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KEY CONCEPTS
Acute leukemias are the most common malignancies in children and the leading cause of cancer-related death in patients younger than 20 years.
Several risk factors correlate with prognosis for acute lymphoblastic leukemia (ALL). Poor prognostic factors include high white blood cell (WBC) count at presentation, very young or very old age at diagnosis, delayed remission induction, and presence of certain cytogenetic abnormalities (eg, Philadelphia chromosome positive [Ph+]).
For children with ALL, remission induction therapy includes vincristine, a corticosteroid, and asparaginase, with or without an anthracycline. For adults with ALL, vincristine, prednisone, anthracycline, and asparaginase are used.
All patients with ALL require prophylactic therapy to prevent CNS disease because of the high risk of central nervous system (CNS) relapse. The choice for therapy includes a combination of cranial irradiation, intrathecal chemotherapy, or high-dose systemic chemotherapy with drugs that cross the blood-brain barrier.
Long-term maintenance therapy for 2 to 3 years is essential to eradicate residual leukemia cells and prolong the duration of remission. Maintenance therapy consists of oral methotrexate and mercaptopurine, with or without monthly pulses of vincristine and a corticosteroid.
Disease-free survival is lower in adults with ALL and has been attributed to greater drug resistance, poor tolerance with subsequent nonadherence, and possibly less-effective therapy. This population is also more likely to have Ph+ ALL, which is associated with a worse outcome, but the use of tyrosine kinase inhibitors (TKIs) has improved treatment results.
Several poor prognostic factors for adult acute myeloid leukemia (AML) include older age, organ impairment, extramedullary disease, and certain cytogenetic and molecular abnormalities.
Treatment of AML usually includes therapy with an anthracycline and cytarabine. Postremission therapy is required in all patients and consists of either consolidation chemotherapy with or without maintenance therapy, or hematopoietic stem cell transplantation (HSCT). Novel oral therapies that inhibit FMS-related tyrosine kinase (FLT-3), isocitrate dehydrogenase (IDH1 and IDH2), and B-cell leukemia/lymphoma (BCL-2) have emerged in the AML treatment landscape.
Treatment of acute promyelocytic leukemia (APL) consists of induction therapy, consolidation, and maintenance therapy. Induction includes tretinoin and an anthracycline; consolidation therapy consists of two to three cycles of anthracycline-based therapy; maintenance consists of pulse doses of tretinoin, mercaptopurine, and methotrexate for 2 years.
Hematopoietic growth factors can be safely and effectively used with myelosuppressive chemotherapy for acute leukemias. They reduce the risk of serious infections, hospital length of stay, and treatment delays but do not prolong disease-free or overall survival.
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Patient Care Process for Ph+ Adult Lymphoblastic Leukemia
Collect
Patient characteristics (eg, age, gender, pregnancy status)
Patient medical history (personal and family)
Social history (eg, tobacco/marijuana, ethanol use)
Current medications including OTCs and herbal products
Confirmation of histological diagnosis
Objective data
Complete blood count (CBC) with differential, platelets
Hepatic function tests
Basic chemistry panel
DIC panel: D-dimer, fibrinogen, PT, PTT
Tumor lysis panel (uric acid, potassium, calcium, phosphate)
Hepatitis B/C serologies, HIV, CMV status
ABO ...