2. Contents
1. Definition
2. Risk factors
3. Sign and symptom
4. Diagnostic test
5. Pathophysiology
6. Treatment
7. Case study
8. Nursing care plan
9. Health educations
3. type of cancer in which the bone marrow
makes excessive immature WBC
(myeloblast)
Start with damaged of DNA in stem cell ->
abnormal myeloid stem cell fails to mature ->
excessive production of myeloblasts in bone
marrow ->blocking production of RBC and
platelets
Causing anemia, neutropenia, thrombocytopenia
Pancytopenia
May spread to skin, brain and gums
AML
6. SIGNS AND SYMPTOMS
Clinical manifestation
• Pale looking
• Headache
• Fever
• Weight loss
• Dyspnea associated with anemia
• Patients with coronary disease may experience angina more frequently.
• Abnormal bleeding may occur (eg, nosebleeds, bleeding gums, heavy menstrual flow)
• Poor skin or wounds healing
• Recurrent infections
• Bone pain
Physical examination
• Nodular rash may represent leukemic infiltration of skin
• Peripheral lymphadenopathy
• Soft tissue mass may represent myeloid sarcoma
• Hepatomegaly or splenomegaly
• Gingival swelling may be seen, with acute monocytic leukemia
7. Diagnostic test
• 1. Laboratory assessment :
• CBC-Hb, Platelet, White blood count
• Comprehensive metabolic panel (levels of hepatic enzymes,
alkaline phosphatase, electrolytes, BUN, and creatinine)
• Uric acid level
• Lactate dehydrogenase level
• Prothrombin time, partial thromboplastin time, fibrinogen
level
• HLA typing for allogeneic SCT
8. 2. Imaging
• Head CT without contrast in patients with major neurologic symptoms to rule out cerebral bleeding resulting
from thrombocytopenia or other coagulopathy.
• MRI of head with contrast when leukemic meningitis is suspected.
• PET/CT
3. Bone marrow biopsy and aspirate
Histologic analyses of blood and bone marrow to detect and quantify neoplastic blast cells
• Morphologic assessment
• Flow cytometry
• Karyotype analysis (cytogenetics)
• Immunohistochemical analysis
• Fluorescence in situ hybridization
• Molecular genetic studies
9. PROGNOSIS
• Cytogenetics
The single most important prognostic factor in AML is cytogenetics, or the chromosomal structure of the leukemic cell.
About
half of people with AML have "normal" cytogenetics; they fall into an intermediate risk group. A number of other
cytogenetic
abnormalities are known to associate with a poor prognosis and a high risk of relapse after treatment.
• Myelodysplastic syndrome
AML arising from a pre-existing myelodysplastic syndrome (MDS) or myeloproliferative disease (so-called secondary AML)
has
a worse prognosis, as does treatment-related AML arising after chemotherapy for another previous malignancy. Both of
these
entities are associated with a high rate of unfavorable cytogenetic abnormalities.
• Expectation of cure
Cure rates in clinical trials have ranged from 20–45%; although clinical trials often include only younger people and those
able
to tolerate aggressive therapies. The overall cure rate for all people with AML (including the elderly and those unable to
tolerate aggressive therapy) is likely lower. Cure rates for promyelocytic leukemia can be as high as 98%.
• Relapse
Relapse is common, and the prognosis is poor. Long-term survival after a relapse is rare.
• Other prognostic factors
age >60 years and elevated lactate dehydrogenase level were also associated with poorer outcomes.
10. From disease
• Hyperleukocytosis
WBC count greater than 100,000 cells/µL is associated with obstruction of blood flow in
small blood vessels
• Aggressive measures (eg, hydration) must be taken to prevent or mitigate tumor lysis syndrome
• Severe end-organ dysfunction, particularly cardiac or respiratory failure
• May result in intracranial or pulmonary hemorrhage, renal failure, or pulmonary failure
• Hemorrhage from coagulopathy
• Coagulopathy occurs much more often in adults with leukemia compared to children
• Intracranial hemorrhage occurs more frequently in patients with acute myelogenous leukemia than in any other
hematologic malignancy
Complication
11. Complications
• DUE TO TREATMENT :
• • Induction chemotherapy
• tumor lysis syndrome, which results in hyperuricemia, hyperkalemia,
• hyperphosphatemia, and hypocalcemia with consequent renal failure,
• cardiac arrhythmias, and sometimes death
• thrombocytopenia; bleeding may occur spontaneously (eg, gastrointestinal)
• or with trivial injury (eg, intravascular catheter placement)
• mucositis, characterized by painful erosive lesions of gastrointestinal mucosa
• that may provide entry to infecting organisms and may be a source of
• bleeding
• Capillary leak syndrome characterized by fever, dyspnea, hypoxemia,
• pulmonary infiltrates, peripheral edema, ascites, and renal and hepatic
• dysfunction
• • Anthracyclines can have a cardiotoxic effect
12. Standard therapy
• Successful treatment of acute myeloid leukemia (AML) requires the control of
bone marrow and systemic disease and specific treatment of central nervous
system (CNS) disease, if present.
• The cornerstone of this strategy includes systemically administered combination
chemotherapy.
• Because only 5% of patients with AML develop CNS disease, prophylactic
treatment is not indicated
• Treatment of newly diagnosed cases involves 2 phases:
• Remission induction (to attain remission)
• Some patients do not achieve remission with first cycle of induction therapy;
disease may respond to repeated cycle with or without dose intensification, or to
a modified regimen
• Post remission (to maintain remission) To prevent relapse
13. Allogeneic transplant
Aim:
In malignant haematological disease, donor
HSCs replace the immune system and help
to eradicate malignancy (Maziarz 2015;
Michel and Berry 2016).
• In non-malignant diseases, where the cause
is dysfunction of the haematopoietic stem
cell (HSC), the HSCT procedure replace the inefficient
patient immune system with
the donor one (Michel and Berry 2016;
Hatzimichael and Tuthill 2010).
14.
15. Radiation therapy
• Ionizing radiation is targeted to site of involvement under direction of a radiation oncologist
Indication
• Central nervous system involvement as demonstrated by presence of blasts in cerebrospinal fluid plus
evidence of increased intracranial pressure
Contraindications
• Poorly controlled diabetes mellitus
• Inflammatory bowel disease
• Diverticulosis
Complications
• Proctitis with bleeding, pain, and diarrhea
• Cystitis with hematuria, dysuria, and incontinence
• Erectile dysfunction
16.
17.
18. In addition to cytogenetic abnormalities,
AML can be associated with gene
mutations that carry prognostic
significance.
• For instance, FLT3 (fms like tyrosine
kinase 3) Internal Tandem Duplications
confer a poor prognosis.
• FLT3 is a proto-oncogene. Signaling plays
a role in cell survival, proliferation, and
differentiation.
• Patients with FLT3/ITD mutations, and
possibly those with FLT3 point mutations,
are consistently reported to have an
increased relapse rate and reduced
overall survival (OS).
19. Case study • Walked in admission
(15/6/2023)
• 165cm, 58.4 kg
• NKDA
• V/S: T: 36.1°C,
• BP: 160/90mmHg,
• Pulse: 93bpm,
• Resp: 19/min,
• Pain score: 0,
• SPO2: 96% under RA,
• Mews: 0
• Mdm L
• 64 years old
• Indonesian
• Acute Myeloid Leukemia
• For Allogeneic SCT Full
match
• With ATG-Flu-Bu
Hb: 10.9 , PLT: 60, TWBC: 2.0
ALT: 16 U/L
AST: 16 U/L
Calcium: 2.15mmol/L (Low, N: 2.2-2.5)
Albumin: 33g/L (Low, N: 35-52)
RP:
- creatinine: 202umol/L (Low, N: 49-90)
-urea: 6.8mmol/L (N: 3.0-9.2)
-eGFR: more than 90
-Na 133 (Normal)
-K 4.3 (Normal)
-Uric Acid: 394 umol/L (N: 150-350)
20. Current medication:
-Tab. Stilnox 10mgON
-Tab. Diazepam 1p0mg ON
-Tab. Xanax 0.5mg BD
-Tab. Controloc 40mg OD
-PO Gaviscon 10mls TDS/PRN
-Tab. Cal-600 Plus 1/1 OD
21. PMhx:
• Chemotherapy done 2 cycle (Gleanegle Hospital, 2023)
• BMA done on (19 April 2023)
• Depression (Dr Ang JK, FEB 2023)
• Special diagnostic done ECHO-EF 60%, ECG: sinus rhythm, PFT: FVC: more than 80% (Sunmed, 12/6/23)
PShx:
• Hysterectomy (2013)
• Appendisectomy (2013)
• Sinus surgery (Indonesia, 2021)
POhx: SVD*2
FMHx: Father (DM)
SHx: ex drinker (stopped since Jan 2023)
22. 15/6/23 Admission day 16/6/23 17/6/23 Day-6 18/6/23 Day-5 19/6/23 Day-4
Hb: 10.9
Plt:60
Wc:2.0
-Consented IJC
-IJC insertion by Dr
Naresh at right neck
Started conditioning
ATG-Flu-Bu
Hb: 10.2
Plt: 51
WC: 2.3
Hb: 9.9
Plt: 40
WC: 2.1
CRP: 11.9
Chimerism
Ufeme: Normal
Blood C&S chemoport
cancelled
IVD NaCL 4 pints/ 24
hour
-Consented
conditioning,collect
ion, transplant, and
blood tx
Urine C&S no
growth
Pre CD34 count:
41.70 cells/uL
PBSC collection
-Total stem clell
collected: 380mls
-Total plasma
collected: 370mls
Post CD34 count:
3.80 cells/uL
IV Heparin 5000 unit
in 50cc NaCL
Chemoport needle
removed
On 12/6/23
EBV IgG
Herpes IgG ½
CMV IgG (305.6 high)
G6PD (N)
APTT (30.2 Low)
HIV ½ -ve
Toxoplasma IgG (3.1
RP1-Na 139
K3.8 Glu: 7.0
Done USG KUB
Blood culture from
peripheral and IJC
-Day 5 no growth
23. 20/6/23 Day -3 21/6/23 Day -2 22/6/23 Day-1 23/6/23 Day 0 24/6/23 Day+1
ALT: 176 high
AST 38 high
Urea: 7.5 high
Albumin 33 low
Hb: 10.1
Plt: 44
WC: 1.1
PBSCT-100mls+2,
60mls*1
(total 260mls,
trial 3 bags)
IVD 2 pints N/saline
28. Diarrhoea due to side effect of chemotherapy
Goal: Patient reduce the risk of dehydration
1. Assess patient for any abdominal discomfort such as pain and frequency of diaarhea
2. Monitor intake and output strictly
3. Monitor patient daily weight
4. Send stool specimen as ordered.
5. Encourage to drink 1-2L of water per day
6. Administered IV fluid as ordered
7. Serve andiarrheal medication as ordered
8. Encourage patient to maintain personal hygiene
29. Risk of bleeding related to disease process
1. Assess the patient's risk factors for bleeding, including a history of bleeding disorders,
current medications, and recent surgery or trauma. Monitor the patient's vital signs,
including blood pressure, heart rate, and respiratory rate. Assess the patient's level of
consciousness and cognitive function.
2. Monitor the patient's vital signs, including blood pressure, heart rate, and respiratory
rate.
3. Implement appropriate measures to prevent falls and trauma, such as using bed rails
and assistive devices during transfers and ambulation.
4. Minimize invasive procedures and use appropriate precautions when performing
venipuncture or other invasive procedures.
5. Monitor the patient for signs and symptoms of bleeding, such as petechiae,
ecchymoses, bleeding gum.
6. Administer medications as ordered for bleeding prevention, such as anticoagulants and
antiplatelet agents.
7. Implement appropriate infection control measures to prevent infections, which can
increase the risk of bleeding.
30. Risk of infection related to side effects of
chemotherapy.
1. Assess the patient for signs of infection, such as fever, chills, increased heart rate, and respiratory distress.
2. Monitor the patient's vital signs, including temperature, and patient's skin for signs of rash or lesions.
3. Minimize the risk of infection, including frequent hand hygiene, isolation precautions as needed, and
appropriate use of personal protective equipment (PPE) by healthcare providers.
4. Encourage the patient to report any signs or symptoms of infection immediately.
5. Administer prophylactic antibiotics, antivirals and antifungals as ordered by the healthcare provider.
6. Perform dressing under aseptic technique.
7. Educate patient on neutropenic diet.
8. Educate the patient and family members on the importance of hand hygiene, including frequent hand
washing with soap and water or using alcohol-based hand sanitizers.
9. Teach the patient to avoid contact with sick individuals and to avoid crowded places.
10. Encourage the patient to maintain good self hygiene such as oral hygiene, daily bath and keeping nails short
to minimize the risk of oral infections.
11. Ensure that the patient's environment is clean and free of potential sources of infection such as changing
linens daily or when necessary, limiting visitors, disposal of unfinished food, and no fresh flowers.
