Leukemia

LEUKEMIA

Reported by: Kristine Anne R. Ocio

WHAT IS CANCER?• CANCER is a complex of diseases which occurs when

normal cells mutate into abnormal cells that take over normal tissue, eventually harming and destroying the host

• A large group of diseases characterized by:–Uncontrolled growth and spread of abnormal cells–Proliferation (rapid reproduction by cell division)–Metastasis (spread or transfer of cancer cells from one organ or part to another not directly connected)

• BENIGN TUMORS

CELL CYCLE• G1-cell enlarges and

synthesizes proteins • S phase-DNA

replication and chromosomes are duplicated

• G2-preparation for mitosis

• M-mitosis• G1-cycle begins again• GO- resting phase

Patterns of Cell Proliferation

Activated only in the presence of cellular degeneration or death or there is a physiologic need for more cells

• Hyperplasia• Dysplasia• Metaplasia• Anaplasia• Neoplasia

HYPERPLASIA

• tissue growth based on an excessiverate of cell division, leading to alarger than usual number of cells

• Normal Hyperplasia

DYSPLASIA• Bizarre cell growth differing in size,shape and cell

arrangement

• Normal Hyperplasia Dysplasia

Normal Hyperplasia Dysplasia Severe Dysplasia Cancer Carcinoma in situ Invasive

Patterns of Cell ProliferationMetaplasia

•conversion of one type of cell in a tissue to another type not normal for that tissue

Anaplasia• change in the DNA cell structure and orientation to

one another, characterized by loss of differentiation and a return to a more primitiveform.

Neoplasia•uncontrolled cell growth, either benign or malignant

DEVELOPMENT OF CANCER• INITIATION- is a mutation in the cells genetic

structure resulting from an inherited mutation, an error that occurs in DNA replication, or following exposure to a chemical, radiation or viral agent.

• PROMOTION- once a cell has been mutated by an initiator, it is susceptible to the effects of promoters

• PROGRESSION-characterized by increased growth rate as well as increased invasiveness and metastasis.

CLASSIFICATION OF CANCER

• Classification is made according to the site of origin, histology (or cell analysis; called grading), and the extent of the disease (called staging).

GRADING• Grade I Cells slightly abnormal and well differentiated• Grade II Cells more abnormal and moderately

differentiated• Grade III Cells very abnormal and poorly differentiated• Grade IV Cells immature and undifferentiated

CANCER STAGING- Staging is the classification of the extent of the disease

CLINICAL STAGINGStage 0 Cancer in situ (limited to surface cells)Stage I Cancer limited to the tissue of origin,

evidence of tumor growthStage II Limited local spread of cancerous cellsStage III Extensive local and regional spreadStage IV Distant metastasis

TNM CLASSIFICATION SYSTEMTumor (T)• T0 No evidence of tumor• Tis Carcinoma in situ (limited to surface cells)• T1-4 Increasing tumor size and involvementNode (N)• N0 No lymph node involvement• N1- 4Increasing degrees of lymph node

involvement• Nx Lymph node involvement cannot be assessedMetastases (M)• M0 No evidence of distant metastases• M1-4 Evidence of distant metastases

LEUKEMIA“white blood”

uncontrolled production of WBC

caused by cancerous mutation of

myelogenous or lymphogenous cells.

Blood’s cellular components originate primarily in the marrow of the bones

TYPES OF WBCs

Neutrophils--60-70% of total WBC-active phagocytes-1st to arrive at a site of injury

Eosinophils-1-3% of circulating WBCs-found in large numbers in mucosa and lungs

Basophils- 1% of WBC count-contain histamine, heparin and other inflammatory mediators-increase during allergic rxn and inflammatory rxn

TYPES OF WBCsMonocytes

-largest-3-8%-phagocytic macrophages-macrophages dispose of foreign and waste material, esp in inflammation

Lymphocytes-20-30%-B cells-humoral immune response and antibody formation-T cells-cellular mediated immunity process

CLASSIFICATION

Onset: Acute/ChronicOriginating Cell: Lymphocytic/Myelocytic

ALL-most common in children

AML and CLL-most common in adults

EPIDIMIOLOGY• estimated 34, 810 new cases of leukemia occur annually; slightly

more than half are acute leukemia and less than half are chronic leukemia

• In 2007 (the most recent year numbers are available),

36,273 people in the United States were diagnosed with leukemia, (M- 20,629, F-15,644)21,928 people in the United States died from leukemia, including 12,434 males and 9,494 females.

(†Source: at:http://www.cdc.gov/uscs.)

SELECTED CAUSES OF DEATHBy Region, Province and CityNumber and Rate/100,000 Population, Philippines, 2004Cagayan de Oro CityNo.Rate

183.5

MORTALITY BY CAUSE, AGE GROUP AND SEXNumber and Rate/100,000 Population, Philippines, 2004MaleFemaleBoth SexesRate*

1,2341,2262,4602.9

Estimated new cases and deaths from leukemia in the United States in 2010

(Source: National CancerInstitute-www.cancer.gov)New Cases:

Deaths:43,05021,840

• incidence is highest among whites and lowest among Chinese, Japanese, and Koreans.

• The incidence in men is about 50% higher than in women for all racial/ethnic groups except Vietnamese, among whom the male rates are only slightly higher.

• Ethnic differences in the incidence rates are small in the youngest adult age group (30-54 years), but become more evident in each of the older age groups.

• Childhood leukemia rates are highest among Filipinos, followed by white Hispanics, non-Hispanic whites and blacks. (www.cdc.gov)

•

PREDISPOSING FACTORS

PRECIPITATING FACTORS

• Unknown• HTLV-1( Viral cause

for Adult T-cell Leukemia)

• Philadelphia chromosome(CML)

• LEGEND:

Disease Process

Diagnostic Exams

Treatment(Drugs and

Procedures)

Symptoms

PATHOPHYSIOLOGY

Predisposing factors

Precipitating factors

Malignant transformation of a

stem cell

Unregulated Proliferation of leukemic cells

Accumulation in the bone marrow

Destruction of large number of

WBC

Decrease function of

WBC

FeverNight Sweats

Oral UlcerationsFrequent Respi,

Urinary, Integumentary

infections.

Infection

Leukemic cells leave bone

marrow

Infiltration in the CNS, testes, skin, GI tract, lymph nodes, liver,

spleen

Leukemic cells replace

hematopoietic elements in

marrow

Increase cellular metabolism

AntibioticsCorticoster

oid

X-RAYS

ChemotherapyRadiation Therapy

BMT,SCTBone marrow

aspiration, Biopsy

Lumbar puncture

RBC and platelet are crowded out

Compete with the proliferation of

normal cells

Thrombocytopenia RBC count

PallorFatigue

TachycardiaLethargyDyspnea

CBC: Platelet<150,000/μL

Anemia

Bleeding

CBC:RBC<4X106/

ΜlHgb may be

less than 10g/100ml.

CBC:RBC<4X106/

ΜlHgb may be

less than 10g/100ml.

petechiae, ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting, heavy menses.

Blood replacement

Bleeding in the Lungs

Abdomal bleeding

Intracranial Bleeding

Increase abdominal girth

PainGuarding

TachycardiaHypotension

PallorDiaphoresis

SOB

Altered mental status

Decreased LOC

Destruction of large number of

WBC

Uric acid may obstruct renal

tubules

Release of subs. Amt of

Uric Acid in the circulation

Renal insufficiency

Increase metabolism

Heat intoleranceWeight lossDyspnea on

exertionTachycardia

Infiltration in the CNS, testes, skin, GI tract, lymph nodes, liver, spleen, and other

organs

Spleenamegaly HepatomegalySwelling of

lymph nodes

Bone marrow/Joint

infiltration

Meningeal Infiltration

Kidney Infiltration

HeadacheAltered LOC

Cranial nerve

impairmentn/v

Renal function impaired

Decreased Urine

Output

Increase BUN and

crea

Lumps in the neck, groin, underarm areas, or

above the collarbone

PAIN

Enlarged abdomen

CT scanMRI

ultrasound

Lymph node

biopsy

COMPLICATIONS• Leukostasis; in setting of high numbers (greater than 50,000/mm3)

of circulating leukemic cells (blasts), blood vessel walls are infiltrated and weakened, with high risk of rupture and bleeding, including intracranial hemorrhage.

• Disseminated intravascular coagulation(DIC).

• Tumor lysis syndrome: rapid destruction of large numbers of malignant cells leads to alteration in electrolytes (hyperuricemia, hyperkalemia, hyperphosphatemia, and hypocalcemia).

• May lead to renal failure and other complications.

• Infection, bleeding, and organ damage.

DIAGNOSTIC EXAMS• CBC and blood smear – peripheral

WBC count varies widely from 1,000 to 100,000/mm3 and may include significant numbers of abnormal immature (blast) cells,

• anemia may be profound-usually indicates normocytic, normochromic anemia;

• platelet count may vary from normal to very low (less than 50,000/mm3) and coagulopathies may exist.

• Hgb may be less than 10g/100ml.

• Normal blood as seen through a microscope.

• The red disks are normal red cells;

• the largest arrow points

to a mature lymphocyte,

• the smaller arrow points to a mature myeloid cell,

• and the small arrowheads indicate

platelets.

A normal mature lymphocyte (left) and a lymphoblast (right).

normal mature myeloid cell (left) and a myeloblast (right).

DIAGNOSTIC EXAMS• Bone marrow aspiration and biopsy – Abnormal WBCs usually make

up 50% or more of the WBCs in the bone marrow. Cells are also studied for chromosomal abnormalities (cytogenetics) and immunologic markers to classify type of leukemia further. The Philadelphia chromosome is the diagnostic marker for CML which results from translocation of genetic material between chromosomes 9 and 22.

• • Lymph node biopsy – to detect the spread.

• Lumbar puncture and examination of cerebrospinal fluid for leukemic cells (especially ALL).

• CT scan- determine the presence of leukemic cells outside of the blood and bone marrow.

MEDICAL MANAGEMENT• Chemotherapy• Radiation Therapy• Leukapheresis (or exchange transfusion to infants) may be

used when abnormally high numbers of white cells are present to reduce the risk of leukostasis and tumor burden before chemotherapy.

• Bone marrow transplant is often used in conjuction with or following chemotherapy or radiation. It could be allogenic or autologous.

• Allogenic Stem cell transplant is an alternative to bone marrow transplant. SCT results in complete and sustained replacement of the recipient’s blood cell lines with cells derived from the donor stem cells.

MEDICAL MANAGEMENT• Antineoplastic agents• Supportive treatments during cancer treatment include:• Antibiotics and immunoglobulin help to prevent or fight infections. • Corticosteroids• Transfusions of red blood cells and platelets.• Epoetin and hematopoietic stimulants help your body make new blood

cells.• Allopurinol to prevent kidney problems and gout.• Immune globulin (IG) helps prevent infections. It is sometimes used for

people with chronic lymphocytic leukemia (CLL), because CLL weakens the immune system.

• Interferon alfa helps your immune system fight disease and may keep cancer cells from growing. It is often given to people who have CML.

• Antiemetic for vomiting•

• Administer blood components as directed. Platelet transfusions may be necessary when platelet count <20,000/mm3 or with active bleeding Other blood products may also be required.

• Keep patient on bed rest during bleeding episodes.

• Teach patient to avoid activities likely to cause injury(eg, contact sports) and other methods to prevent bleeding.

•

Nursing Diagnosis #1: Risk for infection related to altered WBC production and immune function

– Promptly report manifestations of infection:.

– Institute infection protection measures:• Maintain protective isolation as indicated. • Ensure meticulous hand washing among all people in

contact with the client.• Assist as needed with appropriate hygiene measures. • Restrict visitors with colds., flu, or infections. • Provide oral hygiene after every meal. • Avoid invasive procedures when possible, including

injections, intravenous catheters, catheterizations, and rectal and vaginal procedures. When necessary, use strict aseptic technique for all invasive procedures and monitor carefully for infection.

– Monitor vital signs

– Monitor neutrophil levels for relative infection:Neutrophils are the first line of defense against infection. As the levels decrease, the risk for infection increases.

• Explain infection precautions and restrictions and their

rationale.

• Avoid crowds and avoid raw or undercooked food; use condoms. This potential for infection remains after discharge. Avoid exposure to all sources of stagnant water (eg flower vases, denture cups,) and plants. Stagnant water and soil are good media for anaerobic bacterial growth.

Nursing Diagnosis #2: Risk for Injury related to bleeding secondary to bone marrow failure,

thrombocytopenia

• Watch for signs of minor bleeding, such as petechiae, ecchymosis, conjunctival hemorrhage, epistaxis, bleeding gums, bleeding at puncture sites, vaginal spotting, heavy menses.

• Be alert for signs of serious bleeding, such as headache with change in responsiveness, blurred vision, hemoptysis, hematemesis, melena, hypotension, tachycardia, dizziness. Watch out also for complaints of epigastric pain, diminished bowel sounds, increasing abdominal girth, rigidity or guarding.

• Provide soft toothbrush or toothettes and mild mouthwash for mouth care. This minimizes damage to mucous membranes.

NURSING INTERVENTIONS

• Use only an electric razor for shaving. Keep fingernails and toenails short and smooth. Lubricate skin with mild lotion. This minimizes skin excoriation

• Avoid invasive procedures. Biopsy or lumbar puncture should not be done if platelet count is less than 50, 000.

• Instruct to avoid forcefully blowing or picking the nose, forceful coughing or sneezing, and straining to have a bowel movement. These activities can damage mucous membranes, increasing the risk for bleeding.

• Test all urine, stool, emesis for gross and occult blood.• Monitor platelet counts daily.

Nursing Diagnosis #3: Acute pain and discomfort related to mucositis, leukocyte infiltration of systemic

tissues, fever and infection

• Goal: Ease pain and discomfort• – Assess at least q4h for presence, location, intensity, and

characteristics of pain. Pain is potentially distressing symptom. Pain may be symptom of infection.

– Administer analgesics as ordered to control pain. Administer on regular schedule rather than as needed. Avoid aspirin and NSAIDS in thrombocytopenic patients. If oral analgesics in optimal doses are not effective or tolerated, consider IV route.

–Teach and use nonpharmacologic measures, such as the use of music, relaxation breathing, progressive muscle relaxation, distraction and imagery to help manage pain.

–Maintain environment conducive to rest

–Place in a comfortable position; may coordinate with analgesics

Nursing Diagnosis # 4: Activity intolerance related to general weakness, hypermetabolic state, imbalance between oxygen

and supply and demand, effect of drug therapy

• Goal: Improving Activity tolerance

– Evaluate reports of fatigue. Effects of leukemia, anemia and chemotherapy may be cumulative, necessitating assistance.

– Encourage to keep a diary of daily routines and energy levels, noting activities that increase fatigue. This helps client prioritize activities and arrange them around fatigue pattern

– Provide quiet environment and uninterrupted rest periods. Encourage rest periods before meals.

– Implement energy-saving techniques; e.g. sitting, rather than standing, use of shower chair. Assist with ambulation/other activities as indicated. Maximizes available energy for self-care tasks

– Recommend small, nutritious, high-protein meals and snacks throughout the day. Schedule meals around chemotherapy. Give oral hygiene before meals. Smaller meals require less energy for digestion. Increased intake provides fuel for energy

– Provide supplemental oxygen as indicated. This maximizes oxygen available for cellular uptake, improving tolerance of activity.

• •

Nursing Diagnosis #5: Imbalanced nutrition, less than body requirements related to hypermetabolic state,

anorexia, mucositis, pain and nausea • Goal: Improving Nutritional Intake• – Weigh regularly and evaluate weight loss over time to

determine degree of malnutrition. A weight loss of 10% or 20% may indicate malnutrition.

– Address causative or contributing factors to inadequate food intake. • Provide mouth care before and after meals; use a soft

toothbrush or sponges as necessary.• Increase liquid intake with meals. • Ensure the environment is clean and odor free

• Provide medications for pain and nausea 30 minutes before meals, as prescribed

• Provide rest periods before meals

• Offer small, frequent meals

• Provide commercial supplements, such as Ensure

• Suggest measures to improve food tolerance, such as eating dry foods when arising, consuming salty foods if allowed, and avoiding very sweet, rich, or greasy foods.

– Parenteral nutrition is often required to maintain adequate nutrition.

•

Childhood Leukemia and Proximity to Nuclear Power Plants

• Increased childhood leukemia rates around Britain’s Sellafield nuclear power plant(NPP)

• International Journal of Cancer-children under the age of 5 years living within 5 km of an NPP were at more than double the normal risk of developing leukemia

• Significant risk-distance association

• Thus, currently, ionizing radiation is the onlly established environmental risk factor for childhood leukemia

-END-

Thank you…