Leukemia presentation for MSc nursing students

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2. LEUKEMIA
PRESENTED BY : Ms. Zuricka Da Costa
M.Sc. (N) I year
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3. OBJECTIVES
• Definition of Leukemia
• Incidence of Leukemia
• Etiology & Riskfactors ofLeukemia
• ClassificationofLeukemia
• Pathophysiology of Leukemia
• Diagnostic evaluation of Leukemia
• Management of Leukemia
• Complications
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5. LEUKEMIA
The word Leukemia comes from the Greek word
leukos which means "white" and aima which
means "blood".
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6. DEFINITION
Leukemia is a progressive, malignant disease of the
blood forming organs, marked by distorted
proliferation and development of leukocytes and their
precursors in the blood and bone marrow.
-National Cancer Institute
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7. INCIDENCE
• About 3- 4 percent in 1,00,000 population in
India.
• Affects approximately 9 times more in adults
than in children.
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8. ANATOMY AND
PHYSIOLOGY
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10. ETIOLOGY AND RISK
FACTORS
The exact cause is unknown.
• Gender
• Age
• Family history
• Genetic disorders
• Smoking tobacco
• Exposures (radiation or chemicals)
• Previous cancer treatment
• Viral cause
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11. CLASSIFICATION
According to nature of disease
oAcute leukemia
oChronic leukemia
According to type of blood cell affected
oAcute lymphocytic leukemia
oAcute myelogenous leukemia
oChronic lymphocytic leukemia
oChronic myelogenous leukemia
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12. CLASSIFICATION cont.
According to nature of disease
o Acute leukemia
o Chronic leukemia
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14. ACUTE LEUKEMIA
• Characterized by clonal proliferation of immature
hematopoietic cells.
• It develops after malignant transformation of a
single type of immature hematopoietic cells
• Cellular replication and expansion of that
malignant clone.
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15. ACUTE LEUKEMIA -Clinical
manifestations
• Low white blood cell count
• Infections
• Tiredness
• Shortness of breath
• Pale skin
• Sweating usually at night
• Fever
• Bone and joint aches
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16. CHRONIC LEUKEMIA
• In chronic leukemia, the leukemia cells come
from mature cells
• Distinguished by excessive build up relatively
mature but still abnormal WBC.
• Takes months to years to progress.
• Shows no symptoms initially.
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17. CHRONIC LEUKEMIA- Clinical
manifestations
• Malaise
• Weight loss
• Loss of appetite
• Fever
• Night sweats
• Anaemia
• Infections
• Bleeding (nosebleed)
• Enlarged lymph nodes
• Pain or feeling of
fullness in upper left
abdomen.
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18. ACCORDING TO TYPE OF
BLOOD CELLAFFECTED
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19. ACCORDING TO TYPE OF
BLOOD CELLAFFECTED
CONT.
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20. ACUTE LYMPHOCYTIC LEUKEMIA
(ALL)
• Most common type of leukemia
in children, and accounts for
20% of leukemia case in adults.
• Here immature small
lymphocytes proliferate in bone
marrow : most are of B- cell
origin.
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22. ALL- CLINICAL
MANIFESTATION
• Fever
• Pale skin
• Bleeding
• Anorexia, weight loss
• Fatigue
• Weakness
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23. ALL- CLINICAL
MANIFESTATION
• Bone , joint and abdominal pain
• Generalized lymphadenopathy
• Infection
• Hepatosplenomegaly
• Headache
• Mouth sores
• Increased ICP
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24. ALL- DIAGNOSTIC
FINDINGS
• Low RBC count, Hb, Hct, low
platelet count.
• Low, or high WBC count, high LDH
• Transverse lines of rarefaction at
ends of metaphysis of long bones on
X-rays.
• Hypercellular bone-marrow with
lymphoblast.
• Presence of Philadelphia
chromosomes (20-25% cases).
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25. ALL- TREATMENT
• Chemotherapy is the mainstay of treatment
• It is the use of potent drugs or chemicals, often in
combinations or intervals, to kill or damage cancer
cells in the body.
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26. ALL- TREATMENT CONT.
• Prophylactic treatment of the CNS, intrathecal
administration and/or cerebrospinal radiation
to eradicate leukemic cells.
• Diet having high protein and fibre.
• Drink adequate Fluid
• Avoid infection and injury.
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28. ACUTE MYELOGENOUS
LEUKEMIA
(AML)
• This type represents only 1/4th of all leukemia's, in
which 80% of this type in adults.
• It is characterized by uncontrolled proliferation of
myeloblasts in the bone marrow.
• Its onset is often abrupt and dramatic.
• Increases in incidence with advancing age after 60yr.
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30. AML- CLINICAL
MANIFESTATION
• Fatigue and weakness
• Headache
• Mouth sores
• Anaemia
• Bleeding
• Fever
• Infection
• Sternal tenderness
• Gingival hyperplasia
• Mild
hepatosplenomegaly
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31. AML- DIAGNOSTIC
FINDINGS
• Low RBC count, Hb, Hct, Low platelet
count
• Low to high WBC count with myeloblasts.
• High LDH.
• Hypercellular bone marrow with
myeloblasts.
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32. AML- TREATMENT
• Same treatment as ALL.
• Common chemotherapy agent for induction of
AML includes cytarabine and an antitumor
antibiotic such as mitoxantrone.
• Fluid therapy (2000-3000ml/day)
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35. CHRONIC LYMPHOCYTIC
LEUKEMIA
(CLL)
• It is most common type in adults.
• It is characterized by production and accumulation of
functionally inactive but long- lived, small, mature-
appearing lymphocytes.
• The type of lymphocytes involved is usually B- cell
and it may infiltrate other organ like bone marrow,
spleen and liver.
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37. CLL- CLINICAL
MANIFESTATIONS
• Chronic fatigue
• Anorexia
• Splenomegaly &
lymphadenopathy
• Hepatomegaly
• Fever
• Night sweats
• Weight loss
• Frequent infection
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38. CLL- DIAGNOSTIC
FINDINGS
• Mild anemia and thrombocytopenia
• Total WBC count >100,000 /micro L
• Increased peripheral lymphocytes and
lymphocytes in bone marrow
• Autoimmune haemolytic anemia
• Idiopathic thrombocytopenic pupura
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39. CLL - TREATMENT
• Lymphocytic proliferation can be suppressed
with cholrambucil, cyclophosphamide and
prednisolone.
• Monoclonal antibody such as campath maybe
used.
• Transfusion therapy to replace RBCs and
platelet.
• Irradiation of painful enlarged lymph nodes.
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42. CHRONIC MYELOGENOUS
LEUKEMIA
(CML)
• It is caused by excessive development of
mature neoplastic granulocytes in the bone
marrow. The excess neoplastic granulocytes
move into peripheral blood in massive number
and ultimately infiltrate the liver & spleen.
• It increases in incidence with advancing age.
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44. CML- CLINICAL
MANIFESTATION
• Usually no initial
symptoms
• Fatigue and weakness
• Fever
• Sternal tenderness
• Weight loss
• Joint pain, bone pain
• Massive splenomegaly
• Increase in sweating
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45. CML – DIAGNOSTIC
FINDINGS
• Low RBC’s count, Hb, Hct.
• High platelet count initially but later count decreases.
• Increased banded neutrophills and myeloblasts and
often basophils
• Normal number of lymphocytes.
• Normal or low number of monocytes.
• Nucleated red cells
• Presence of Philadelphia chromosomes in 90% 0f
patients
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46. • Philadelphia chromosome.
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47. CML- TREATMENT
• It can be treated with drug like imatinib or dasatinib
• Combination chemotherapy includes prednisolone,
vincristine or methotrexate.
• Imatinib and other tyrosine kinase inhibitor target the
BCR –ABL protein that is present in nearly all patient
with CML.
• Take measures to prevent infection
• Promote safety
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49. PATHOPHYSIOLOGY
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50. CLINICAL
MANIFESTATION
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51. DIAGNOSTIC
EVALUATION
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52. DIAGNOSTIC
EVALUATION
• Health history
• Physical examination
• CBC
• Lipid profile (lactate dehydrogenase)- elevated
• Polymerase chain reaction- presence of biomarkers
• Liver function test- elevated
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53. DIAGNOSTIC
EVALUATION cont.
• C reactive protein- elevated {10 milligram per
liter (mg/L)}
• Bone marrow aspiration
• Bone marrow biopsy
• Cytogenetic
• Chest X ray - swollen lymph nodes
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55. X-ray Showing swollen lymph
nodes
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56. MANAGEMENT
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57. MANAGEMENT
• Patient having high levels of WBC Count must
start with initial emergent treatment.
• It includes leukapheresis and hydroxyurea.
• Chemotherapy is a mainstay for leukemia
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58. LEUKAPHERESIS
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59. MANAGEMENT cont.
• Combination therapy should be initiated.
Purpose of using multiple drug are:
– Decrease drug resistance
– Minimize the drug toxicity to the patient by using
multiple drug with varying toxicity
– Interrupt cell growth at multiple points in the cell
cycle.
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60. CHEMOTHERAPY
• It is the use of potent drugs or chemicals, often in
combinations or intervals, to kill or damage cancer
cells in the body.
• Normally, healthy cells divide and grow in a
controlled pattern. As each cell divides, a replica is
produced. Cancer cells, on the other hand, grow
uncontrollably and rapidly with no pattern. When a
cancer cell comes into contact with a normal cell, the
cancer cell takes over and copies itself many times,
overburdening the body with cancer cells
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61. Chemotherapy cont.
• All chemotherapy drugs interfere
with cancer cells ability to grow or
multiply.
• It attack cancer cells by interacting
with the cancer cell's DNA or RNA
(genetic makeup). This interaction
changes the DNA in such a way that
it kills the cancer cell or prevents it
from growing or dividing.
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62. Other Modes of Attack
• Hormones such as prednisone and dexamethasone
(Decadron) in high doses can kill lymphoma or
lymphocytic leukemia cells.
• Antimitotic drugs such as vincristine (Oncovin) or
vinblastine (Velban) damage cancer cells by blocking a
process called mitosis (cell division), preventing cancer
cells from dividing and multiplying.
• Antibodies made specifically to attach to cancer cells
interfere with a cancer cell's function and kill the cell.
Some antibodies are combined with a toxin or
radioactive substance.
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63. It involves three phases:
Induction
Therapy
Post
induction
or post
remission
therapy
Maintenance
therapy
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64. Induction Therapy
• The first phase of treatment is induction therapy. Its
goal is to "induce" remission (when no evidence of
the disease is left).
• Specifically, induction therapy for leukemia attempts
to:
– Kill as many leukemic cells as possible with
chemotherapy
– Get healthy blood cell counts back to normal
– Get rid of all signs of the disease for an extended
time
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65. Post induction or post remission
therapy
• After induction therapy is complete and the patient is
in remission, another phase of treatment is needed
called “post-remission therapy,” or “consolidation
therapy.”
• This second phase of treatment is used to destroy any
stray leukemic cells not found by blood
or marrow tests. Without post-remission therapy, the
leukemia will likely return.
• This phase usually lasts several months.
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66. Maintenance therapy
• The maintenance phase is the final phase
of treatment that lasts for two to three years. It's used
to kill any remaining cells that could cause a
recurrence.
• It is a treatment with low doses of same drug as in
induction phase given every 3-4 week.
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67. Side effects
• Chemo drugs can affect some normal cells in the
body, which can lead to side effects. The side
effects of chemo depend on the type and dose of
drugs given and the length of time they are taken.
Common side effects can include:
– Hair loss
– Mouth sores
– Loss of appetite
– Nausea and vomiting
– Diarrhea or constipation
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68. Side effects cont.
• Chemo drugs also affect the normal cells in bone
marrow, which can lower blood cell counts. This can
lead to:
– Increased risk of infections (from having too few
normal white blood cells)
– Easy bruising or bleeding (from having too few
blood platelets)
– Fatigue and shortness of breath (from having too
few red blood cells)
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69. MANAGEMENT cont.
The other options are :
• Watchful waiting
• Corticosteroids
• Radiation therapy
• Immunotherapy
• Biological therapy
• Targeted therapy
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70. RADIATION THERAPY
• Radiation therapy (also called radiotherapy)
uses high-energy rays to kill leukemia cells.
• This type of therapy takes place 5 days a week
for several weeks.
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71. BIOLOGICAL THERAPY
• Biological therapy for leukemia is treatment that
improves the body's natural defences against the
disease.
• One type of biological therapy is a substance
called a monoclonal antibody. It's given by IV
infusion
• The side effects of biological therapy differ with
the types of substances used, and from person to
person. It commonly cause a rash or swelling
where the drug is injected.
• They also may cause a headache, muscle aches, a
fever, or weakness.
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72. TARGETED THERAPY
• Targeted therapies use drugs that block
the growth of leukemia cells.
• For example, a targeted therapy may
block the action of an abnormal protein
that stimulates the growth of leukemia
cells.
• Side effects include swelling, bloating,
and sudden weight gain. Targeted
therapy can also cause anaemia,
nausea, vomiting, diarrhoea, muscle
cramps, or a rash.
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73. MANAGEMENT cont.
HEMATOPOIETIC STEM CELL
TRANSPLANTATION
• Any procedure where hematopoietic stem cells of any
donor and any source are given to a recipient with
intention of repopulating/replacing the hematopoietic
system in total or in part.
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74. Hematopoietic stem cell
transplantation- Types of transplant
cont.
• Autologous (your own cells)
• Allogeneic cells from another person
– Sibling
– Unrelated Donor
– Parent or relative
– or source: Umbilical cord
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75. AUTOGENIC HEMATOPOIETIC STEM
CELL TRANSPLANTATION
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77. SUPPORTIVE CARE
• INFECTIONS
• ANEMIAAND BLEEDING
• DENTAL PROBLEMS
• Diet and management
• Symptomatic management
• Discharge and home care– physical, psychological,
economic, spiritual necessary
• Continuation of medications on dicharge
• Folow up
• Sign and symptoms to inform if occurs on discharge
• Prevention of infections - instructions
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78. MANAGEMENT cont.
NURSING MANAGEMENT
• Obtain health history, focusing on fatigue, weight
loss, night sweats, and activity intolerance.
• Assess for signs of bleeding & infection.
• Evaluate splenomegaly, lymphodenopathy &
hepatomegaly.
• Examine patient for abnormal breathing sounds, skin
lesions.
• Inspect the patient for the sign of infection & the
incidence of frequency of infection.
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79. MANAGEMENT cont.
NURSING DIAGNOSIS:
• Risk for infection related inadequate secondary
defences: alteration in mature WBCs
• Acute pain related to enlarged lymph nodes as
evidenced by pain score level
• Activity intolerance related to generalised weakness
as verbalized by patient.
• Risk for deficit fluid volume related to haemorrhage,
vomiting .
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80. COMPLICATION
• Infection
• Multiorgan dysfunction
• Bleeding
• Thrombophlebitis
• DIC
• Leukostasis
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81. ACUTE MYELOID
LUEKEMIA: Advancement in
diagnosis and treatment
• This article reviewed the latest developments related to
the diagnosis and treatment of AML.
• Current chemotherapy agents have limited therapeutic
efficacy, with an approximate 50–70% complete
remission (CR) rate after induction and with only 20–30%
of patients achieving long-term disease-free survival.
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82. • Through an extensive search they found out new
therapies like Tyrosine kinase 3 inhibitors,
immunotherapy, cellular therapy is the newer trend to
treat luekemia.
• A major task for medical workers is to improve the
survival of AML patients while minimizing
treatment-related toxicity. These therapy and gene
sequencing techniques should set the basis for next-
generation diagnostic methods. Further, target therapy
should be the focus of future clinical research in the
exploration of therapeutic possibilities.
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83. Drug Duo a
Weapon Against a Common Leukemia
 Dr. Tait Shanafelt, professor of medicine at Stanford
University
• A two-drug combo helps patients with a common form of
leukemia survive longer than the current standard of care, a
new clinical trial finds.
• The phase 3 trial of more than 500 U.S. patients with chronic
lymphocytic leukemia (CLL) found that a combination of
rituximab and ibrutinib extended patient survival.
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84. • Specifically, 89.4% of the patients who received the
experimental drug combination did not have any
progression of their leukemia about three years after
treatment, compared with 72.9% of those who
received the traditional chemotherapy combination.
• As to overall survival, regardless of whether the
disease had progressed or not, the trial found that
three years after treatment, 98.8% of patients who
received the two-drug combination were alive,
compared with 91.5% of those who received the
traditional treatment.
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85. REFERENCE
• Lewis S L, Bucher L, Dirksen SR, Heitkemper MM. Lewis Medical Surgical
Nursing.2nd ed. New Delhi.Elsevier.2014.
• Bare BG, Smeltzer SC, Hinkle JL, Cheever KH. Brunner and Suddarths Textbook
of Medical Surgical Nursing.12th ed. New Delhi: Lippincott.2011.
• Black JM, Esther MJ.Medical Surgical Nursing:Clinical Management for
Continuity of care .5th ed.New Delhi.Jaypee publishers:2000.
• Sandra MN. Lippincott manual of nursing practice.10edition. New delhi. Wolter
kluwer publication.2014
• Chugh S N. Textbook of medicine for MBBS. 2 edition. India: arya publication;
2013
• Mehta SR, Thappa LB, Pokhrel N, Thladhar K. Oncology nursing.1st ed. Jaypee
publication pvt. Ltd. 2007
• Baig QM.Principles and practice of chemotherapy. 1st ed. Jaypee publication pvt.
Ltd. 2012
• Yu GM, Zheng HY. Acute myeloid luekemia- advancement in diagnosis and
treatment. Chin Med J(Engl).130(2).211-18.2017 DOI: 10.41031066-6999.198004
• The mystery of luekemia in older adults. Nursing made incredibly easy. 10(1).45-46
DOI: 10.1097/01.NME.000041025/8784.28
• Dr. Tait Shanafelt. Drug Duo a Weapon Against a Common Leukemia. New
England Journal of Medicine.381(5).2019
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