1. HAEMATOLOGY MODULE: LEUKAEMIA (LECTURE 1) CHEMOTHERAPY Adult Medical-Surgical Nursing

2. Leukaemia: Description A group of malignant disorders affecting: White blood cells (lymphocytes or granulocytes) Bone marrow Lymph system Spleen

3. Leukaemia: Characteristics Uncontrolled abnormal white cell division in the bone marrow: → i ncreased number of dysfunctional white blood cells: Immature blast cells Mature but dysfunctional cells It is a systemic malignant disease: There is no primary tumour and metastases

4. Leukaemia: Aetiology Both genetic and environmental factors involved

5. Leukaemia Aetiology: Genetic Propensity Oncogenes: Chromosome changes from normal to abnormal genes

6. Leukaemia Aetiology: Environment Oncogenes are triggered or enhanced by exposure (even prenatal) to: Chemical agents (benzene, dyes) Radiation Environmental pollutants Smoking Drugs of addiction Viruses (Immunological deficiencies expose further)

7. Leukaemia: Classification Myeloid Leukaemia: affects granulocytes (from myeloid stem cells) Lymphocytic Leukaemia: affects lymphocytes (from lymphoid stem cells) May be: Acute (blast cells) Chronic (mature but dysfunctional cells)

8. Leukaemia: Classification Acute Myelogenous Leukaemia (AML) Acute Lymphocytic Leukaemia (ALL) Chronic Myelogenous Leukaemia (CML) Chronic Lymphocytic Leukaemia (CLL)

9. Acute Myelogenous Leukaemia (AML)

10. AML: Description 85% of acute leukaemia incidence in adults Acute onset Proliferation of myeloblasts, immature granulocytes in the blood circulation

11. AML: Pathophysiology Uncontrolled abnormal cell division leading to: Immature dysfunctional myeloblasts crowd the bone marrow and circulation Infiltrate lymph nodes, spleen, liver, central nervous system → node enlargement, lymphadenopathy, splenomegaly, hepatomegaly Crowding out of normal erythroblast and platelet development in bone marrow: ↓ RBC and platelet count

12. AML: Clinical Manifestations Sudden onset Patient is very susceptible to infection: Prone to opportunistic infection as Candida Albicans Fatigue Pallor Bleeding tendency Bone pain: damaged overcrowded marrow

13. AML: Diagnosis CBC Blood film: Extremely ↑ number of immature white cells (myeloblasts) and ↓ RBC and platelets Bone marrow biopsy: crowding of myeloblasts Lumbar puncture CT scan for evidence of leukaemia outside blood or bone marrow

14. AML: Aims of Treatment Induce remission (disease control), that is no evidence of the disease : Blood and bone marrow appear normal (<5% blast cells) Achieved by chemotherapy If relapse occurs, must restart the whole treatment regime Becomes ↑ more difficult to attain remission or cure May get partial remission (evidence of disease in bone marrow still)

15. Chemotherapy

16. The treatment of choice for Leukaemia Uses different combinations of drugs to destroy malignant cells

17. Chemotherapy: Multiple Drug Protocol A multiple drug regime or protocol: Interrupts cell growth and division at different stages of the cell cycle Therefore it is more effective Minimises toxicity from high doses of a single agent Reduces drug resistance

18. Chemotherapy Protocols Protocols have acronyms: as COAP Cyclophosphamide Oncovan Arabinoside Prednisone Each drug taken singly or with another has a specific action on bone marrow cells

19. Stages of Chemotherapy There are three stages or phases of chemotherapy: Induction phase Intensification (consolidation or sanctuary phase) Maintenance

20. Chemotherapy: Induction Phase Aggressive treatment: Uses multiple drug protocol Seeks to destroy malignant cells in: Blood Tissues Bone marrow Aims to achieve remission (< 5% blasts in bone marrow)

21. Intensification/ Consolidation Phase After remission achieved: Immediate intensive treatment for several months Aims to eliminate remaining leukaemic cells Includes intra-thecal chemotherapy (sanctuary phase) if leukaemic cells cross blood-brain barrier (ALL)

22. Chemotherapy: Maintenance Low doses of chemotherapy continued for years Follow-up until declared cured

23. Leukaemia: Adjuvant Therapy Steroids Sedatives and anti-emetics (Haloperidol, Cyclizine) Blood transfusions Neupogen (encourages leukopoiesis) Bone marrow transplant depends on histocompatibility of donor and recipient Bone marrow transplant follows remission Success rate for bone marrow transplant is still quite low

24. Chemotherapy: Toxic Effects Toxicity to veins and local tissues/ may cause local tissue excoriation Nephrotoxicity/ cardio- / hepatotoxicity Nausea and vomiting Alopecia Compromised immune response: Infection risk (isolation) Reduced erythropoiesis (anaemia) Reduced platelet production (bleeding tendency)

25. Chemotherapy: Nursing Responsibilities Preparation: Gown, double gloves, eye goggles Designated preparation cupboard Double-checking Patient preparation: Adequate blood count, patient information Administration: fluid pre-load, pre-medication IV monitoring, close observation of site Emotional and physical support throughout and in the community