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Essentials of Diagnosis
Short duration of symptoms, including
fatigue, fever, and bleeding.
Cytopenias or pancytopenia.
More than 20% blasts in the bone marrow.
Blasts in peripheral blood in 0% of
patients.
Classify as acute myeloid leu!emia "#M$or acute lymphoblastic leu!emia "#$$.
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General Considerations
#cute leu!emia is a hematopoieticprogenitor cell malignancy.
&ncontrolled proliferation cells and replace
normal bone marrow elements. #rise with no clear cause. 'owever,
radiation and some to(ins "ben)ene areleu!emogenic. # number of
chemotherapeutic agents "especiallycyclophosphamide, melphalan, otheral!ylating agents, and etoposide maycause leu!emia.
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General Considerations
Most of the clinical findings in acute
leu!emia are due to replacement of
normal bone marrow elements by the
malignant cell. $ess common manifestations result from
organ infiltration "s!in, gastrointestinal
tract, meninges. #cute leu!emia is potentially curable
with combination chemotherapy.
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General Considerations
#$$ comprises *0% of the acute leu!emias
of childhood. +he pea! incidence is
between and - years of age. t is also
seen in adults, causing appro(imately 20%of adult acute leu!emias.
#cute myeloid leu!emia "#M$ is primarily
an adult disease with a median age
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Symptoms and Signs
Bleeding "usually due to thrombocytopenia /
S!in
Mucosal surfaces
inggival bleeding
1pista(is
Menorrhagia
$ess commonly, widespread bleeding isseen in patients with disseminated
intravascular coagulation "C.
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Symptoms and Signs
nfection is due to neutropenia "falls below
3004mc$. +he most common pathogens
are gram5negative bacteria (Escherichia
coli, Klebsiella, Pseudomonas or fungi"Candida, Aspergillus. Common
presentations include cellulitis, pneumonia,
and perirectal infections6 death within a few
hours may occur if treatment withappropriate antibiotics is delayed.
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Symptoms and Signs
7atients may also see! medical attention / um hypertrophy Bone and 8oint pain
+he most dramatic presentation ishyperleu!ocytosis, in which a mar!edlyelevated circulating blast count "usually 9200,0004mc$ leads to impaired circulation /
'eadache Confusion yspnea
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Laboratory Findings
+he hallmar! of acute leu!emia is the
combination of pancytopenia with
circulating blasts
'owever, blasts may be absent from theperipheral smear in as many as :0% of
cases ";aleu!emic leu!emia;.
+he bone marrow is usually hypercellular
and dominated by blasts. More than 20%
blasts are re
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Laboratory Findings
'yperuricemia may be seen. f C is present / +he fibrinogen level will be reduced +he prothrombin time prolonged =ibrin degradation products or fibrin 5dimers present.
7atients with #$$ "especially + cell may have amediastinal mass visible on chest radiograph.Meningeal leu!emia will have blasts present in thespinal fluid, seen in appro(imately 3% of cases atdiagnosis6 it is more common in monocytic types of#M$.
+he #uer rod, an eosinophilic needle5li!e inclusion inthe cytoplasm, is pathognomonic of #M$
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Laboratory Findings
#M$ classification by ;=#B,; "=rench,#merican, British was based of morphologyand histochemistry /
#cute undifferentiated leu!emia "M0
#cute myeloblastic leu!emia "M: #cute myeloblastic leu!emia withdifferentiation "M2
#cute promyelocytic leu!emia "#7$ "M #cute myelomonocytic leu!emia "M> #cute monoblastic leu!emia "M3 1rythroleu!emia "M? Mega!aryoblastic leu!emia "M-
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Differential Diagnosis
#M$ must be distinguished from othermyeloproliferative disorders /
Chronic myeloid leu!emia Myelodysplastic syndromes.
#$$ must be separated from otherlymphoproliferative disease such as /
Chronic lymphocytic leu!emia $ymphomas
'airy cell leu!emia. #typical lymphocytosis of mononucleosis and
pertussis.
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Treatment
+he first step in treatment is to obtain
complete remission /
normal peripheral blood with resolution of
cytopenias normal bone marrow with no e(cess blasts
normal clinical status.
+he type of initial chemotherapy dependson the subtype of leu!emia.
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AML
#M$ are treated with a combination / anthracycline "daunorubicin or idarubicin plus cytarabine, either alone or in combination with other
agents.
+his therapy will produce complete remission in *0%of patients under age ?0 years and in 30@?0% ofolder patients.
#7$ is treated differently from other forms of #M$.nduction therapy should include anthracycline plusall5trans5retinoic acid.
Aith this approach 0@3% of patients will achievecomplete remission.
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ALL
#dults with #$$ are treated / aunorubicin incristine
7rednisone #sparaginase +his treatment produces complete
remissions in 0% of patients.
emission induction therapy for #$$ is lessmyelosuppressive than treatment for #M$and does not necessarily produce marrowaplasia
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Prognosis
#ppro(imately -0@*0% of adults with #M$ under age ?0years achieve complete remission. 'igh5dose postremission chemotherapy leads to cure in
3@>0% of these patients, and high5dose cytarabine hasbeen shown to be superior to therapy with lower doses.
#llogeneic bone marrow transplantation is curative in 30@
?0% of cases. #utologous bone marrow transplantation may be superior
to nonablative chemotherapy. Dlder adults with #M$ achieve complete remission in up
to 30% of instances.
+he cure rates for older patients with #M$ have been verylow "appro(imately :0@:3% even if they achieveremission and are able to receive postremissionchemotherapy.