Bone marrow aspiration and biopsy: The removal of a small piece of bone
and bone marrow by inserting a needle into the hipbone or breastbone. A pathologist views
the bone and bone marrow samples under a microscope to look for abnormal
cells.
- Cytogenetic analysis: A test in which the cells in a sample of blood or
bone marrow are viewed under a microscope to look for certain changes in
the chromosomes.
- Immunophenotyping: A process used to identify cells, based on the types
of antigens or markers on the surface of the cell. This process is used to
diagnose the subtype of AML by comparing the cancer cells to normal cells
of the immune system.
Once adult AML has been diagnosed, tests are done to find out if the cancer
has spread to other parts of the body.
The extent or spread of cancer is usually described as stages.
In adult acute myeloid leukemia (AML), the subtype of AML and whether the leukemia
has spread outside the blood and bone marrow are used instead of the stage
to plan treatment. The following tests and procedures may be used to determine
if the leukemia has spread:
- Chest x-ray: An x-ray of the organs and bones inside the chest. An x-ray
is a type of energy beam that can go through the body and onto film, making
a picture of areas inside the body.
- Lumbar puncture: A procedure used to collect cerebrospinal fluid from the
spinal column. This is done by placing a needle into the spinal column. This
procedure is also called an LP or spinal tap.
- Ultrasound: A procedure in which high-energy sound waves (ultrasound) are
bounced off internal tissues or organs in the abdomen and make echoes. The
echoes form a picture of body tissues called a sonogram.
There is no standard staging system for adult AML.
The disease is described as untreated, in remission, or recurrent.
Untreated adult AML
In untreated adult AML, the disease is newly diagnosed. It has
not been treated except to relieve symptoms such as fever, bleeding, or pain
and the following are true:
- The complete blood count is abnormal.
- At least 20% of the cells in the bone marrow are blasts (leukemia cells).
- There are signs or symptoms of leukemia.
Adult AML in remission
In adult AML in remission, the disease has been treated and the
following are true:
- The complete blood count is normal.
- Less than 5% of the cells in the bone marrow are blasts (leukemia cells).
- There are no signs or symptoms of leukemia in the brain and spinal cord
or elsewhere in the body.
Recurrent Adult AML
Recurrent AML is cancer that has recurred (come back) after it
has been treated. The AML may come back in the blood or bone marrow.
Certain factors affect prognosis (chance of recovery) and treatment options.
The prognosis (chance of recovery) and treatment options depend
on:
- The age of the patient.
- The subtype of AML.
- Whether the patient received chemotherapy in the past to treat a different
cancer.
- Whether there is a history of a blood disorder such as myelodysplastic
syndrome.
- Whether the cancer has spread to the central nervous system.
- Whether the cancer has been treated before or recurred (come back).
It is important that acute leukemia be treated right away.
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There are different types of treatment for patients
with adult acute myeloid leukemia.
Different types of treatment are available for patients with adult acute
myeloid leukemia (AML). Some treatments are standard (the currently used treatment),
and some are being tested in clinical trials. Before starting treatment, patients
may want to think about taking part in a clinical trial. A treatment clinical
trial is a research study meant to help improve current treatments or obtain
information on new treatments for patients with cancer. When clinical trials
show that a new treatment is better than the standard treatment, the new treatment
may become the standard treatment.
The 2 treatment phases of adult AML are:
- Remission induction therapy: This is the first phase of treatment. Its
purpose is to kill the leukemia cells in the blood and bone marrow. This
puts the leukemia into remission.
- Maintenance therapy: This is the second phase of treatment. It begins after
the leukemia is in remission. The purpose of maintenance therapy is to kill
any remaining leukemia cells that may not be active but could begin to regrow
and cause a relapse. This phase is also called remission continuation therapy.
Chemotherapy
Chemotherapy is a cancer treatment that uses drugs to stop the
growth of cancer cells, either by killing the cells or by stopping the cells
from dividing. When chemotherapy is taken by mouth or injected into a vein
or muscle, the drugs enter the bloodstream and can reach cancer cells throughout
the body (systemic chemotherapy). When chemotherapy is placed directly into
the spinal column (intrathecal chemotherapy), an organ, or a body cavity such
as the abdomen, the drugs mainly affect cancer cells in those areas (regional
chemotherapy). Intrathecal chemotherapy may be used to treat adult AML that
has spread, or may spread to the brain and spinal cord. Combination chemotherapy is
treatment using more than one anticancer drug. The way the chemotherapy is
given depends on the subtype of the cancer being treated and whether it has
spread to the brain and spinal cord.
Radiation therapy
Radiation therapy is a cancer treatment that uses high-energy x-rays or
other types of radiation to kill cancer cells. There are two types of radiation
therapy. External radiation therapy uses a machine outside the body to send
radiation toward the cancer. Internal radiation therapy uses a radioactive substance
sealed in needles, seeds, wires, or catheters that are placed directly into
or near the cancer. The way the radiation therapy is given depends on the type
and stage of the cancer being treated.
Stem cell transplantation
Stem cell transplantation is a method of giving chemotherapy and
replacing blood-forming cells that are abnormal or destroyed by the cancer
treatment. Stem cells (immature blood cells) are removed from the blood or
bone marrow of the patient or a donor and are frozen and stored. After the
chemotherapy is completed, the stored stem cells are thawed and given back
to the patient through an infusion. These reinfused stem cells grow into (and
restore) the body's blood cells.
Other drug therapy
Arsenic trioxide and all-trans retinoic acid (ATRA) are
anticancer drugs that kill leukemia cells, stop the leukemia cells from dividing,
or help the leukemia cells mature into white blood cells. These drugs are used
in the treatment of a subtype of AML called acute promyelocytic leukemia.
Biologic therapy
Biologic therapy is a treatment that uses the patient's immune
system to fight cancer. Substances made by the body or made in a laboratory
are used to boost, direct, or restore the body's natural defenses against cancer.
This type of cancer treatment is also called biotherapy or immunotherapy.
One type of biologic therapy is monoclonal antibody therapy. Monoclonal
antibody therapy uses antibodies that are made in the laboratory from a single
type of immune system cell. These antibodies can identify substances on cancer
cells or normal substances that may help cancer cells grow. The antibodies
attach to the substances and kill the cancer cells or block their growth. Monoclonal
antibodies are given by infusion. They may be used alone or to deliver drugs, toxins,
or radioactive material directly to cancer cells.
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Standard treatment of untreated adult acute myeloid
leukemia (AML) during the remission induction phase depends on
the subtype of AML and may include the following:
- Combination chemotherapy.
- High-dose combination chemotherapy.
- Stem cell transplantation using donor stem cells.
- All-trans retinoic acid (ATRA) plus chemotherapy.
- Intrathecal chemotherapy.
Standard treatment of adult AML during the remission phase
depends on the subtype of AML and may include the following:
- Combination chemotherapy.
- High-dose chemotherapy, with or without radiation therapy,
and stem cell transplantation using the patient's stem cells.
- High-dose chemotherapy and stem cell transplantation using
donor stem cells.
Standard treatment of recurrent adult AML depends on
the subtype of AML and may include the following:
- Combination chemotherapy.
- Biologic therapy with monoclonal antibodies.
- Stem cell transplantation.
- Low-dose radiation therapy as palliative therapy to relieve symptoms and
improve quality of life.
- Arsenic trioxide therapy.
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