Subject:

leukemia
Professor:
Ia marashkhia
Researcher:
ALIREZA FARHADIYEH (1701940)
What is leukemia? What are the different types of
leukemia?
Leukemia is a malignancy (cancer) of blood cells. In leukemia, abnormal blood
cells are produced in the bone marrow. Usually, leukemia involves the production
of abnormal white blood cells -- the cells responsible for fighting infection.
However, the abnormal cells in leukemia do not function in the same way as
normal white blood cells. The leukemia cells continue to grow and divide,
eventually crowding out the normal blood cells. The end result is that it becomes
difficult for the body to fight infections, control bleeding, and transport oxygen.

There are different types of leukemia, based upon how quickly the disease
develops and the type of abnormal cells produced. Leukemia is called an acute
leukemia if it develops rapidly. Large numbers of leukemia cells accumulate very
quickly in the blood and bone marrow, leading to symptoms such
as tiredness, easy bruising, and susceptibility to infections. Acute leukemia
requires fast and aggressive treatment.

There are around 60,000 new cases of leukemia each year in the U.S. and over
24,000 deaths due to leukemia. Leukemia makes up about 3.7% of all new
cancer cases.

Chronic leukemias develop slowly over time. These leukemias may not cause
specific symptoms at the beginning of their course. If left untreated, the cells may
eventually grow to high numbers, as in acute leukemias causing similar
symptoms.

Leukemias are further classified as myeloid or lymphoid, depending upon the

type of white blood cell that makes up the leukemia cells. A basic understanding
of the normal development of blood cells is needed to understand the different
types of leukemia. Normal blood cells develop from stem cells that have the
potential to become many cell types. Myeloid stem cells mature in the bone
marrow and become immature white cells called myeloid blasts. These myeloid
blasts further mature to become either red blood cells, platelets, or certain kinds
of white blood cells. Lymphoid stem cells mature in the bone marrow to become
lymphoid blasts. The lymphoid blasts develop further into T or B lymphocytes (T-
cells or B-cells), special types of white blood cells. Myeloid or myelogenous
leukemias are made up of cells that arise from myeloid cells, while lymphoid
leukemias arise from lymphoid cells. Knowing the type of cell involved in
leukemia is important in choosing the appropriate treatment.

Common types of leukemia

 Acute lymphocytic leukemia (ALL, also known as acute lymphoblastic

leukemia) is the most common type of leukemia in children, but it can also
affect adults. In this type of leukemia, immature lymphoid cells grow rapidly
in the blood. It affects almost 6,000 people per year in the U.S.
 Acute myeloid leukemia (AML, also called acute myelogenous leukemia)
involves the rapid growth of myeloid cells. It occurs in both adults and
children and affects about 19,500 people each year in the U.S.
 Chronic lymphocytic leukemia (CLL) is a slow-growing cancer of lymphoid
cells that usually affects people over 55 years of age. It is estimated to
affect about 21,000 people in the U.S. every year. It almost never occurs in
children or adolescents.
  Chronic myeloid leukemia (CML, also known as chronic myelogenous
leukemia) is a type of chronic myeloproliferative disorder that primarily
affects adults and occurs in about 8,400 people every year in the U.S.

Less common types of leukemia account for about 6,000 cases of leukemia each
year in the U.S.

 Hairy cell leukemia is an uncommon type of chronic leukemia.

 Chronic myelomonocytic leukemia (CMML) is another type of chronic
leukemia that develops from myeloid cells.
 Juvenile myelomonocytic leukemia (JMML) is a type of myeloid leukemia
that usually occurs in children under 6 years of age.
 Large granular lymphocytic leukemia (LGL leukemia) is a type of chronic
leukemia that develops from lymphoid cells. It can be slow- or fast-
growing.
 Acute promyelocytic leukemia (APL) is a subtype of AML.

What are leukemia risk factors?

Exposure to radiation is known to increase the risk of developing AML, CML, or
ALL. Increases in leukemia were observed in people surviving atomic bombs.
Radiation therapy for cancer can also increase the risk of leukemia. Exposure to
certain chemicals, including benzene (used commonly in the chemical industry),
increases the risk of leukemia. Cigarette smoking is known to increase the risk of
developing AML.
Certain genetic disorders can increase the risk; Down syndrome, Li-Fraumeni
syndrome, and other medical conditions can increase the risk of developing
leukemia. Blood disorders known as myelodysplastic syndromes confer an
increased risk of developing AML. Human T-cell leukemia virus type 1 (HTLV-1)
is a virus that causes a rare type of leukemia. Certain chemotherapy drugs for
cancer can increase the risk for AML or ALL.

Having risk factors does not mean that a person will definitely get leukemia, and
most people with risk factors will not develop the disease. Likewise, not everyone
who develops leukemia has an identifiable risk factor.

What are leukemia symptoms and signs?

The symptoms and signs of leukemia depend upon the type of leukemia. As
stated earlier, slow-growing or chronic leukemia may not cause any symptoms at
the outset, while aggressive or rapidly growing leukemia may lead to severe
symptoms. The symptoms of leukemia arise from a loss of function of the normal
blood cells or from accumulation of the abnormal cells in the body.

Signs and symptoms of leukemia typically include the following:

 Fevers
 Night sweats
 Swollen lymph nodes that are usually painless
 Feelings of fatigue, tiredness
 Easy bleeding or bruising, causing bluish or purplish patches on the skin or
tiny red spots on the skin, or recurring nosebleeds
  Frequent infections
 Bone or joint pain
 Weight loss that is unintentional and otherwise unexplained, or loss of
appetite
 Enlargement of the spleen or liver, which can lead to abdominal pain or
swelling
 Red spots on the skin (petechiae)

If leukemia cells have infiltrated the brain, symptoms such as

headaches, seizures, confusion, loss of muscle control, and vomiting can occur.

How do physicians diagnose leukemia?

Hematologists are specialist physicians who diagnose and treat blood diseases,
including leukemia; hematologist-oncologists treat blood diseases like leukemia,
as well as other types of cancers.

In addition to a medical history (asking about symptoms and risk factors) and a
physical exam to look for signs of leukemia (lymph node enlargement,
enlargement of spleen), the diagnosis of leukemia typically involves laboratory
studies of a blood sample. Abnormal numbers of blood cells may suggest a
diagnosis of leukemia, and the blood sample may also be examined under the
microscope to see if the cells appear abnormal. A sample of the bone marrow
may also be obtained to establish the diagnosis. For a bone marrow aspirate, a
long, thin needle is used to withdraw a sample of bone marrow from the hip
bone, under local anesthesia. A bone marrow biopsy involves insertion of a thick,
hollow needle into the hip bone to remove a sample of the bone marrow, using
local anesthesia.

Cells from the blood and bone marrow are further tested if leukemia cells are
present. These additional tests look for genetic alterations and expression of
certain cell surface markers by the cancer cells (immunophenotyping). The
results of these tests are used to help determine the precise classification of the
leukemia and to decide on optimal treatment.

Other tests that may be useful include a chest X-ray to determine if there
are enlarged lymph nodes or other signs of disease and a lumbar puncture to
remove a sample of cerebrospinal fluid to determine if the leukemia cells have
infiltrated the membranes and space surrounding the brain and spinal cord.

Imaging tests such as MRI and CT scanning can also be useful for some patients
to determine the extent of disease.

What are leukemia treatment options?

There are a number of different medical approaches to the treatment of
leukemia. Treatment will typically depend upon the type of leukemia, the patient's
age and health status, as well as whether or not the leukemia cells have spread
to the cerebrospinal fluid. The genetic changes or specific characteristics of the
leukemia cells as determined in the laboratory can also determine the type of
treatment that may be most appropriate.

Watchful waiting may be an option for some people with a chronic leukemia who
do not have symptoms. This involves close monitoring of the disease so that
treatment can begin when symptoms develop. Watchful waiting allows the patient
to avoid or postpone the side effects of treatment. The risk of waiting is that it
may eliminate the possibility of controlling the leukemia before it worsens.
Treatments for leukemia include chemotherapy (major treatment modality for
leukemia), radiation therapy, biological therapy, targeted therapy, and stem cell
transplant. Combinations of these treatments may be used. Surgical removal of
the spleen can be a part of treatment if the spleen is enlarged.

Acute leukemia needs to be treated when it is diagnosed, with the goal of

inducing a remission (absence of leukemia cells in the body). After remission is
achieved, therapy may be given to prevent a relapse of the leukemia. This is
called consolidation or maintenance therapy. Acute leukemias can often be cured
with treatment.

Chronic leukemias are unlikely to be cured with treatment, but treatments are
often able to control the cancer and manage symptoms. Some people with
chronic leukemia may be candidates for stem cell transplantation, which does
offer a chance for cure.

Many patients opt to receive a second opinion before beginning treatment for
leukemia. In most cases, there is time to receive a second opinion and consider
treatment options without making the treatment less effective. However, in rare
cases of very aggressive leukemias, treatment must begin immediately. One
should discuss with a doctor the possibility of obtaining a second opinion and any
potential delays in treatment. Most doctors welcome the possibility of a second
opinion and should not be offended by a patient's wish to obtain one.

Chemotherapy

Chemotherapy is the administration of drugs that kill rapidly dividing cells such as
leukemia or other cancer cells. Chemotherapy may be taken orally in pill or tablet
form, or it may be delivered via a catheter or intravenous line directly into the
bloodstream. Combination chemotherapy is usually given, which involves a
combination of more than one drug. The drugs are given in cycles with rest
periods in between.

Sometimes, chemotherapy drugs for leukemia are delivered directly to the

cerebrospinal fluid (known as intrathecal chemotherapy). Intrathecal
chemotherapy is given in addition to other types of chemotherapy and can be
used to treat leukemia in the brain or spinal cord or, in some cases, to prevent
spread of leukemia to the brain and spinal cord. An Ommaya reservoir is a
special catheter placed under the scalp for the delivery of chemotherapy
medications. This is used for children and some adult patients as a way to avoid
injections into the cerebrospinal fluid.

Side effects of chemotherapy depend on the particular drugs taken and the
dosage or regimen. Some side effects from chemotherapy drugs include hair
loss, nausea, vomiting, mouth sores, loss of appetite, tiredness, easy bruising or
bleeding, and an increased chance of infection due to the destruction of white
blood cells. There are medications available to help manage the side effects of
chemotherapy.

Some adult men and women who receive chemotherapy sustain damage to the
ovaries or testes, resulting in infertility. Most children who receive chemotherapy
for leukemia will have normal fertility as adults, but depending on the drugs and
dosages used, some may have infertility as adults.

Biological therapy

Biological therapy is any treatment that uses living organisms, substances that
come from living organisms, or synthetic versions of these substances to treat
cancer. These treatments help the immune system recognize abnormal cells and
then attack them. Biological therapies for various types of cancer can include
antibodies, tumor vaccines, or cytokines (substances that are produced within
the body to control the immune system). Monoclonal antibodies are antibodies
that react against a specific target that are used in the treatment of many kinds of
cancer. An example of a monoclonal antibody used in the treatment of leukemia
is alemtuzumab, which targets the CD52 antigen, a protein found on B-cell
chronic lymphocytic leukemia (CLL) cells. Interferons are cell signaling chemicals
that have been used in the treatment of leukemia.

Side effects of biological therapies tend to be less severe than those of

chemotherapy and can include rash or swelling at the injection site for IV
infusions of the therapeutic agents. Other side effects can include headache,
muscle aches, fever, or tiredness.

Targeted therapy

Targeted therapies are drugs that interfere with one specific property or function
of a cancer cell, rather than acting to kill all rapidly growing cells indiscriminately.
This means there is less damage to normal cells with targeted therapy than with
chemotherapy. Targeted therapies may cause the target cell to cease growing
rather than to die, and they interfere with specific molecules that promote growth
or spread of cancers. Targeted cancer therapies are also referred to as
molecularly targeted drugs, molecularly targeted therapies, or precision
medicines.

Monoclonal antibodies (described above in the section on biologic therapy) are

also considered to be targeted therapies since they specifically interfere and
interact with a specific target protein on the surface of cancer
cells. Imatinib (Gleevec) and dasatinib (Sprycel) are examples of targeted
therapies that are used to treat CML, some cases of ALL, and some other
cancers. These drugs target the cancer-promoting protein that is formed by the
BCR-ABL gene translocation.

Targeted therapies are given in pill form or by injection. Side effects can include
swelling, bloating, and sudden weight gain. Other side effects can
include nausea, vomiting, diarrhea, muscle cramps, or rash.

Radiation therapy

Radiation therapy uses high energy radiation to target cancer cells. Radiation
therapy may be used in the treatment of leukemia that has spread to the brain, or
it may be used to target the spleen or other areas where leukemia cells have
accumulated.

Radiation therapy also causes side effects, but they are not likely to be
permanent. Side effects depend on the location of the body that is irradiated. For
example, radiation to the abdomen can cause nausea, vomiting, and diarrhea.
With any radiation therapy, the skin in the area being treated may become red,
dry, and tender. Generalized tiredness is also common while undergoing
radiation therapy.

What is the prognosis of leukemia?

The prognosis of leukemia depends upon the type of leukemia that is present
and the age and health status of the patient. Mortality (death) rates for leukemia
are higher in the elderly than in younger adults and children. In many cases,
leukemia can be managed or cured with treatments available today. In particular,
childhood ALL has a very high 5-year survival rate.

Modern treatments have led to a greater than fourfold increase since 1960 in
five-year survival rates for leukemia. Five-year survival rates for different types of
leukemia from 2007-2013 are approximately:

CML: 68%

CLL: 86%

AML: 27% overall, 66% for children and teens younger than 15

ALL: 71% overall, over 90% for children

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