A CASE OF ACUTE MYELOID LEUKEMIA

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					 A CASE OF ACUTE
MYELOID LEUKEMIA

   PROF S SHIVAKUMAR

   P SENTHIL KUMAR MD PG
   Rajendran
   42 yrs/ M
   c/o
       Multiple swellings in the neck and
        submandibular region
       Fever
       Breathlessness                       3months
       Pain abdomen
       Loss of appetite/ Loss of wt.
       No cough with sputum
       No dysuria, rashes, jaundice
       Bowel and bladder - N
   Past H/o
       No DM/ HTN/ IHD/ PT/ BA/ STROKE

   Personal H/o
       Smoker/ alcoholic
       Agricultural worker

   Family H/o
       Nil

   Treatment H/o
       Pt on ATT for PL effusion past 3 months
   O/E
       Conscious
       Oriented
       Febrile
       Pallor +
       Clubbing+
       Subconjunctival hemorrhage
       Submandibular/ cervical / supraclavicular LN +
       No icterus/ cyanosis/ PE/ JVP.
   RS
       BS                Lt mamary/ infra axillary/
                               infrascapular areas
       Stony dullness
       Chest wall movements    Lt side

   CVS
       S1 S2 +
       No murmur
   ABD
       No organomegaly
       No FF
                       LAB
   Hemogram
       Hb         -   5.6 g/dl
       TLC        -   30,100/cu mm
       DC         -   blast 60% P24 L 04
                       Myelocyte 12
       Platlets   -   20.000/ cu mm
       RBC        -   1.6 million/ cu mm
       PCV        -   15 %
    PERIPHERAL SMEAR
   RBC      -   Normochromic Normocytes
       and few hypochromic microcytes.
             -   No hemoparasites seen

   WBC     -    Count increased with BLASTS
            showing occasional Auer Rods.

   PLATLETS-    Diminished
        BONE MARROW
   Hypercellular Marrow replaced by Leukemic cells
    with BLAST showing MYELOID MONOCYTIC
    differentiation up to 70 %
   ERYTHROPOIESIS
   MEGAKARYOPOIESIS
   CYTOCHEMISTRY
       MPO   -   Inconclusive
       PAS   -   Neg
   RFT
       Urea         -   32 mg/dl
       Creatinine   -   0.8 mg/dl
   Bl sugar             -    105 mg/dl
   LFT
       TB           -   0.7 mg/dl
       DB           -   0.3 mg/ dl
       SGOT         -   24 Iu/L
       SGPT         -   22 Iu/L
       SAP          -   1O5 Iu/L
   CXR             -   Lt pleural effusion
   ECG             -   WNL
   USG ABD         -   Lt pleural effusion
                    -   LIVER/ SPLEEN normal

   SPUTUM
       AFB         -   Neg
       Grams stain -   Neg
       Malig cells -   Neg
 Pleural      Fluid
    Protein     -     4.6 g/dl
    Sugar       -     84 mg/dl
    WBC         -     2600/ cu mm
                       ( P 11 L 39 )
    RBC         -     30,000/cu mm
    Smear       -     +ve for MALIGNANT CELLS
    Grams stain -     No organisms
    AFB         -     Neg
                Problems

   Fever
   Lymphadenopathy
   Pleural effusion
   Subconjunctival hemorrhage
   Loss of wt
    DIAGNOSIS

ACUTE MYELOID LEUKEMIA
 – M4 WITH MALIGNANT
 PLEURAL EFFUSION
ACUTE
MYELOID
LEUKEMIA
       ETIIOLOGY
   HEREDITY - Downs , Klinefelters, patau,
         Chromosomal breakage syndromes
   RADIATION
   CHEMICAL - Benzene, smoking, paint,
               petroleum, pesticides.
   DRUGS      - Alkylating agents, Topo
               isomerase II inhibitors,
      Chloramphenicol and phenyl butazone.
          CLINICAL FEATURES
   Age of onset - Adult onset and incidence increases
                    with age
   M/F             - 4.4 : 3
   Fatigue
   LOW/ LOA
   Fever with or without infection
   Bleeding symtoms
   Bone pain
   Lymphadenapathy
   Hepatosplenomegaly
   GI, PUL, Intra cranial, Retinal hhage (APL – M3)
   Chloroma ( M1 M2)
   Gum hypertrophy (M4 M5 )
BLOOD PARAMETERS
  Anemia with dec Retic count

  WBC     – mean 15,000
          <5000 in 25 – 40%
          > 100,000 in 20%
          No malig cells in 5%
          Dysfunction +

  Platlets - < 100,000 in 75%
           < 25000 in 25%
           Dysfunction +
CLASSIFICATIONS
   FAB
       Based on Morphological charecteristics
       BLAST cells > 30 %


   WHO
       BLAST cells > 20 %
       Based on Morphology, Molecular and CF.
                     FAB
   M0     -   Minimal diff
   M1     -   Myeloblastic without maturation
   M2     -   Myeloblastic with maturation
   M3     -   Promyelocytic
   M4     -   Myelomonocytic
   M4E0   -   Marrow eosinophilia
   M5     -   Monocytic
   M6     -   Erythroleukemia
   M7     -   Megakaryoblastic
                                WHO
   AML I – GENETIC abnormalities
           t ( 8/21), inv (16), t (16/16)
          MLL abnormalities
          APL t ( 15/ 17)


   AML II- Following myelodysplasia/
      myeloproliferative disorders

   AML III- Following DRUG induced
      myelodysplasia

   AML IV – M0 to M7 of FAB , panmyelosis,
      basophilic and myeloid sarcoma
              PROGNOSIS
   GOOD                             POOR
       Young age                        Advanced age ( > 60)
       Chromosomal defects              Chrom defects ( inv 3, -
        (t8/21, inv 16, t15/17)           7)
       Rapid induction of CR            Asso med illness
       Long duration of CR              Prolonged cytopenias
                                         Prev myelodysplasia
                                         Drug induced AML
                                         Delayed and short
                                          duration of CR
    MANAGEMENT
   REMISSION INDUCTION



   POST REMISSION MANAGEMENT
             REMISSION INDUCTION
                 (7&3 REGIME)
   CYTARABINE
       100 – 200 mg / sq m/ day IV infusion   7 days


   ANTHRACYCLINE
       Daunorubicin – 45- 60mg/sq m/day IV    3 days
       Idarubicin   - 12 mg/sq m/ day IV


   With or without ETOPOSIDE
COMPLETE REMISSION
   Blood
        WBC >1500
        Platlet > 1 Lac
        RBC count not considered
        No BLAST cells
   BM
       Trilineage cellularity > 20%
       Blast cell             < 5%
       NO Auer rods
       RT PCR/ FISH to r/o residual leukemic cells
   If 7 & 3 Regime
       50% - CR


   start 5 & 2 Regime
       25% - CR
       25% - NO CR


   NO CR
       50% - Drug Resistance
       50% - Fatal complications of Drugs
POST REMISSION MANAGEMENT
    AGE < 65 yrs               AGE > 65 YRS

   HIGH DOSE                     LESS INTENSIVE
    CYTARABINE                     CHEMOTHERAPY
       3-4 cycles
       3 g/sq m / day bd on
        1,3 & 5 th day

                                  STEM CELL Tx
   STEM CELL Tx
                                      Non myeloablative
       Autologous                     Allogenic
       allogenic
    TREATMENT OF APL ( M3)
   TRETINOIN( Maturation of blast cells,No DIC)
       45 mg/ sqm/day                 Untill
                                   remission
   ANTHRACYCLINES

   Maintanance therapy
       Tretnoin or chemotherapy
  RELAPSE

STEM CELL TX

				
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posted:9/6/2011
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