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Chronic Leukemia

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Chronic Lymphocytic Leukemia

Chronic Myelogenous Leukemia


Chronic Lymphocytic Leukemia

General Information About Chronic Lymphocytic Leukemia

Chronic lymphocytic leukemia is a type of cancer in which the bone marrow makes too many lymphocytes (a type of white blood cell).

Chronic lymphocytic leukemia (also called CLL) is a blood and bone marrow disease that usually gets worse slowly. CLL is the second most common type of leukemia in adults. It often occurs during or after middle age; it rarely occurs in children.

Normally, the body produces bone marrow 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 CLL, too many stem cells develop into a type of white blood cell called lymphocytes. There are 3 types of lymphocytes:

  • B lymphocytes that make antibodies to help fight infection.
  • T lymphocytes that help B lymphocytes make antibodies to fight infection.
  • Natural killer cells that attack cells with cancer or a virus.

The lymphocytes in CLL are not able to fight infection very well. Also, as the amount 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 result in infection, anemia, and easy bleeding.

Older age can affect the risk of developing chronic lymphocytic leukemia.

Risk factors for CLL include the following:

  • Being middle-aged or older, male, or white.
  • A family history of CLL or cancer of the lymph system.
  • Having relatives who are Russian Jews or Eastern European Jews.

Possible signs of chronic lymphocytic leukemia include swollen lymph nodes and tiredness.

Usually CLL does not cause any symptoms and is found during a routine blood test. Sometimes symptoms occur that may be caused by CLL or by other conditions. A doctor should be consulted if any of the following problems occur:

  • Painless swelling of the lymph nodes in the neck, underarm, stomach, or groin.
  • Tiredness that does not go away.
  • Pain or fullness below the ribs.
  • Fever and infection.
  • Weight loss (unexplained).

Tests that examine the blood, bone marrow, and lymph nodes are used to detect (find) and diagnose chronic lymphocytic leukemia.

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 patientís 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.

  • Cytogenetic analysis: A test in which a sample of blood or bone marrow is looked at under a microscope to find out if there are changes in the structure or number of chromosomes in the lymphocytes.

  • 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 lymphocytes (cancer) began from the B lymphocytes or the T lymphocytes.

  • 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 sample under a microscope to look for abnormal cells.

Certain factors affect treatment options and prognosis (chance of recovery).

Treatment options depend on:

  • The stage of the disease.
  • Red blood cell, white blood cell, and platelet blood counts.
  • Whether there are symptoms, such as fever, chills, or weight loss.
  • Whether the liver, spleen, or lymph nodes are larger than normal.
  • The response to initial treatment.
  • Whether the CLL has recurred (come back).

The prognosis (chance of recovery) depends on:

  • Whether there is a change in the DNA and the type of change, if there is one.
  • Whether lymphocytes are spread throughout the bone marrow.
  • The stage of the disease.
  • Whether the CLL gets better with treatment or has recurred (come back).
  • Whether the CLL progresses to lymphoma or prolymphocytic leukemia.
  • The patient's general health.

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Stages of Chronic Lymphocytic Leukemia

After chronic lymphocytic leukemia has been diagnosed, tests are done to find out how far the cancer has spread in the blood and bone marrow.

Staging is the process used to find out how far the cancer has spread. It is important to know the stage of the disease in order to plan the best treatment. The following tests may be used in the staging process:

  • 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 sample under a microscope to look for abnormal cells.

  • 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, such as the lymph nodes.

  • MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body, such as the brain and spinal cord. This procedure is also called nuclear magnetic resonance imaging (NMRI).

  • CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, 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.

  • 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.

  • Antiglobulin test: A test in which a sample of blood is looked at under a microscope to find out if there are any antibodies on the surface of red blood cells or platelets. These antibodies may react with and destroy the red blood cells and platelets. This test is also called a Coomb's test.

The following stages are used for chronic lymphocytic leukemia:

Stage 0

In stage 0 chronic lymphocytic leukemia, there are too many lymphocytes in the blood, but there are no other symptoms of leukemia. Stage 0 chronic lymphocytic leukemia is indolent (slow-growing).

Stage I

In stage I chronic lymphocytic leukemia, there are too many lymphocytes in the blood and the lymph nodes are larger than normal.

Stage II

In stage II chronic lymphocytic leukemia, there are too many lymphocytes in the blood, the liver or spleen is larger than normal, and the lymph nodes may be larger than normal.

Stage III

In stage III chronic lymphocytic leukemia, there are too many lymphocytes in the blood and there are too few red blood cells. The lymph nodes, liver, or spleen may be larger than normal.

Stage IV

In stage IV chronic lymphocytic leukemia, there are too many lymphocytes in the blood and too few platelets. The lymph nodes, liver, or spleen may be larger than normal and there may be too few red blood cells.

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Refractory Chronic Lymphocytic Leukemia

Refractory chronic lymphocytic leukemia is cancer that does not get better with treatment.

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Treatment Option Overview

There are different types of treatment for patients with chronic lymphocytic leukemia.

Different types of treatment are available for patients with chronic lymphocytic leukemia. 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.

Clinical trials are taking place in many parts of the country. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Four types of standard treatment are used:

Watchful waiting

Watchful waiting is closely monitoring a patientís condition without giving any treatment until symptoms appear or change. This is also called observation. During this time, problems caused by the disease, such as infection, are treated.

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.

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 in the spinal column, a body cavity such as the abdomen, or an organ, the drugs mainly affect cancer cells in those areas. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Surgery

Splenectomy is surgery to remove the spleen.

Other types of treatment are being tested in clinical trials. These include the following:

Monoclonal antibody therapy

Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances in the body 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.

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 the patient or a donor, frozen, and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. Over time, these reinfused stem cells grow into (and restore) the bodyís blood cells.

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Treatment Options by Stage

Stage 0 Chronic Lymphocytic Leukemia

Treatment of stage 0 chronic lymphocytic leukemia is usually watchful waiting.

Stage I Chronic Lymphocytic Leukemia

Treatment of stage I chronic lymphocytic leukemia may include the following:

  • Watchful waiting when there are few or no symptoms.
  • Chemotherapy with 1 or more drugs, with or without steroids.
  • Low-dose external radiation therapy to areas of the body where cancer is found, such as the spleen or lymph nodes.
  • A clinical trial of monoclonal antibodies.
  • A clinical trial of chemotherapy with stem cell transplantation.

Stage II Chronic Lymphocytic Leukemia

Treatment of stage II chronic lymphocytic leukemia may include the following:

  • Watchful waiting when there are few or no symptoms.
  • Chemotherapy with 1 or more drugs, with or without steroids.
  • Low-dose external radiation therapy to areas of the body where cancer is found, such as the spleen or lymph nodes.
  • Radiation therapy to the spleen as palliative therapy to relieve symptoms and improve quality of life.
  • A clinical trial of monoclonal antibodies.
  • A clinical trial of chemotherapy with stem cell transplantation.

Stage III Chronic Lymphocytic Leukemia

Treatment of stage III chronic lymphocytic leukemia may include the following:

  • Watchful waiting when there are few or no symptoms.
  • Chemotherapy with 1 or more drugs, with or without steroids.
  • Splenectomy.
  • Radiation therapy to the spleen as palliative therapy to relieve symptoms and improve quality of life.
  • A clinical trial of monoclonal antibodies.
  • A clinical trial of chemotherapy with stem cell transplantation.

Stage IV Chronic Lymphocytic Leukemia

Treatment of stage IV chronic lymphocytic leukemia may include the following:

  • Watchful waiting.
  • Chemotherapy with 1 or more drugs, with or without steroids.
  • Splenectomy.
  • Radiation therapy to the spleen as palliative therapy to relieve symptoms and improve quality of life.
  • A clinical trial of monoclonal antibodies.
  • A clinical trial of chemotherapy with stem cell transplantation.

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Treatment Options for Refractory Chronic Lymphocytic Leukemia

Treatment of refractory chronic lymphocytic leukemia may include the following:

  • A clinical trial of chemotherapy with stem cell transplantation.
  • A clinical trial of a new treatment.

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Chronic Myelogenous Leukemia

General Information About Chronic Myelogenous Leukemia

Chronic myelogenous leukemia is a disease in which the bone marrow makes too many white blood cells.

Chronic myelogenous leukemia (also called CML or chronic granulocytic leukemia) is a slowly progressing blood and bone marrow disease that usually occurs during or after middle age, and rarely occurs in children. Normally, the body produces bone marrow 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 CML, the body tells too many bone marrow stem cells to develop into a type of white blood cell called granulocytes. Some of these bone marrow stem cells never become mature white blood cells. These are called blasts. Over time, the granulocytes and blasts crowd out the red blood cells and platelets in the bone marrow.

Possible signs of chronic myelogenous leukemia include tiredness, night sweats, and fever.

These and other symptoms may be caused by CML or by other conditions. A doctor should be consulted if any of the following problems occur:

  • Tiredness that does not go away.
  • Lack of energy.
  • Weight loss (unexplained).
  • Night sweats.
  • Fever.
  • Pain or fullness below the ribs on the left side.

Sometimes CML does not cause any symptoms at all.

Most people with CML have a gene mutation (change) called the Philadelphia chromosome.

Every cell in the body contains DNA (genetic material) that determines how the cell looks and acts. DNA is contained inside chromosomes. In CML, part of the DNA from one chromosome moves to another chromosome. This change is called the ďPhiladelphia chromosome.Ē It results in the bone marrow making an enzyme, called tyrosine kinase, that causes too many stem cells to develop into white blood cells (granulocytes or blasts).

The Philadelphia chromosome is not passed from parent to child.

Tests that examine the blood and bone marrow are used to detect (find) and diagnose chronic myelogenous leukemia.

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 an enlarged spleen. A history of the patientís 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.

  • Cytogenetic analysis: A test in which cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes, such as the Philadelphia chromosome.

  • 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 both the bone and bone marrow samples under a microscope to look for abnormal cells.

Certain factors affect prognosis (chance of recovery) and treatment options.

The prognosis (chance of recovery) and treatment options depend on the following:

  • The patientís age.
  • The phase of CML.
  • The amount of blasts in the blood or bone marrow.
  • The size of the spleen at diagnosis.
  • The patientís general health.

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Stages of Chronic Myelogenous Leukemia

After chronic myelogenous leukemia has been diagnosed, tests are done to find out if the cancer has spread.

Staging is the process used to find out how far the cancer has spread. There is no standard staging system for chronic myelogenous leukemia (CML). Instead, the disease is classified by phase: chronic phase, accelerated phase, or blastic phase. It is important to know the phase in order to plan treatment. The following tests and procedures may be used to find out the phase:

  • Cytogenetic analysis: A test in which cells in a sample of blood or bone marrow are viewed under a microscope to look for certain changes in the chromosomes, such as the Philadelphia chromosome.

  • 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 both the bone and bone marrow samples under a microscope to look for abnormal cells.

Chronic myelogenous leukemia has 3 phases.

As the amount of blast cells increases in the blood and bone marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may result in infections, anemia, and easy bleeding, as well as bone pain and pain or fullness below the ribs on the left side. The amount of blast cells in the blood and bone marrow and the severity of symptoms determine the phase of the disease.

Chronic phase

In chronic phase CML, there are 5% or fewer blast cells in the blood and bone marrow.

Accelerated phase

In accelerated phase CML, there are 6% to 30% blast cells in the blood and bone marrow.

Blastic phase

In blastic phase CML, there are 30% or more blast cells in the blood or bone marrow. When tiredness, fever, and an enlarged spleen occur during the blastic phase, it is called blast crisis.

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Relapsed Chronic Myelogenous Leukemia

In relapsed CML, the number of blast cells increases after a remission.

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Treatment Option Overview

There are different types of treatment for patients with chronic myelogenous leukemia.

Different types of treatment are available for patients with CML. 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.

Six types of standard treatment are used:

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, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Other drug therapy

Imatinib (Gleevec) is a new type of cancer drug, called a tyrosine kinase inhibitor. It blocks the enzyme, tyrosine kinase, that causes stem cells to develop into more white blood cells (granulocytes or blasts) than the body needs.

Biologic therapy

Biologic therapy is a treatment that uses the patientís immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the bodyís natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.

High-dose chemotherapy with stem cell transplantation

High-dose chemotherapy with stem cell transplantation is a method of giving high doses of 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 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 bodyís blood cells.

Donor lymphocyte infusion (DLI)

Donor lymphocyte infusion (DLI) is a cancer treatment that may be used after stem cell transplantation. Lymphocytes (a type of white blood cell) from the stem cell transplant donor are removed from the donorís blood and may be frozen for storage. The donorís lymphocytes are thawed if they were frozen and then given to the patient through one or more infusions. The lymphocytes see the patientís cancer cells as not belonging to the body and attack them.

Surgery

Splenectomy is surgery to remove the spleen.

Other types of treatment are being tested in clinical trials.

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Treatment Options for Chronic Myelogenous Leukemia

Chronic Phase Chronic Myelogenous Leukemia

Treatment of chronic phase chronic myelogenous leukemia may include the following:

  • High-dose chemotherapy with donor stem cell transplantation.
  • Biologic therapy (interferon) with or without chemotherapy.
  • Other drug therapy (Gleevec).
  • Chemotherapy.
  • Splenectomy.
  • A clinical trial of a new treatment.

Accelerated Phase Chronic Myelogenous Leukemia

Treatment of accelerated phase chronic myelogenous leukemia may include the following:

  • Stem cell transplantation.
  • Other drug therapy (Gleevec).
  • Biologic therapy (interferon) with or without chemotherapy.
  • High-dose chemotherapy.
  • Chemotherapy.
  • Transfusion therapy to replace red blood cells, platelets, and sometimes white blood cells, to relieve symptoms and improve quality of life.
  • A clinical trial of a new treatment.

Blastic Phase Chronic Myelogenous Leukemia

Treatment of blastic phase chronic myelogenous leukemia may include the following:

  • Other drug therapy (Gleevec).
  • Chemotherapy using one or more drugs.
  • High-dose chemotherapy.
  • Donor stem cell transplantation.
  • Chemotherapy as palliative therapy to relieve symptoms and improve quality of life.
  • A clinical trial of a new treatment.

Relapsed Chronic Myelogenous Leukemia

Treatment of relapsed chronic myelogenous leukemia may include the following:

  • Donor stem cell transplantation.
  • Donor lymphocyte infusion.
  • Biologic therapy (interferon).
  • A clinical trial of biologic therapy, combination chemotherapy, or other drug therapy (Gleevec).

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Chronic Leukemia