Sandbox:ab: Difference between revisions

Jump to navigation Jump to search
 
(206 intermediate revisions by 2 users not shown)
Line 1: Line 1:
<div style="width: 1px; height: 1px; background-color: #999999; position: fixed; top: 10px; left: 10px"></div>
<div style="width: 90%; -webkit-user-select: none;">
{| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 5%; background: #A8A8A8; position: fixed; top: 250px; right: 20px; border-radius: 10px 10px 10px 10px;" cellpadding="0" cellspacing="0" ;
|-
! style="padding: 0 5px; font-size: 80%; background: #A8A8A8;" align="center" |{{fontcolor|#2B3B44|Acute leukemia<BR>Resident Survival Guide}}
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Overview|Overview]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Causes|Causes]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#FIRE: Focused Initial Rapid Evaluation|FIRE]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Complete Diagnostic Approach|Diagnosis]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Treatment|Treatment]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Do's|Do's]]
|-
! style="font-size: 80%; padding: 0 5px; background: #DCDCDC; border-radius: 5px 5px 5px 5px;" align="left" |[[{{PAGENAME}}#Don'ts|Don'ts]]
|}
__NOTOC__
__NOTOC__
{{SI}}                                                                  
 
{{CMG}}
{{CMG}}; {{AE}} {{ABehjat}}
 
{{SK}} Acute lymphocytic leukemia, Acute myeloid leukemia, ALL, AML
==Overview==
==Overview==
Acute Leukemia is a malignancy of bone marrow myeloid and lymphoblastic precursor cells, in which these poorly differentiated hematopoietic cells proliferate rapidly. Hence, their accumulation would disrupt the performance of bone marrow to produce normal blood cells
<div align="center"><gallery heights="200" widths="200">
Image:AML_(2).png
Image:ALL2.png
</gallery>
</div>
==Causes==
AML and ALL are life-threatening diseases, which would result in death if left untreated. In the majority of cases, etiology is not apparent.
===Common Causes of AML===
*[[Gene mutations:FLT3, IDHI, IDH2, KRAS, DNMT3A, NPM1]]
*[[Chromosomal translocations, deletions, and inversions]]
*[[ Benzene or radiation exposure chronically]]<ref name="pmid23634996">{{cite journal| author=Cancer Genome Atlas Research Network. Ley TJ, Miller C, Ding L, Raphael BJ, Mungall AJ | display-authors=etal| title=Genomic and epigenomic landscapes of adult de novo acute myeloid leukemia. | journal=N Engl J Med | year= 2013 | volume= 368 | issue= 22 | pages= 2059-74 | pmid=23634996 | doi=10.1056/NEJMoa1301689 | pmc=3767041 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23634996  }} </ref> <ref name="pmid8361504">{{cite journal| author=Thirman MJ, Gill HJ, Burnett RC, Mbangkollo D, McCabe NR, Kobayashi H | display-authors=etal| title=Rearrangement of the MLL gene in acute lymphoblastic and acute myeloid leukemias with 11q23 chromosomal translocations. | journal=N Engl J Med | year= 1993 | volume= 329 | issue= 13 | pages= 909-14 | pmid=8361504 | doi=10.1056/NEJM199309233291302 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8361504  }} </ref>


==Historical Perspective==
*In Italy, for the first time in a 69-year-old patient, who was presented with cardiogenic shock due to COVID-19 infection, myocardial involvement by viral particles was pathologically proved through biopsy. <ref name="TavazziPellegrini2020">{{cite journal|last1=Tavazzi|first1=Guido|last2=Pellegrini|first2=Carlo|last3=Maurelli|first3=Marco|last4=Belliato|first4=Mirko|last5=Sciutti|first5=Fabio|last6=Bottazzi|first6=Andrea|last7=Sepe|first7=Paola Alessandra|last8=Resasco|first8=Tullia|last9=Camporotondo|first9=Rita|last10=Bruno|first10=Raffaele|last11=Baldanti|first11=Fausto|last12=Paolucci|first12=Stefania|last13=Pelenghi|first13=Stefano|last14=Iotti|first14=Giorgio Antonio|last15=Mojoli|first15=Francesco|last16=Arbustini|first16=Eloisa|title=Myocardial localization of coronavirus in COVID‐19 cardiogenic shock|journal=European Journal of Heart Failure|volume=22|issue=5|year=2020|pages=911–915|issn=1388-9842|doi=10.1002/ejhf.1828}}</ref>


==Classification==
===Common Causes of ALL===
There is no specific classification for COVID-19 associated cardiogenic shock.
*[[Radiation exposure]]
For more information regarding general classification, see the [[cardiogenic shock classification]].
*[[Genetic disorders; e.g., Down syndrome, ataxia-telangiectasia, Fanconi anemia]]
*[[Certain infections: e.g., HTLV-1]] <ref name="pmid23523389">{{cite journal| author=Inaba H, Greaves M, Mullighan CG| title=Acute lymphoblastic leukaemia. | journal=Lancet | year= 2013 | volume= 381 | issue= 9881 | pages= 1943-55 | pmid=23523389 | doi=10.1016/S0140-6736(12)62187-4 | pmc=3816716 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23523389  }} </ref>


==Pathophysiology==
==FIRE==
Two mechanisms are more probable to contribute to cardiogenic shock related to Covid-19:
A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.
* Direct invasion of the virus into the cardiomyocytes
* Cytokine storm activated by T helper cells (Th1 and Th2) and trigger a systemic hyperinflammatory response.<ref name="SiddiqiMehra2020">{{cite journal|last1=Siddiqi|first1=Hasan K.|last2=Mehra|first2=Mandeep R.|title=COVID-19 illness in native and immunosuppressed states: A clinical–therapeutic staging proposal|journal=The Journal of Heart and Lung Transplantation|volume=39|issue=5|year=2020|pages=405–407|issn=10532498|doi=10.1016/j.healun.2020.03.012}}</ref> <ref name="YeWang2020">{{cite journal|last1=Ye|first1=Qing|last2=Wang|first2=Bili|last3=Mao|first3=Jianhua|title=The pathogenesis and treatment of the `Cytokine Storm' in COVID-19|journal=Journal of Infection|volume=80|issue=6|year=2020|pages=607–613|issn=01634453|doi=10.1016/j.jinf.2020.03.037}}</ref>


*Focused Initial Rapid Evaluation (FIRE) in AML <ref name="TallmanWang2019">{{cite journal|last1=Tallman|first1=Martin S.|last2=Wang|first2=Eunice S.|last3=Altman|first3=Jessica K.|last4=Appelbaum|first4=Frederick R.|last5=Bhatt|first5=Vijaya Raj|last6=Bixby|first6=Dale|last7=Coutre|first7=Steven E.|last8=De Lima|first8=Marcos|last9=Fathi|first9=Amir T.|last10=Fiorella|first10=Melanie|last11=Foran|first11=James M.|last12=Hall|first12=Aric C.|last13=Jacoby|first13=Meagan|last14=Lancet|first14=Jeffrey|last15=LeBlanc|first15=Thomas W.|last16=Mannis|first16=Gabriel|last17=Marcucci|first17=Guido|last18=Martin|first18=Michael G.|last19=Mims|first19=Alice|last20=O’Donnell|first20=Margaret R.|last21=Olin|first21=Rebecca|last22=Peker|first22=Deniz|last23=Perl|first23=Alexander|last24=Pollyea|first24=Daniel A.|last25=Pratz|first25=Keith|last26=Prebet|first26=Thomas|last27=Ravandi|first27=Farhad|last28=Shami|first28=Paul J.|last29=Stone|first29=Richard M.|last30=Strickland|first30=Stephen A.|last31=Wieduwilt|first31=Matthew|last32=Gregory|first32=Kristina M.|last33=Hammond|first33=Lydia|last34=Ogba|first34=Ndiya|title=Acute Myeloid Leukemia, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology|journal=Journal of the National Comprehensive Cancer Network|volume=17|issue=6|year=2019|pages=721–749|issn=1540-1405|doi=10.6004/jnccn.2019.0028}}</ref><ref>{{cite book | last = Jameson | first = J | title = Harrison's principles of internal medicine | publisher = McGraw-Hill Education | location = New York | year = 2018 | isbn = 978-1259643996 }}</ref>:


==Differentiating COVID-19 associated cardiogenic shock from other Diseases==
{{Family tree/start}}
*[[Cardiogenic shock]] related to COVID-19 must be differentiated from other diseases when hemodynamics not changing, such as:
{{Family tree | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Obtain patient's medical history and focus on these signs and symptoms:''' <br> ❑ [[Fatigue]] <br> ❑ [[Weight loss]] <br> ❑ [[Anorexia]] <br> ❑ [[Bone pain]] <br> ❑ [[Bleeding]]  <br> ❑ [[Early satiety]] <br> ❑ History of specific and chronic exposures such as alkylating agents, benzene, radiation, or previous chemotherapy <br> ❑ [[Headache]] <br> ❑ [[History of recurrent fever]]</div>}}
:* COVID-19 associated distributive shock
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
:* COVID-19 associated hypovolemic shock
{{Family tree | | | | | | | | | | | | | | F01 | | | | | | | | | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> ❑ [[Fever]] <br>  ❑ [[Ecchymosis]] <br>  ❑ [[Lymphadenopathy]] <br>❑ [[Splenomegaly]] <br> ❑ [[Hepatomegaly]]<br> ❑ Mediastinal mass  <br>❑ Abnormalities in cranial nerve examination <br> ❑ [[Skin Petechiae]]<br> ❑ Testicular enlargement < <br>  </div> }}
:* COVID-19 associated mixed (distributive and cardiogenic shock) <ref name="BoukhrisHillani2020">{{cite journal|last1=Boukhris|first1=Marouane|last2=Hillani|first2=Ali|last3=Moroni|first3=Francesco|last4=Annabi|first4=Mohamed Salah|last5=Addad|first5=Faouzi|last6=Ribeiro|first6=Marcelo Harada|last7=Mansour|first7=Samer|last8=Zhao|first8=Xiaohui|last9=Ybarra|first9=Luiz Fernando|last10=Abbate|first10=Antonio|last11=Vilca|first11=Luz Maria|last12=Azzalini|first12=Lorenzo|title=Cardiovascular Implications of the COVID-19 Pandemic: A Global Perspective|journal=Canadian Journal of Cardiology|year=2020|issn=0828282X|doi=10.1016/j.cjca.2020.05.018}}</ref> <ref name="RajagopalKeller2020">{{cite journal|last1=Rajagopal|first1=Keshava|last2=Keller|first2=Steven P.|last3=Akkanti|first3=Bindu|last4=Bime|first4=Christian|last5=Loyalka|first5=Pranav|last6=Cheema|first6=Faisal H.|last7=Zwischenberger|first7=Joseph B.|last8=El Banayosy|first8=Aly|last9=Pappalardo|first9=Federico|last10=Slaughter|first10=Mark S.|last11=Slepian|first11=Marvin J.|title=Advanced Pulmonary and Cardiac Support of COVID-19 Patients|journal=Circulation: Heart Failure|volume=13|issue=5|year=2020|issn=1941-3289|doi=10.1161/CIRCHEARTFAILURE.120.007175}}</ref>
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}


==Epidemiology and Demographics==
{{Family tree | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Hematologic evaluation:'''<br>
* The prevalence of cardiogenic shock-associated COVID-19 has not yet been reported.There are several anecdotal reports of cardiogenic shock related to COVID-19:
❑ [[CBD including platelets and WBCs)]] <br> ❑ [[Uric acid]], [[BUN]], [[Cr]], [[Liver function test]]s, [[bilirubin]],[[Ca]], [[P]], [[Sodium]], [[potassium]], <br> ❑ [[amylase]], and [[lipase]] <br> ❑ [[Lactate dehydrogenase]] <br> ❑ [[PT]], [[PTT]] <br> ❑ [[D-dimer]], [[fibrinogen]] <br>  ❑ [[Viral antibodies]], [[(varicella-zoster]], [[CMV]]), [[HSV-1]] ❑ Peripheral blood smear</div>}}
*  A 69-year-old patient from Italy has been reported by Tavazzi et al., as a cardiogenic shock-associated COVID-19 case. The patient had flu-like symptoms when he was hospitalized and quickly deteriorated into respiratory distress and cardiogenic shock. <ref name="TavazziPellegrini2020">{{cite journal|last1=Tavazzi|first1=Guido|last2=Pellegrini|first2=Carlo|last3=Maurelli|first3=Marco|last4=Belliato|first4=Mirko|last5=Sciutti|first5=Fabio|last6=Bottazzi|first6=Andrea|last7=Sepe|first7=Paola Alessandra|last8=Resasco|first8=Tullia|last9=Camporotondo|first9=Rita|last10=Bruno|first10=Raffaele|last11=Baldanti|first11=Fausto|last12=Paolucci|first12=Stefania|last13=Pelenghi|first13=Stefano|last14=Iotti|first14=Giorgio Antonio|last15=Mojoli|first15=Francesco|last16=Arbustini|first16=Eloisa|title=Myocardial localization of coronavirus in COVID‐19 cardiogenic shock|journal=European Journal of Heart Failure|volume=22|issue=5|year=2020|pages=911–915|issn=1388-9842|doi=10.1002/ejhf.1828}}</ref>
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
*  Four patients with cardiogenic shock complication related to COVID-19 were reported by Sanchez-Recalde, et al. They were hospitalized between 1 March and 15 April 2020 including:
**  A 42-year-old woman, who had dyslipidemia as a cardiovascular risk factor
**  A 50-year-old man, without any cardiovascular risk factors, admitted by severe bilateral pneumonia related to COVID-19. After a few hours, he developed cardiogenic shock.
**  A 75-year-old man did not have any cardiovascular risk factors and was admitted due to dyspnea, chest pain, and bilateral SARS-CoV-2 pneumonia.
** A 37-year-old woman, obese with a history of deep venous thrombosis, had symptoms of dyspnea and chest pain <ref name="Sánchez-RecaldeSolano-López2020">{{cite journal|last1=Sánchez-Recalde|first1=Ángel|last2=Solano-López|first2=Jorge|last3=Miguelena-Hycka|first3=Javier|last4=Martín-Pinacho|first4=Jesús Javier|last5=Sanmartín|first5=Marcelo|last6=Zamorano|first6=José L.|title=COVID-19 and cardiogenic shock. Different cardiovascular presentations with high mortality|journal=Revista Española de Cardiología (English Edition)|year=2020|issn=18855857|doi=10.1016/j.rec.2020.04.012}}</ref>


==Causes==
{{Family tree | | | | | | | | | | | | | | B02 | | | | | | | | | | | | | | | B02= <div style="float: left; text-align: left; line-height: 150% ">'''Radiologic assessment:''' <br> ❑ '''[[CXR]] (PA and lateral)  <br> ❑ [[PET]] or [[CT scan]] (if [[extramedullary disease]] is doubted based on symptoms and physical exam)  <br>  ❑  [[CT]], or [[MRI]], and other  imaging methods to diagnose [[ICH]], [[brain]] or [[spinal cord tumor]]s, and [[leptomeningeal disease]] (if patient presenting notable CNS signs and symptoms <br> </div>}}
The causes of cardiogenic shock related to COVID-19 might include:
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">''' ❑ [[Bone marrow aspiration]] and biopsy <br> </div>}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}
 
*Focused Initial Rapid Evaluation (FIRE) in ALL:<ref name="pmid23523389">{{cite journal| author=Inaba H, Greaves M, Mullighan CG| title=Acute lymphoblastic leukaemia. | journal=Lancet | year= 2013 | volume= 381 | issue= 9881 | pages= 1943-55 | pmid=23523389 | doi=10.1016/S0140-6736(12)62187-4 | pmc=3816716 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23523389  }} </ref> <ref name="pmid31910389">{{cite journal| author=Brown P, Inaba H, Annesley C, Beck J, Colace S, Dallas M | display-authors=etal| title=Pediatric Acute Lymphoblastic Leukemia, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology. | journal=J Natl Compr Canc Netw | year= 2020 | volume= 18 | issue= 1 | pages= 81-112 | pmid=31910389 | doi=10.6004/jnccn.2020.0001 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31910389  }} </ref> <ref name="pmid25060251">{{cite journal| author=Rose-Inman H, Kuehl D| title=Acute leukemia. | journal=Emerg Med Clin North Am | year= 2014 | volume= 32 | issue= 3 | pages= 579-96 | pmid=25060251 | doi=10.1016/j.emc.2014.04.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25060251  }} </ref>
 
{{Family tree/start}}
{{Family tree | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Take a precise medical history and focus on these signs and symptoms:''' <br> ❑ [[Fatigue]] <br>  ❑ [[Anorexia]] <br> ❑ [[Bone and joint pain]] <br> ❑ [[Bleeding]]  <br> ❑ [[Weakness and lethargy]] <br> ❑ History of prior exposures with alkylating agents, radiation, or previous chemotherapy (less prevalent than AML) <br> ❑ [[Headache]] <br> ❑ [[History of bleeding or unexplained bruising]] <br> ❑ History of congenital syndroms <br> ❑ [[Night sweats, weight loss and fever(B symptoms)]] <br>❑ [[Abdominal distention]] <br></div>}}
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | F01 | | | | | | | | | | | | | | |F01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> ❑ [[Fever]] <br> ❑ [[Tachycardia]]<br>  ❑ Mediastinal mass <br>  ❑ [[Lymphadenopathy]] <br>❑ [[Splenomegaly]] <br> ❑ [[Hepatomegaly]]<br> ❑ Abnormalities in cranial nerve examination <br> ❑ [[Skin Petechiae]] <br> ❑Testicular enlargement (rare) <br> </div> }}
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}


* Newly emerging COVID-19 associated myocarditis, cardiac arrhythmias, cardiomyopathy, or an acute coronary syndrome deteriorated into cardiogenic shock
{{Family tree | | | | | | | | | | | | | | B01 | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Hematologic evaluation:'''<br>
* Worsening of previous left ventricular failure due to COVID-19 <ref name="MahajanChandra2020">{{cite journal|last1=Mahajan|first1=Kunal|last2=Chandra|first2=K.Sarat|title=Cardiovascular comorbidities and complications associated with coronavirus disease 2019|journal=Medical Journal Armed Forces India|year=2020|issn=03771237|doi=10.1016/j.mjafi.2020.05.004}}</ref>
❑ [[CBD including platelets and WBCs)]] <br> ❑ [[Uric acid]], [[BUN]], [[Cr]], [[Liver function test]]s, [[bilirubin]] <br> ❑ [[Lactate dehydrogenase]] , potassium, phosphates, and calcium <br> ❑ d-dimer, fibrinogen, PT, and PTT <br> ❑ Peripheral blood smear <br> </div>}}
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}


== Complications and Prognosis==
{{Family tree | | | | | | | | | | | | | | B02 | | | | | | | | | | | | | | | B02= <div style="float: left; text-align: left; line-height: 150% ">'''Radiologic assessment:''' <br> ❑ '''[[CXR]] (PA and lateral) to rule out mediastinal masses  <br>  ❑  Brain CT scan and MRI  with contrast if neurologic signs and symptoms have existed <br> ❑ Scrotal ultrasound for assessing testicular involvement <br> ❑ Echocardiogram or cardiac scan <br>  A whole body PET or CT scan when lymphoblastic lymphoma is doubted </div>}}
According to an observational study in China, COVID-19 associated cardiogenic shock has a poor prognosis. In spite of using Extracorporeal membrane oxygenation (ECMO), 83% of patients died. <ref name="pmid32105632">{{cite journal| author=Yang X, Yu Y, Xu J, Shu H, Xia J, Liu H | display-authors=etal| title=Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. | journal=Lancet Respir Med | year= 2020 | volume= 8 | issue= 5 | pages= 475-481 | pmid=32105632 | doi=10.1016/S2213-2600(20)30079-5 | pmc=7102538 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32105632  }} </ref> <ref name="pmid7274628">{{cite journal| author=Takahashi M, Arai H, Kokubo T, Furukawa F, Kurata Y, Ito N| title=An ultrastructural study of precancerous and cancerous lesions of the pancreas in Syrian golden hamsters induced by N-nitrosobis(2-oxopropyl)amine. | journal=Gan | year= 1980 | volume= 71 | issue= 6 | pages= 825-31 | pmid=7274628 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7274628  }} </ref>
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">''' ❑ [[Bone marrow aspiration]] and biopsy <br> </div>}}
{{Family tree | | | | | | | | | | | | | | |!| | | | | | | | | | | | | | | |}}
{{Family tree | | | | | | | | | | | | | | E01 | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">''' ❑ [[Lumbar puncture]] <br> </div>}}
{{Family tree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree/end}}


== Diagnosis ==
==Diagnosis==
===Diagnostic Criteria===
Diagnostic criteria of acute myeloid leukemia and acute lymphoblastic leukemia are similar to one another.
*The diagnosis of [disease name] is made when at least [number] of the following [number] diagnostic criteria are met:
*According to the 2016 WHO criteria observing ≥20% blasts in the bone marrow biopsy or peripheral blood smear is diagnostic for AML. These genetic abnormalities in AML are diagnostic even with less than 20% marrow blasts: inv(16), t(16;16), t(8;21), and t(15;17).<ref name="pmid10643532">{{cite journal| author=Harris NL, Jaffe ES, Diebold J, Flandrin G, Muller-Hermelink HK, Vardiman J | display-authors=etal| title=The World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues. Report of the Clinical Advisory Committee meeting, Airlie House, Virginia, November, 1997. | journal=Ann Oncol | year= 1999 | volume= 10 | issue= 12 | pages= 1419-32 | pmid=10643532 | doi=10.1023/a:1008375931236 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10643532  }} </ref>
:*[criterion 1]
:*[criterion 2]
:*[criterion 3]
:*[criterion 4]
=== Symptoms ===


The history of patients presented cardiogenic shock related to COVID-19, according to a few anecdotal reports were different. Some did not have any cardiovascular risk factors.
*Presenting ≥20% of leukemic lymphoblasts in bone marrow aspirate and biopsy would prove ALL.<ref name="pmid25408859">{{cite journal| author=Chiaretti S, Zini G, Bassan R| title=Diagnosis and subclassification of acute lymphoblastic leukemia. | journal=Mediterr J Hematol Infect Dis | year= 2014 | volume= 6 | issue= 1 | pages= e2014073 | pmid=25408859 | doi=10.4084/MJHID.2014.073 | pmc=4235437 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25408859  }} </ref>
:*A 69-year-old patient from Italy has been reported by Tavazzi et al., as a cardiogenic shock-associated COVID-19 case. The patient had flu-like symptoms when he was hospitalized and quickly deteriorated into respiratory distress and cardiogenic shock. <ref name="TavazziPellegrini2020">{{cite journal|last1=Tavazzi|first1=Guido|last2=Pellegrini|first2=Carlo|last3=Maurelli|first3=Marco|last4=Belliato|first4=Mirko|last5=Sciutti|first5=Fabio|last6=Bottazzi|first6=Andrea|last7=Sepe|first7=Paola Alessandra|last8=Resasco|first8=Tullia|last9=Camporotondo|first9=Rita|last10=Bruno|first10=Raffaele|last11=Baldanti|first11=Fausto|last12=Paolucci|first12=Stefania|last13=Pelenghi|first13=Stefano|last14=Iotti|first14=Giorgio Antonio|last15=Mojoli|first15=Francesco|last16=Arbustini|first16=Eloisa|title=Myocardial localization of coronavirus in COVID‐19 cardiogenic shock|journal=European Journal of Heart Failure|volume=22|issue=5|year=2020|pages=911–915|issn=1388-9842|doi=10.1002/ejhf.1828}}</ref>
Four patients with cardiogenic shock complication related to COVID-19 were reported by Sanchez-Recalde, et al. They were hospitalized between 1 March and 15 April 2020 including:<ref name="Sánchez-RecaldeSolano-López2020">{{cite journal|last1=Sánchez-Recalde|first1=Ángel|last2=Solano-López|first2=Jorge|last3=Miguelena-Hycka|first3=Javier|last4=Martín-Pinacho|first4=Jesús Javier|last5=Sanmartín|first5=Marcelo|last6=Zamorano|first6=José L.|title=COVID-19 and cardiogenic shock. Different cardiovascular presentations with high mortality|journal=Revista Española de Cardiología (English Edition)|year=2020|issn=18855857|doi=10.1016/j.rec.2020.04.012}}</ref>


:*A 42-year-old woman, who had dyslipidemia as a cardiovascular risk factor
==Treatment==
:*A 50-year-old man, without any cardiovascular risk factors, admitted by severe bilateral pneumonia related to COVID-19. After a few hours, he developed cardiogenic shock.
:*A 75-year-old man did not have any cardiovascular risk factors and was admitted due to dyspnea, chest pain, and bilateral SARS-CoV-2 pneumonia.
:*A 37-year-old woman, obese with a history of deep venous thrombosis, had symptoms of dyspnea and chest pain


=== Physical Examination ===
{{familytree/start |summary=Sample 6}}
*When Systolic Blood Pressure is lower than 90 mmHg for more than 15 minutes with impaired organ perfusion while Urine output is less than 30 m/hr in a COVID-19 patient cardiogenic shock should be considered.<ref name="DhakalSweitzer2020">{{cite journal|last1=Dhakal|first1=Bishnu P.|last2=Sweitzer|first2=Nancy K.|last3=Indik|first3=Julia H.|last4=Acharya|first4=Deepak|last5=William|first5=Preethi|title=SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart|journal=Heart, Lung and Circulation|year=2020|issn=14439506|doi=10.1016/j.hlc.2020.05.101}}</ref>
{{familytree | | | | | | | | | | | | | | | | | | A01 |A01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treatment of a patient with definitive AML'''<ref name="pmid26376137">{{cite journal| author=Döhner H, Weisdorf DJ, Bloomfield CD| title=Acute Myeloid Leukemia. | journal=N Engl J Med | year= 2015 | volume= 373 | issue= 12 | pages= 1136-52 | pmid=26376137 | doi=10.1056/NEJMra1406184 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26376137  }} </ref> <ref name="pmid27895058">{{cite journal| author=Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T | display-authors=etal| title=Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. | journal=Blood | year= 2017 | volume= 129 | issue= 4 | pages= 424-447 | pmid=27895058 | doi=10.1182/blood-2016-08-733196 | pmc=5291965 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27895058  }} </ref> <ref>{{cite book | last = Jameson | first = J | title = Harrison's principles of internal medicine | publisher = McGraw-Hill Education | location = New York | year = 2018 | isbn = 978-1259643996 }}</ref>  
</div>}}
{{familytree | | | | | | | | | |,|-|-|-|-|-|-|-|-|^|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|-|.| | | }}
{{familytree | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | B02 | |B01=<div style="float: left; text-align: left; width: 25em; padding:1em;">'''Treating for the first time(new case)''' </div>|B02= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Cases with relapsed/refractory AML''' </div>}}
{{familytree  | |,|-|-|-|-|-|-|-|+|-|-|-|-|-|-|-|-|-|-|.| | | | | | | | | | | | | | | | | |!| | }}
{{familytree  | C01 | | | | | | C02 | | | | | | | | | C03 | | | | | | | | | | | | | | | | C04 |C01= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Favorable-Risk Cytogenetics''' </div>|C02= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Intermediate-Risk Cytogenetics''' </div>
|C03= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Poor-Risk Cytogenetics|C04= <div style="float: left; text-align: left; width: 25em; padding:1em;">'''Salvage therapy''' </div>}}
{{familytree | |!| | | | | | | |!| | | | | | | | | | |!| | | | |!| | | | | | | | | | | | |!| | }}
{{familytree | D01 | | | | | | D02 | | | | | | | | | D03 | | | | | | | | | | | | | | | | D04 | |D01= Select one of these therapies: <br> ❑ 1. Induction treatment: Cytarabine-based regimen + Daunorubicin. If a complete remission is achieved, postremission consolidation therapy as maintenance should be started: intermediate  dose of Cytarabine) <br> ❑ 2.Investigational drugs(clinical trial): for cases aged younger than 60 years, a standard chemotherapy regimen including a backbone of Cytarabine + Anthracycline has been recommended. After complete remission, postremission therapy have to be regarded.
|D02=Select one of these treatments: <br>
❑ 1. Investigational therapy: for patients older than 65 or have more comorbidities and high-risk illnesses or cases who cannot tolerate Cytarabine-based regimen + Daunorubicin, changing their regiments to an investigational therapy could be regarded. (administrate one chemotherapy drug or combine their treatment with non-intensive medications fitting with the patient such as decitabine, azacitidine). After complete remission, postremission therapy have to be regarded.<br> ❑ 2. Induction treatment: Cytarabine-based regimen + Daunorubicin (could be suitable for young and elderly patients). If complete remission(CR) is achieved, postremission consolidation therapy as maintenance should be started to prevent relapse, including: <br>
:*  Allogenic hematopoietic cell transplantation, which is the preferred treatment, or <br>
:*  If the patient is younger than 60 years autologous hematopoietic cell  transplantation is recommended, or <br> 
:*  Intermediate  dose of Cytarabine
||D03= Select one of these therapies:<br> 1. Induction treatment: Cytarabine-based regimen + Daunorubicin (could be suitable for both young and elderly patients). After complete remission(CR) achieved, postremission consolidation therapy should be started to prevent relapse, including Allogenic hematopoietic cell transplantation, which is the preferred treatment. When there is not any accessible HLA-matched donor, using an alternate donor has been recommended. <br> 2. Investigational therapy: for patients older than 65 or have more comorbidities and high-risk illnesses or cases who cannot tolerate Cytarabine-based regimen + Daunorubicin, changing their regiments to an investigational therapy could be regarded. (administrate one chemotherapy drug or combine their treatment with non-intensive medications fitting with the patient such as decitabine, azacitidine). After complete remission, postremission therapy has to be regarded.<br> |D04=Patients with relapsed and refractory AML who has an HLA-matched donor accessible for allogenic HCT or cases who attained second complete remission after salvage therapy while there is an available appropriate donor should undergo allogenic hematopoietic cell  transplantation. Those who do not have these conditions have to be treated based on clinical trials (investigational therapy).  }}
{{familytree/end}}


*Physical examination may be remarkable for Covid-19 associated cardiogenic shock:<ref>{{cite book | last = Tse | first = FirstName | title = Oxford Desk Reference : Cardiology | publisher = OUP Oxford | location = Oxford | year = 2011 | isbn = 978-0-19-956809-3 }} </ref>
:* Assessment of consciousness level
:* Extremities whether they are warm or cool is helpful for evaluation of cardiogenic shock
:* Vital signs (tachycardia and hypotension and tachypnea)
:* Evaluation of volume status: CVP (increased JVP), edema
:* Skin pallor


=== Laboratory Findings ===
Treatment of acute lymphoblastic leukemia includes three phases:<ref name="pmid21220592">{{cite journal| author=Bassan R, Hoelzer D| title=Modern therapy of acute lymphoblastic leukemia. | journal=J Clin Oncol | year= 2011 | volume= 29 | issue= 5 | pages= 532-43 | pmid=21220592 | doi=10.1200/JCO.2010.30.1382 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21220592  }} </ref>
*In COVID-19 patients, it is essential to differentiate the shock types. Two tests are more valuable to clarify this, which are elevated in cardiogenic shock related to COVID-19 :
:*serum brain natriuretic peptide (BNP)
:*Troponin


*
:*Induction therapy, i.e., prednisolone, vincristine, cytarabine <br>
:*Administrating Central Nervous System prophylaxis, i.e., methotrexate
:*Chemotherapy as a maintenance treatment for two years
:*Stem cell transplantation in adults who are eligible while there is a suitable donor


===Imaging Findings===
==Do's==
*There are no [imaging study] findings associated with [disease name].
:* Before starting the therapy, taking a precise history and physical examination have to be done to diagnose any kind of comorbidities ,i.e. heart failure or renal diseases that affect the prognosis and treatment choices.
*[Imaging study 1] is the imaging modality of choice for [disease name].
*On [imaging study 1], [disease name] is characterized by [finding 1], [finding 2], and [finding 3].
*[Imaging study 2] may demonstrate [finding 1], [finding 2], and [finding 3].
=== Other Diagnostic Studies ===
*[Disease name] may also be diagnosed using [diagnostic study name].
*Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].


== Treatment ==
:*HLA-typing evaluation have to be done for all of the AML cases In the pretreatment assessment.
=== Medical Therapy ===
:*Seven days after the induction phase of chemotherapy ended, bone marrow biopsy must be done in order to assess the remission situation.
*There is no treatment for [disease name]; the mainstay of therapy is supportive care.
:* In the induction chemotherapy process of AML for most of the cases, cytarabine IV infusion should be administrated for seven days consecutively + anthracycline on days one to three.(known as "7+3" regimens)<ref name="pmidhttps://pubmed.ncbi.nlm.nih.gov/9045305">{{cite journal| author=Bishop JF| title=The treatment of adult acute myeloid leukemia. | journal=Semin Oncol | year= 1997 | volume= 24 | issue= 1 | pages= 57-69 | pmid=https://pubmed.ncbi.nlm.nih.gov/9045305 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9045305 }} </ref> <ref name="TallmanWang2019">{{cite journal|last1=Tallman|first1=Martin S.|last2=Wang|first2=Eunice S.|last3=Altman|first3=Jessica K.|last4=Appelbaum|first4=Frederick R.|last5=Bhatt|first5=Vijaya Raj|last6=Bixby|first6=Dale|last7=Coutre|first7=Steven E.|last8=De Lima|first8=Marcos|last9=Fathi|first9=Amir T.|last10=Fiorella|first10=Melanie|last11=Foran|first11=James M.|last12=Hall|first12=Aric C.|last13=Jacoby|first13=Meagan|last14=Lancet|first14=Jeffrey|last15=LeBlanc|first15=Thomas W.|last16=Mannis|first16=Gabriel|last17=Marcucci|first17=Guido|last18=Martin|first18=Michael G.|last19=Mims|first19=Alice|last20=O’Donnell|first20=Margaret R.|last21=Olin|first21=Rebecca|last22=Peker|first22=Deniz|last23=Perl|first23=Alexander|last24=Pollyea|first24=Daniel A.|last25=Pratz|first25=Keith|last26=Prebet|first26=Thomas|last27=Ravandi|first27=Farhad|last28=Shami|first28=Paul J.|last29=Stone|first29=Richard M.|last30=Strickland|first30=Stephen A.|last31=Wieduwilt|first31=Matthew|last32=Gregory|first32=Kristina M.|last33=Hammond|first33=Lydia|last34=Ogba|first34=Ndiya|title=Acute Myeloid Leukemia, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology|journal=Journal of the National Comprehensive Cancer Network|volume=17|issue=6|year=2019|pages=721–749|issn=1540-1405|doi=10.6004/jnccn.2019.0028}}</ref>
*The mainstay of therapy for [disease name] is [medical therapy 1] and [medical therapy 2].
*[Medical therapy 1] acts by [mechanism of action 1].
*Response to [medical therapy 1] can be monitored with [test/physical finding/imaging] every [frequency/duration].
   
=== Surgery ===
*Surgery is the mainstay of therapy for [disease name].
*[Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
*[Surgical procedure] can only be performed for patients with [disease stage] [disease name].
=== Prevention ===
*There are no primary preventive measures available for [disease name].
*Effective measures for the primary prevention of [disease name] include [measure1], [measure2], and [measure3].


*Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].
==Don'ts==
:*If the patient with AML has a coagulopathy disorder and is susceptible to bleeding, do not have to undergo lumbar puncture in the workup process before correcting that.
:*Without the assessment of cardiac symptoms and echocardiogram, chemotherapy medications which are cardiotoxic should not be administrated. <ref name="TallmanWang2019">{{cite journal|last1=Tallman|first1=Martin S.|last2=Wang|first2=Eunice S.|last3=Altman|first3=Jessica K.|last4=Appelbaum|first4=Frederick R.|last5=Bhatt|first5=Vijaya Raj|last6=Bixby|first6=Dale|last7=Coutre|first7=Steven E.|last8=De Lima|first8=Marcos|last9=Fathi|first9=Amir T.|last10=Fiorella|first10=Melanie|last11=Foran|first11=James M.|last12=Hall|first12=Aric C.|last13=Jacoby|first13=Meagan|last14=Lancet|first14=Jeffrey|last15=LeBlanc|first15=Thomas W.|last16=Mannis|first16=Gabriel|last17=Marcucci|first17=Guido|last18=Martin|first18=Michael G.|last19=Mims|first19=Alice|last20=O’Donnell|first20=Margaret R.|last21=Olin|first21=Rebecca|last22=Peker|first22=Deniz|last23=Perl|first23=Alexander|last24=Pollyea|first24=Daniel A.|last25=Pratz|first25=Keith|last26=Prebet|first26=Thomas|last27=Ravandi|first27=Farhad|last28=Shami|first28=Paul J.|last29=Stone|first29=Richard M.|last30=Strickland|first30=Stephen A.|last31=Wieduwilt|first31=Matthew|last32=Gregory|first32=Kristina M.|last33=Hammond|first33=Lydia|last34=Ogba|first34=Ndiya|title=Acute Myeloid Leukemia, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology|journal=Journal of the National Comprehensive Cancer Network|volume=17|issue=6|year=2019|pages=721–749|issn=1540-1405|doi=10.6004/jnccn.2019.0028}}</ref>


==References==
==References==
{{Reflist|2}}
[[Category:Pick One of 28 Approved]]


{{WS}}
{{reflist|2}}
{{WH}}
 
[[Category:Disease]]
[[Category:Oncology]]
[[Category:Medicine]]
[[Category:Resident survival guide]]

Latest revision as of 19:00, 3 November 2020

Acute leukemia
Resident Survival Guide
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alieh Behjat, M.D.[2]

Synonyms and keywords: Acute lymphocytic leukemia, Acute myeloid leukemia, ALL, AML

Overview

Acute Leukemia is a malignancy of bone marrow myeloid and lymphoblastic precursor cells, in which these poorly differentiated hematopoietic cells proliferate rapidly. Hence, their accumulation would disrupt the performance of bone marrow to produce normal blood cells

Causes

AML and ALL are life-threatening diseases, which would result in death if left untreated. In the majority of cases, etiology is not apparent.

Common Causes of AML


Common Causes of ALL

FIRE

A Focused Initial Rapid Evaluation (FIRE) should be performed to identify patients in need of immediate intervention.

  • Focused Initial Rapid Evaluation (FIRE) in AML [4][5]:
 
 
 
 
 
 
 
 
 
 
 
 
 
Obtain patient's medical history and focus on these signs and symptoms:
Fatigue
Weight loss
Anorexia
Bone pain
Bleeding
Early satiety
❑ History of specific and chronic exposures such as alkylating agents, benzene, radiation, or previous chemotherapy
Headache
History of recurrent fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Fever
Ecchymosis
Lymphadenopathy
Splenomegaly
Hepatomegaly
❑ Mediastinal mass
❑ Abnormalities in cranial nerve examination
Skin Petechiae
❑ Testicular enlargement <
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Radiologic assessment:
CXR (PA and lateral)
PET or CT scan (if extramedullary disease is doubted based on symptoms and physical exam)
CT, or MRI, and other imaging methods to diagnose ICH, brain or spinal cord tumors, and leptomeningeal disease (if patient presenting notable CNS signs and symptoms
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bone marrow aspiration and biopsy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  • Focused Initial Rapid Evaluation (FIRE) in ALL:[3] [6] [7]
 
 
 
 
 
 
 
 
 
 
 
 
 
Take a precise medical history and focus on these signs and symptoms:
Fatigue
Anorexia
Bone and joint pain
Bleeding
Weakness and lethargy
❑ History of prior exposures with alkylating agents, radiation, or previous chemotherapy (less prevalent than AML)
Headache
History of bleeding or unexplained bruising
❑ History of congenital syndroms
Night sweats, weight loss and fever(B symptoms)
Abdominal distention
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Fever
Tachycardia
❑ Mediastinal mass
Lymphadenopathy
Splenomegaly
Hepatomegaly
❑ Abnormalities in cranial nerve examination
Skin Petechiae
❑Testicular enlargement (rare)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Hematologic evaluation:
CBD including platelets and WBCs)
Uric acid, BUN, Cr, Liver function tests, bilirubin
Lactate dehydrogenase , potassium, phosphates, and calcium
❑ d-dimer, fibrinogen, PT, and PTT
❑ Peripheral blood smear
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Radiologic assessment:
CXR (PA and lateral) to rule out mediastinal masses
❑ Brain CT scan and MRI with contrast if neurologic signs and symptoms have existed
❑ Scrotal ultrasound for assessing testicular involvement
❑ Echocardiogram or cardiac scan
A whole body PET or CT scan when lymphoblastic lymphoma is doubted
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bone marrow aspiration and biopsy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Diagnosis

Diagnostic criteria of acute myeloid leukemia and acute lymphoblastic leukemia are similar to one another.

  • According to the 2016 WHO criteria observing ≥20% blasts in the bone marrow biopsy or peripheral blood smear is diagnostic for AML. These genetic abnormalities in AML are diagnostic even with less than 20% marrow blasts: inv(16), t(16;16), t(8;21), and t(15;17).[8]
  • Presenting ≥20% of leukemic lymphoblasts in bone marrow aspirate and biopsy would prove ALL.[9]

Treatment

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treatment of a patient with definitive AML[10] [11] [12]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treating for the first time(new case)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cases with relapsed/refractory AML
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Favorable-Risk Cytogenetics
 
 
 
 
 
Intermediate-Risk Cytogenetics
 
 
 
 
 
 
 
 
Poor-Risk Cytogenetics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Salvage therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Select one of these therapies:
❑ 1. Induction treatment: Cytarabine-based regimen + Daunorubicin. If a complete remission is achieved, postremission consolidation therapy as maintenance should be started: intermediate dose of Cytarabine)
❑ 2.Investigational drugs(clinical trial): for cases aged younger than 60 years, a standard chemotherapy regimen including a backbone of Cytarabine + Anthracycline has been recommended. After complete remission, postremission therapy have to be regarded.
 
 
 
 
 
Select one of these treatments:

❑ 1. Investigational therapy: for patients older than 65 or have more comorbidities and high-risk illnesses or cases who cannot tolerate Cytarabine-based regimen + Daunorubicin, changing their regiments to an investigational therapy could be regarded. (administrate one chemotherapy drug or combine their treatment with non-intensive medications fitting with the patient such as decitabine, azacitidine). After complete remission, postremission therapy have to be regarded.
❑ 2. Induction treatment: Cytarabine-based regimen + Daunorubicin (could be suitable for young and elderly patients). If complete remission(CR) is achieved, postremission consolidation therapy as maintenance should be started to prevent relapse, including:

  • Allogenic hematopoietic cell transplantation, which is the preferred treatment, or
  • If the patient is younger than 60 years autologous hematopoietic cell transplantation is recommended, or
  • Intermediate dose of Cytarabine
 
 
 
 
 
 
 
 
Select one of these therapies:
1. Induction treatment: Cytarabine-based regimen + Daunorubicin (could be suitable for both young and elderly patients). After complete remission(CR) achieved, postremission consolidation therapy should be started to prevent relapse, including Allogenic hematopoietic cell transplantation, which is the preferred treatment. When there is not any accessible HLA-matched donor, using an alternate donor has been recommended.
2. Investigational therapy: for patients older than 65 or have more comorbidities and high-risk illnesses or cases who cannot tolerate Cytarabine-based regimen + Daunorubicin, changing their regiments to an investigational therapy could be regarded. (administrate one chemotherapy drug or combine their treatment with non-intensive medications fitting with the patient such as decitabine, azacitidine). After complete remission, postremission therapy has to be regarded.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patients with relapsed and refractory AML who has an HLA-matched donor accessible for allogenic HCT or cases who attained second complete remission after salvage therapy while there is an available appropriate donor should undergo allogenic hematopoietic cell transplantation. Those who do not have these conditions have to be treated based on clinical trials (investigational therapy).
 


Treatment of acute lymphoblastic leukemia includes three phases:[13]

  • Induction therapy, i.e., prednisolone, vincristine, cytarabine
  • Administrating Central Nervous System prophylaxis, i.e., methotrexate
  • Chemotherapy as a maintenance treatment for two years
  • Stem cell transplantation in adults who are eligible while there is a suitable donor

Do's

  • Before starting the therapy, taking a precise history and physical examination have to be done to diagnose any kind of comorbidities ,i.e. heart failure or renal diseases that affect the prognosis and treatment choices.
  • HLA-typing evaluation have to be done for all of the AML cases In the pretreatment assessment.
  • Seven days after the induction phase of chemotherapy ended, bone marrow biopsy must be done in order to assess the remission situation.
  • In the induction chemotherapy process of AML for most of the cases, cytarabine IV infusion should be administrated for seven days consecutively + anthracycline on days one to three.(known as "7+3" regimens)[14] [4]

Don'ts

  • If the patient with AML has a coagulopathy disorder and is susceptible to bleeding, do not have to undergo lumbar puncture in the workup process before correcting that.
  • Without the assessment of cardiac symptoms and echocardiogram, chemotherapy medications which are cardiotoxic should not be administrated. [4]

References

  1. Cancer Genome Atlas Research Network. Ley TJ, Miller C, Ding L, Raphael BJ, Mungall AJ; et al. (2013). "Genomic and epigenomic landscapes of adult de novo acute myeloid leukemia". N Engl J Med. 368 (22): 2059–74. doi:10.1056/NEJMoa1301689. PMC 3767041. PMID 23634996.
  2. Thirman MJ, Gill HJ, Burnett RC, Mbangkollo D, McCabe NR, Kobayashi H; et al. (1993). "Rearrangement of the MLL gene in acute lymphoblastic and acute myeloid leukemias with 11q23 chromosomal translocations". N Engl J Med. 329 (13): 909–14. doi:10.1056/NEJM199309233291302. PMID 8361504.
  3. 3.0 3.1 Inaba H, Greaves M, Mullighan CG (2013). "Acute lymphoblastic leukaemia". Lancet. 381 (9881): 1943–55. doi:10.1016/S0140-6736(12)62187-4. PMC 3816716. PMID 23523389.
  4. 4.0 4.1 4.2 Tallman, Martin S.; Wang, Eunice S.; Altman, Jessica K.; Appelbaum, Frederick R.; Bhatt, Vijaya Raj; Bixby, Dale; Coutre, Steven E.; De Lima, Marcos; Fathi, Amir T.; Fiorella, Melanie; Foran, James M.; Hall, Aric C.; Jacoby, Meagan; Lancet, Jeffrey; LeBlanc, Thomas W.; Mannis, Gabriel; Marcucci, Guido; Martin, Michael G.; Mims, Alice; O’Donnell, Margaret R.; Olin, Rebecca; Peker, Deniz; Perl, Alexander; Pollyea, Daniel A.; Pratz, Keith; Prebet, Thomas; Ravandi, Farhad; Shami, Paul J.; Stone, Richard M.; Strickland, Stephen A.; Wieduwilt, Matthew; Gregory, Kristina M.; Hammond, Lydia; Ogba, Ndiya (2019). "Acute Myeloid Leukemia, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology". Journal of the National Comprehensive Cancer Network. 17 (6): 721–749. doi:10.6004/jnccn.2019.0028. ISSN 1540-1405.
  5. Jameson, J (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. ISBN 978-1259643996.
  6. Brown P, Inaba H, Annesley C, Beck J, Colace S, Dallas M; et al. (2020). "Pediatric Acute Lymphoblastic Leukemia, Version 2.2020, NCCN Clinical Practice Guidelines in Oncology". J Natl Compr Canc Netw. 18 (1): 81–112. doi:10.6004/jnccn.2020.0001. PMID 31910389.
  7. Rose-Inman H, Kuehl D (2014). "Acute leukemia". Emerg Med Clin North Am. 32 (3): 579–96. doi:10.1016/j.emc.2014.04.004. PMID 25060251.
  8. Harris NL, Jaffe ES, Diebold J, Flandrin G, Muller-Hermelink HK, Vardiman J; et al. (1999). "The World Health Organization classification of neoplastic diseases of the hematopoietic and lymphoid tissues. Report of the Clinical Advisory Committee meeting, Airlie House, Virginia, November, 1997". Ann Oncol. 10 (12): 1419–32. doi:10.1023/a:1008375931236. PMID 10643532.
  9. Chiaretti S, Zini G, Bassan R (2014). "Diagnosis and subclassification of acute lymphoblastic leukemia". Mediterr J Hematol Infect Dis. 6 (1): e2014073. doi:10.4084/MJHID.2014.073. PMC 4235437. PMID 25408859.
  10. Döhner H, Weisdorf DJ, Bloomfield CD (2015). "Acute Myeloid Leukemia". N Engl J Med. 373 (12): 1136–52. doi:10.1056/NEJMra1406184. PMID 26376137.
  11. Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T; et al. (2017). "Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel". Blood. 129 (4): 424–447. doi:10.1182/blood-2016-08-733196. PMC 5291965. PMID 27895058.
  12. Jameson, J (2018). Harrison's principles of internal medicine. New York: McGraw-Hill Education. ISBN 978-1259643996.
  13. Bassan R, Hoelzer D (2011). "Modern therapy of acute lymphoblastic leukemia". J Clin Oncol. 29 (5): 532–43. doi:10.1200/JCO.2010.30.1382. PMID 21220592.
  14. Bishop JF (1997). "The treatment of adult acute myeloid leukemia". Semin Oncol. 24 (1): 57–69. PMID https://pubmed.ncbi.nlm.nih.gov/9045305 Check |pmid= value (help).