HAEMATOLOGY MODULE: LEUKAEMIA (LECTURE 1)

CHEMOTHERAPY

Adult Medical-Surgical Nursing

Leukaemia: Description

A group of malignant disorders affecting:

White blood cells (lymphocytes or granulocytes)

Bone marrow

Lymph system

Spleen

Leukaemia: Characteristics

Uncontrolled abnormal white cell division in the bone marrow:

→ increased number of dysfunctional white blood cells:

Immature blast cells Mature but dysfunctional cells

It is a systemic malignant disease:There is no primary tumour and metastases

Leukaemia: Aetiology

Both genetic and environmental factors involved

Leukaemia Aetiology: Genetic Propensity

Oncogenes:

Chromosome changes from normal to abnormal genes

Leukaemia Aetiology: Environment

Oncogenes are triggered or enhanced by exposure (even prenatal) to:

Chemical agents (benzene, dyes)RadiationEnvironmental pollutantsSmokingDrugs of addictionViruses(Immunological deficiencies expose further)

Leukaemia: Classification

Myeloid Leukaemia: affects granulocytes (from myeloid stem cells)

Lymphocytic Leukaemia: affects lymphocytes (from lymphoid stem cells)

May be:Acute (blast cells)

Chronic (mature but dysfunctional cells)

Leukaemia: Classification

Acute Myelogenous Leukaemia (AML)

Acute Lymphocytic Leukaemia (ALL)

Chronic Myelogenous Leukaemia (CML)

Chronic Lymphocytic Leukaemia (CLL)

Acute Myelogenous Leukaemia (AML)

AML: Description

85% of acute leukaemia incidence in adults

Acute onset

Proliferation of myeloblasts, immature granulocytes in the blood circulation

AML: Pathophysiology

Uncontrolled abnormal cell division leading to:

Immature dysfunctional myeloblasts crowd the bone marrow and circulation

Infiltrate lymph nodes, spleen, liver, central nervous system

→ node enlargement, lymphadenopathy, splenomegaly, hepatomegaly

Crowding out of normal erythroblast and platelet development in bone marrow: ↓ RBC and platelet count

AML: Clinical Manifestations

Sudden onsetPatient is very susceptible to infection: Prone to opportunistic infection as Candida

AlbicansFatiguePallorBleeding tendencyBone pain: damaged overcrowded marrow

AML: Diagnosis

CBCBlood film:Extremely ↑ number of immature white cells

(myeloblasts) and ↓ RBC and platelets

Bone marrow biopsy: crowding of myeloblasts

Lumbar punctureCT scan for evidence of leukaemia outside

blood or bone marrow

AML: Aims of Treatment

Induce remission (disease control), that is no evidence of the disease :

Blood and bone marrow appear normal (<5% blast cells)

Achieved by chemotherapyIf relapse occurs, must restart the whole

treatment regime Becomes ↑ more difficult to attain remission or

cureMay get partial remission (evidence of disease in

bone marrow still)

Chemotherapy

Chemotherapy

The treatment of choice for Leukaemia

Uses different combinations of drugs to destroy malignant cells

Chemotherapy: Multiple Drug

Protocol

A multiple drug regime or protocol:

Interrupts cell growth and division at different stages of the cell cycle

Therefore it is more effectiveMinimises toxicity from high doses of a single

agentReduces drug resistance

Chemotherapy Protocols

Protocols have acronyms: as COAP

CyclophosphamideOncovanArabinosidePrednisone

Each drug taken singly or with another has a specific action on bone marrow cells

Stages of Chemotherapy

There are three stages or phases of chemotherapy:

Induction phase

Intensification (consolidation or sanctuary phase)

Maintenance

Chemotherapy: Induction Phase

Aggressive treatment:

Uses multiple drug protocolSeeks to destroy malignant cells in:BloodTissuesBone marrowAims to achieve remission (< 5% blasts in

bone marrow)

Intensification/ Consolidation

Phase

After remission achieved:

Immediate intensive treatment for several months

Aims to eliminate remaining leukaemic cells

Includes intra-thecal chemotherapy (sanctuary phase) if leukaemic cells cross blood-brain barrier (ALL)

Chemotherapy: Maintenance

Low doses of chemotherapy continued for years

Follow-up until declared cured

Leukaemia: Adjuvant Therapy

Steroids Sedatives and anti-emetics (Haloperidol,

Cyclizine)Blood transfusionsNeupogen (encourages leukopoiesis) Bone marrow transplant depends on

histocompatibility of donor and recipientBone marrow transplant follows remissionSuccess rate for bone marrow transplant is

still quite low

Chemotherapy: Toxic Effects

Toxicity to veins and local tissues/ may cause local tissue excoriation

Nephrotoxicity/ cardio- / hepatotoxicityNausea and vomiting AlopeciaCompromised immune response:Infection risk (isolation)Reduced erythropoiesis (anaemia)Reduced platelet production (bleeding

tendency)

Chemotherapy: Nursing

Responsibilities

Preparation:Gown, double gloves, eye gogglesDesignated preparation cupboardDouble-checking Patient preparation: Adequate blood count, patient informationAdministration: fluid pre-load, pre-medicationIV monitoring, close observation of siteEmotional and physical support throughout

and in the community