Acute Lymphoblastic Leukemia ALL Treatment,Patient Workup Monitoring

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ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)

Related topics

ALL Diagnosis and Prognostic Features

Relapse Management,Radiation Therapy and Precautions

Dr Ira Shah
M.D, DCH(Gold Medalist), FCPS, DNB
Edited by Dr. Bharat R Agarwal
Consultant Pediatric Hematologist and Oncologist.

Q.How do you work-up a patient of ALL?

A. The essential laboratory work up is :

Hb, total and differential WBC count
Bone marrow aspirate
Chest-X ray (mediastinal mass)
Uric acid and electrolytes: Na, K, Ca, PO4
LDN/ Renal function tests/ Liver function tests
Diagnostic lumbar puncture.

Q. What is the treatment of ALL?

A. Successful treatment of children with ALL requires the control of systemic disease (marrow, liver, spleen, lymph nodes etc) as well as the treatment (or prevention) of extramedullary disease in sanctuary sites like the CNS and the testicular region.

Only 3% of patients have detectable CNS involvement at diagnosis (>, 5 WBC/ cu mm with presence of lymphoblasts), however, unless specific therapy is directed toward the CNS, 50% or more children will eventually develop overt CNS leukemia. Hence, all children with ALL should receive some form of CNS prophylaxis.

Treatment of ALL is divided into stages :-

Remission induction
Consolidation or intensification
Maintenance therapy.

CNS sanctuary therapy is given at each stage.

Induction chemotherapy - Three- drug induction therapy using vincristine. Prednisolone/ dexamethasone, L-asparaginase in conjunction with intrathecal therapy results in complete remission rate of greater than 95%. For patients with high risk , an anthracycline (daunorubicin) may be included. The aim of induction phase is to induce remission. In general, patients will achieve complete remission within the first 4 weeks. Patients who require more than 4 weeks to achieve remission or those who demonstrate more than 25% blasts in the bone marrow or have persistent blasts in the peripheral blood after 1 week of intensive induction therapy have a poor prognosis. (A bone marrow is done at the end of induction to establish remission status)

CNS Prophylaxis - Intrathecal (IT)

Chemotherapy with IT methotrexate with or without systemic methorexate is used for CNS prophylaxis. For patients at high risk of CNS relapse (e.g. age> 10 years, presence of hyperleukocytosis or T cell ALL), use of cranial irradiation is controversial.

Consolidation / Intensification - It is given to consolidate the remission achieved during induction phase. It may involve the use of intermediate or high dose methotrexate, same drugs as used in induction, other drug combinations, extended use of high dose L-asparaginase or combinations of above.

Maintenance - Most protocols include daily oral mercaptopurine and weekly oral methotrexate. If the patient has not had cranial irradiation, intrathecal chemotherapy for CNS prophylaxis is continued in the maintenance phase.

Monthly pulses of vincristine and prednisolone/ dexamethasone are often added to the standard maintenance regimen. Maintenance chemotherapy is generally given for 2 to 3 years to achieve complete remission.

Q. How do you monitor a patient during maintenance?

A. During this period, it is important to monitor and maintain the WBC count (ANC) between 1000 to 1500 or as mentioned in the protocol sheet. It is also important to monitor for clinical signs of relapse like persistent unexplained fever, hepatosplenomegaly, lymphadenopathy, testicular enlargement or new CNS deficits as well as suspicious peripheral blood values.

Next : Relapse Management,Radiation Therapy and Precautions

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