Day #97 - Acute lymphoblastic leukemia

Today we discussed a case of a young man with severe back pain, progressive and persistent in association with anemia. We went through the clinical reasoning and arrived at the correct diagnosis (in general) as a hematologic malignancy.

The skeletal fractures were something of a mystery; however, in children early osteoporosis and fracture can be the presenting complaint so perhaps this is why! The treatment, as for hypercalcemia of malignancy includes intravenous pamidronate.

We were surprised by the finding of acute lymphoblastic leukemia, which is classically a childhood leukemia but is being seen in higher numbers in adults. The article above is a great review of ALL and this article discusses the treatment in more detail.

---

B-cell maturation and associated malignancies

---

Tumour lysis syndrome (is seen in ALL with chemotherapy):

With rapid tumour turnover, or rapid tumour death from chemotherapy there is a predisposition towards:

• Hyperuricemia(greater than 476 or 25% increase from baseline) can cause gout and renal failure
• Hyperphosphatemia (greater than 1.45) can cause renal failure
• Hypocalcemia, potentially severe (less than 1.75)
  
• Hyperkalemia (greater than 6.0)
  
• lactic acidosis

Symptoms:

• nausea, vomitting, diarhea, anorexia
• hematuria
• heart failure, arrythmias, syncope, sudden death
  
• seizure
• cramps, tetany
  

Prevention of tumour lysis syndrome complications:

• Adequate hydration, usually with a hypotonic bicarbonate solution (i.e. 2AMPS bicarb in 1L D5W)
• Diuretics if volume overloaded
• Allopurinol or rasburicase for prevention of urate nephropathy

---

A quick word on transfusions:

• Single donor HLA matched platelets for all patients who may receive a bone marrow biopsy
• Radiated blood productes