For 2nd year B.Sc Nursing students

1. LEUKEMIA
Presented By:
Mr. Nandish.S
Asso. Professor
Mandya Institute of Nursing Sciences

3. INTRODUCTION :
 The stem cells in bone marrow produce specific types of blood
cells.
 Lymphoid stem cells produce either “T or B Lymphocytes”
 Myeloid stem cells differentiate into three broad cells like RBC,
WBC & Platelets.

4. DEFINITION :
 It is a group of malignant disorders affecting the blood & blood
forming tissues of the bone marrow, lymph system & spleen.
 It is a cancer of blood, characterized by the rapid growth of
abnormal blood cells which takes place in bone marrow.
 It is a group of blood cancers that begin in bone marrow & result
in high numbers of abnormal blood cells.

5. INCIDENCE / AGE OF ONSET :
- Acute Myelogenous Leukemia (AML) increases with advancing
age. Peak incidence between 60 – 70 years of age.
- Acute Lymphocytic Leukemia (ALL) peak incidence between 2
– 9 years of age.
- Chronic Myelogenous Leukemia (CML) peak incidence is
between 25 – 60 years.
- Chronic Lymphocytic Leukemia (CLL) predominant in men
around 50 – 70 years.

6. ETIOLOGY :
 Exact cause is unknown.
 There is no single specific causative factor / agent.
 Combination of predisposing factors like Genetic & Environmental
influences.
( Chromosomal changes like Down syndrome)
Chronic exposure to chemical agents like Benzene, alkylating agents,
etc.
Radiation exposure – very common in Radiologist, people reside
nuclear bomb test sites nuclear reactor accidents.
Patients who treated with radiation & chemotherapy.
Continued ….

7. Cytotoxic therapy of breast, Lung & Testicular cancer.
Congenital Anomaly
Viral infection : caused by human T – cell leukemia virus type 1
(common in south western Japan, Caribbean & central Africa)
Immunologic deficiencies.

9. PATHOPHYSIOLOGY :
Due to etiology
Lack of control on cell division
Normal bone marrow to be replaced by immature & undifferentiated
leukocytes
Circulation of these abnormal cells all body parts
Infiltration of blood forming organs (spleen & lymph nodes)
Clinical features

10. CLASSIFICATION / TYPES :
It is done based on :
 Onset
- Acute & Chronic
 Type of WBC involved
- Acute Myelogenous Leukemia (AML)
- Acute Lymphocytic Leukemia (ALL)
- Chronic Myelogenous Leukemia (CML)
- Chronic Lymphocytic Leukemia (CLL)

11. ACUTE LEUKEMIA :
 Onset is sudden.
 Affect younger age group frequently.
 It is characterized by clonal proliferation of immature hematopoietic
cells.
 Bone marrow fails to produce healthy blood cells.
 It develops following malignant transformation of a single type of
immature hematopoietic cell, followed by cellular replication.
 Immediate treatment is required to avoid rapid progression.

12. CHRONIC LEUKEMIA :
 Disease onset is insidious & more gradual.
 Usually less aggressive.
 It Involve more mature forms of WBC.
 The cells are produced at higher rate than normal.
 Commonly seen in old age people.

13. ACUTE MYELOGENOUS LEUKEMIA :
 It is also called as Acute Non Lymphoblastic Leukemia (ANLL).
 Its onset is Abrupt and Dramatic.
 It represents 1/4th of all Leukemia.
 It results from defect in the hematopoietic stem cells.
 Increase in incidence with advancing age, whereas peak incidence is
between 60 to 70 years.
 It is characterized by uncontrolled proliferation of myeloblasts
(precursor of basophils & eosinophils).

14. It is manifested by :
 Fatigue & Weakness
 Headache
 Mouth sore
 Pallor from Anemia
 Petechiae (pinpoint red or purple hemorrhagic spots on skin)
 Fever (due to neutropenia)
 Minimal hepatosplenomegaly
 Lymphadenopathy
 Sternal tenderness (due to expansion of bone marrow)
 Gingival Hyperplasia.

15. Diagnostic findings shows that
 Low RBC Count, Hemoglobin
 Low platelet count
 High WBC count with myeloblasts
 Hypercellular bone marrow (Leukemic Myeloblasts). It can be
further classified into 7 subgroups based on cytogenetics, histology
& morphology of blasts.

17. MANAGEMENT :
The main objective of treatment is to achieve complete remission with no
evidence of residual leukemia.
It is done by ;
1. Induction therapy – it involves aggressive administration of
chemotherapy drugs.
- Here patient needs hospitalization for several weeks.
- High doses of Cytarabine & either Daunorubicin, Idarubicin or
Mitoxantrone is given to the patient.
- Doses & drugs choice is done based on patient’s physical status & age.
Continued ….

18. 2. Consolidation therapy
 It is implemented to eliminate any residual leukemia cells that are not
clinically detectable & reduce the chance of recurrence.
 Multiple treatment cycles of various agents are used (Cytarabine) with
low dosage.
3. Hematopoietic Stem Cell Transplantation (HSCT)
 After finding the suitable tissue match for bone marrow replacement,
high dose of chemotherapy is initiated. Sometimes it is planned in
combination with Radiation therapy.
 When the hematopoietic function of patient’s bone marrow is
destroyed, then Donor stem cells are infused to re-initiate blood cell
production.
 They have the risk of Infection & Graft – versus - host disease.

19. 4. Supportive care
 It is planned when the patient is aged and they have significant
comorbidity like extremely poor cardiac, renal, pulmonary or hepatic
function.
 It includes administration of antileukemia drugs like hydroxyurea or
hypomethylating agents like Azacitidine.
 Antimicrobial therapy and blood transfusion can also be planned as
needed.
 Death occurs frequently within months due to infection or bleeding.

20. CHRONIC MYELOID LEUKEMIA :
It accounts for 15 to 20 % of all cases.
It is seen between 20 & 60 years of age.
It is due to mutation in the myeloid stem cell. There will be
translocation of genetic material between 9 and 22 chromosomes (from
22 to 9).
Philadelphia Chromosome : a chromosome abnormality that causes
chronic myeloid leukemia.
It is associated with benzene exposure and high doses of radiation.

21.  It is developed due to excessive development of mature neoplastic
granulocytes in the bone marrow.
 excessive neoplastic granulocytes in the peripheral blood infiltrate
liver & spleen.
 It has a chronic stable phase, followed by development of more acute,
aggressive phase referred to as blastic phase.

22. It is manifested by :
 Patient may be asymptomatic.
 Leukocytosis (count will exceed 1,00,000/mm3)
 Shortness of breath & confusion
 Fatigue, weakness & fever
 Weight loss
 Joint & bone pain
 Massive, tender splenomegaly
 Increasing number of granulocytes in the peripheral blood
(Accelerated phase)
 Anemia & Thrombocytopenia

23. Diagnostic studies shows that :
• Decreased RBC Count
• High platelet count in the early stage & lower count in later stage
• Low number of monocytes
Medical management includes administration of Tyrosine Kinase
inhibitors. Ex – Imatinib, Dasatinib, Nilotinib
• They work by blocking signals within cells & prevent cells from
growing and dividing.
• Avoid Antacids, Acetaminophen and grape juice as they limit drug
absorption.

24. ACUTE LYMPHOCYTIC LEUKEMIA :
 It results from an uncontrolled proliferation of immature cells or
Lymphoblasts derived from lymphoid stem cell.
 The cell of origin is precursor to the B – Lymphocytes in majority of
cases (75%)
 It is most common in young children : boys are affected more than
girls, with a peak incidence at 4 years of age.
 It is very responsive to treatment.

25. It is manifested by :
 Fever
 Pallor
 Anorexia
 Fatigue & weakness
 Bone & Joint pain
 Lymphadenopathy
 Weight loss
 Abdominal pain due to Hepatosplenomegaly
 Cranial Nerve palsies or Headache.

26. Investigation reveal that
 Increased or decreased leukocyte count.
 Decreased RBC / Hemoglobin count
 Hypercellular bone marrow with lymphoblasts
 Lymphoblasts present in CSF
 Presence of Philadelphia chromosome (It is a specific genetic
abnormality present in chromosome 22 in case of Leukemia cancer
cells)

27.  The goal of treatment is to obtain rapid hematologic recovery.
 Treatment plans are based on genetic markers of disease.
 Treatment protocols tend to be very complex due wide use of
chemotherapeutic agents & complicated administration schedules.
 Corticosteroid (Dexamethasone) is used as it is more toxic to
Lymphoid cells & has better CNS penetration.
 Anthracycline is included with Asparaginase (Elspar).
 Hematopoietic Stem Cell Transplantation (HSCT) is considered if the
testing results suggest risk of relapse.
 Monoclonal Antibodies are selected & being utilized in the context of
Salvage therapy.

28. CHRONIC LYMPHOCYTIC LEUKEMIA :
 It is a most common malignancy seen in older Adults, seen between
the ages of 50 to 70 years.
 A strong familial predisposition exists with this type.
 It is characterized by production & accumulation of functionally
inactive small mature lymphocytes.
 These Lymphocytes infiltrate into bone marrow, spleen & liver.
 It includes enlargement of Lymph node enlargement.

29. PATHOPHYSIOLOGY :
Malignant clone of mature B - Lymphocytes
These cells escape apoptosis (programmed cell death)
Excessive accumulation of cells in bone marrow & circulation
Lymphocytes travel easily in small capillaries & reach lungs and brain
They also accumulate in Lymph nodes & spleen
Rapid aggressive progression of disease

30. It is manifested by :
 Fatigue
 Anorexia
 Drenching sweats (specially at night)
 Unintentional weight loss
 Lymphadenopathy & splenomegaly
 Life threatening infections (Herpes Zoster)
 Second malignancies (skin)

31. Diagnostic studies shows that :
 Mild anemia & Thrombocytopenia as the disease progress.
 Increased Leukocyte count (more than 1,00,000)
 Rise in peripheral lymphocytes.
Complications :
 Autoimmune hemolytic Anemia
 Idiopathic Thrombocytopenic Purpura

32. GENERAL MANAGEMENT :
Chemotherapy :
It is implemented under 2 stages.
1st stage : Induction therapy (initial step to induce remission)
2nd stage : Post Induction or Post Remission chemotherapy.
It includes ;
- Intensification
- Consolidation
- Maintenance therapy.

33. Induction Therapy :
 Here treatment aimed to destroy leukemic cells in the tissues,
peripheral blood & bone marrow.
 It helps to restore normal hematopoiesis.
Drugs involved are :
 Chemotherapeutics – Cytarabine
 Anti Tumor Antibiotics – Daunorubicin , Doxorubicin , Idaribicin

34. Post Induction Chemotherapy :
1. Intensification Therapy
• It begins immediately after induction therapy for several months.
• Medications used in the induction are continued, but at the higher
dosages.
2. Consolidation Therapy
• It is started after remission is achieved.
• It consists of one or two additional courses of same drugs which are
used in induction.
• It eliminate remaining leukemic cells that may or may not be clinically
evident.

35. 3.Maintenance Therapy :
• Treatment with lower dose of same drugs is used.
• Other drugs can be given, but for the period of 3 to 4 weeks.
• In addition to chemotherapy, corticosteroids & radiation therapy can
also be used.
• Cranial radiation is planned if brain involvement is seen.

36. PHARMACOLOGICAL THERAPY
1. Alkylating Agents : Busulfan, Chlorambucil, Cyclophosphamide
2. Anti Tumor Antibiotics : Daunorubicin, Doxorubicin, Mitoxantrone,
Idarubicin
3. Anti Metabolites : Cytarabine, 6-mercaptopurine, Methotrexate,
Fludarabine
4. Corticosteroids : Prednisone, Betamethasone
5. Nitrosoureas : carmustine
6. Mitotic Inhibitors : Vincristine, Vinblastine

37. OTHER TREATMENTS :
1. Biological Therapy : It is used to help the immune system to
recognize and attack leukemia cells.
Ex : Rituximab, Gemtuzumab ozogamicin
2. Targetted Therapy : Here drugs are used that can attack the specific
vulnerabilities with in cancer cells.
Ex: Imatinib
3. Radiation Therapy : It uses X –Ray or other high energy beams to
damage the leukemia cells & to stop their growth.

38. NURSING DIAGNOSIS :
1. Imbalanced Nutrition less than body requirement related to anorexia
& inadequate food intake.
2. Activity Intolerance related to fatigue & weakness.
3. Impaired oral mucous membrane related to low platelet count.
4. Ineffective therapeutic regimen management related to lack of
knowledge regarding on disease process and management.
5. Fatigue & Activity intolerance related to anemia & deconditioning.
6. Anxiety & Grieving due to uncertainity about future & anticipatory
loss.
7. Risk for infection related to bone marrow depression.

39. NURSING INTERVENTIONS :
- Preventing & managing infection.
- Managing mucositis.
- Improving nutritional intake.
- Easing pain & discomfort.
- Decreasing fatigue & activity intolerance.
- Maintaining fluid & electrolyte balance.
- Improving self care : bathing, grooming and toileting.
- Managing anxiety & grief.
- Engaging spiritual well being.
- Promoting home, community based & transitional care.