Leukemia Notes

Leukostasis

  • Blasts can get sticky and can plug
  • Lung: hypoxia, DOE, infiltrate
  • CNS: AMS, confusion, ICH
  • rx: hydroxyurea. Place phoresis catheter for leukophoresis
  • ddx if blast > 50k or if absolute blast > 100k

Neutropenic fever

  • ANC < 1000 and falling or ANC < 500
  • 100.4 for >1 hour or 100.5
  • Start cefepime 2gm q8h or Zosyn 4.5 gm, 1st dose stat
  • Start vanc if soft tissue, rash, port, or MRSA concerns

AML Rx

Cytotoxic Induction

  • Cytarabine and anthracycline (Daunorubicin or idarubicin)
  • 7+3 cycle
  • New agent: Vyxeos, CPX-351

Consolidation Rx

  • chemo or stem cell transplant

Noncytotoxic

  • Venetoclax with either azacytidine/decitabine or low dose cytarabine
  • Better for older patients
  • No induction/consolidation, repeat until doesn’t work anymore or transplant

APML

  • if suspicious, start transretinoic acid
  • Pancytopenic, leukocytosis, DIC panel positive
  • Transfuse FFP/cryo to keep fibrinogen > 150 and plt > 50k.
  • ATRA induced differentiation syndrome
    • low temp, hypoxia, capillary leak picture with fluid
    • high fatality, respond in 2-3 days
    • rx: decadron 10mg IV BID
    • hold ATRA/ATO if severe

TLS

  • allopurinol: prevent uric acid production
  • IV hydration, NS or D5 with bicarb
  • lasix to keep even
  • rasburicase
  • monitor electrolytes

Solid Tumor Mechanical Disasters

SVC

  • dx with CT
  • if malignant: needs tissue biopsy first
  • rx: decadron 10mg IV once and 8mg po q8, chemo w or wo rad

Hypercalcemia

  • breast cancer, lung cancer, rcc, mm
  • PTHrP release, osteoclast activation
  • rx: IV hydration, lasix IV, bisphophonate (takes 2-4 days), zoledronic acid 4mg IV over 15 min, pamidronate 60-90 IV over 2 hours if renal dysfunction
  • don’t use thiazide diuretics
  • don’t use phosphorus products: can cause calciflaxis

Bleeding

  • Avoid asa, plavix, nsaids
  • <10k plt, increased risk of major bleeding
  • transfuse if <10k, except ITP
  • Don’t transfuse when TTP suspected