The cancer of soft tissues of bone marrow and blood is known as Leukemia. The cells of blood are formed in bone marrow. Leukemia happens when there is problem in the production of blood cells especially white blood cells or Leucocytes but some Leukemias start in other blood cell types too.
Pathophysiology of Leukemia:-
- Leukemia occurs when the DNA of immature blood cells get damage due to some reason
- This damaged DNA cause the blood cells to grow and divide continuously
- These abnormal blood cells do not die when they should naturally and start accumulating in the blood stream
- Due to this overcrowding of abnormal blood cells; healthy blood cells suffer a damage and they die unnatural death
- Also these abnormal cells prevent the normal ones to grow and function normally
- This leads to various complications like anemia, infections, bleedings etc.
- Pathologically, Leukemia is subdivided into a number of groups; the commonest being Acute Leukemia and Chronic Leukemia.
- Leukemia is also differentiated on the basis of which type of blood cells are affected. This divides this deadly disease into lymphoblastic or lymphocytic leukemia and myeloid or myelogenous leukemia.
- Acute Leukemia:- In acute leukemia, the production of abnormal blood cells occurs very fast and shows immediate signs and symptoms. The worsening of these symptoms too occurs rapidly. This is the commonest leukemia seen in children.
- Chronic Leukemia:- This type the blood stream has relatively mature but still abnormal blood cells which as relatively slow progression. It remains quite asymptomatic for many years and is the commonest leukemia in adults.
- Lymphocytic Leukemia:- In this type, the components of blood called lymphocytes ie white blood cells are affected.
- Myeloid Leukemia:- In this type, the affected components of blood are granulocytes, red blood cells and/ or platelets.
Types Of Leukemia:-
Acute Lymphocytic Leukemia (ALL):-
- ALL starts in bone marrow where blood cells are made
- This type of leukemia is more common in children
- Though it affects elders who are above 65yrs of age
- Acute Lymphocytic Leukemia usually worsens quickly
- But it is the most successfully treated type of childhood leukemia
- The survival rates of ALL are 85% in children and about 50% in adults
- Symptoms of ALL in children and adults include fever, weakness or feeling tired, bruising, bleeding, spots under the skin from bleeding, pain in bones and loss of appetite
- The standard treatment for Acute Lymphocytic Leukemia is Chemotherapy and Radiotherapy (RT)
- Precursor B acute lymphoblastic leukemia
- Precursor T acute lymphoblastic leukemia
- Burkitts leukemia
- Acute biphenotypic leukemia
Acute Myelogenous Leukemia (AML):-
• This is also known as Acute Myeloid Leukemia, Acute Myelocytic Leukemia, Acute Granulocytic Leukemia or Acute Non-Lymphocytic Leukemia
• This is more common in elders than children
• Children with Down’s syndrome and other genetic conditions are more susceptible to this
• Men are the common victims of this than women
• AML tends to worsen quickly
• The incidence of AML increases as the age advances
• AML is more of a acquired disease
• Though the exact cause of AML is unknown; high doses of radiation, exposure to the chemical benzene, smoking and other tobacco usage, chemotherapy used to treat other types of cancer are some of the predisposing factors that cause this dreadful disease
• Symptoms of AML in adults include fatigue, fever, night sweats, unexplained weight loss, joint pain, painless blue or purple lumps
• Symptoms of AML in children are weakness, fatigue, fever, night sweats, easy bruising and bleeding and joint pain
• The survival rate of AML is 40%
• The standard treatment for AML is Chemotherapy
• Subtypes of AML are-
1. Acute Promyelocytic Leukemia
2. Acute Megacaryoblastic Leukemia
3. Acute Myeloblastic Leukemia
Chronic Lymphocytic Leukemia (CLL):-
• In chronic Lymphocytic Leukemia, bone marrow produces excessive number of white blood cells (lymphocytes)
• These lymphocytes which are also known as Leukemia cells do not have the capacity to fight infections
• When such lymphocytes get accumulated in blood stream; there remains no room for healthy blood cells making the patient susceptible to conditions like Anemia, infections etc.
• Adults above 55yrs of age are more often affected with CLL with sometimes occurring in youngers
• Children are almost never affected with CLL
• Symptoms of CLL include fatigue, night sweats, anemia, unexplained weight loss, spleenomegaly, painful and swollen lymph nodes, poor appetite and infections
• CLL is almost incurable
• Subtype of CLL –
- B – cell prolymphocytic leukemia
Chronic Myeloid Leukemia (CML):-
- Chronic Myeloid Leukemia is also known as Chronic Myelogenous Leukemia or Chronic Granulocytic Leukemia
- CML is more common in elders who are above 50 yrs of age and is rarely seen in children
- Males are more prone to chronic myeloid leukemia than females
- Majority of the people suffering with chronic myeloid leukemia have a gene mutation called Philadelphia Chromosome
- CML is classified into three distinct phases known as Chronic phase, Accelerated Phase and the Blast crisis phase
- Symptoms of CML include spleenomegaly, fatigue, unexplained weight loss, night sweats etc
- Subtype of CML -
1. Chronic Myelomonocytic Leukemia
Leukemia in Children:-
- Leukemia are the most common cancers seen in children and teens
- Every one child or teen out of three suffers from leukemia
- Most common childhood leukemia is ALL ie Acute Lymphocytic Leukemia
- Less common types of childhood leukemia are -
- Chronic Myelogenous Leukemia / Chronic Myeloid Leukemia (CML)
- Juvenile mylomonocytic leukemia
- Acute Lymphocytic Leukemia is common in children with age group of 2 to 8 years old
- Acute myelogenous leukemia (AML) can happen at any age, but most cases happen in kids younger than 2 and teens
- Chronic myelogenous leukemia is most common in teenagers
- Juvenile myelomonocytic leukemia (JMML) majorly affects infants and toddlers
Other Rare Types of Leukemia:-
There are few other types of Leukemia which are quite rare. They are –
- Hairy Cell Leukemia
- T – cell Prolymphocytic Leukemia
- Large Granular Lymphocytic Leukemia
- Adult T – cell Leukemia
- Clonal Eiosinophilias
Causes of Leukemia:-
The exact cause of Leukemia is still not known. But there are a few factors or causes which increase risk for the disease. They are –
- Mutations in DNA – These mutations can cause leukemia by deactivating the tumor suppressing genes which disturbs the regulation of cell death. These mutations can occur due to exposure to radiations or carcinogenic elements.
- Human T- lymphotrophic virus – These are human retrovirus which increase the risk for leukemia
- Exposure to chemicals like Benzene – Chronic exposure to benzene cause chromosomal aberrations in the blood leucocytes and bone marrow increasing the risk for leukemia
- Use of tobacco – Tobacco smoke contains carbon monoxide, cyanide and other carcinogens which increase risk of Leukemia
- Genetic conditions – Some people have genetic predisposition for leukemia. Also people with chromosomal abnormalities like Down’s syndrome and other genetic conditions are at higher risk
Signs and Symptoms of Leukemia:-
Since the blood stream in leukemia is full of abnormal blood cells, the healthy blood cells are not able to perform their task causing main symptoms like –
- Anemia – since the count of RBC’s becomes low
- Infections – since count of WBC’s becomes low
- Excessive bleeding – since count of platelets becomes low
- Petechial haemorrhage – as low platelet count causes disturbance in blood clotting process
- Excessive Fatigue
- Night sweats
- Fever with chills
- Enlarged liver
- Enlarged Spleen
- Unexplained weight loss
- Headache – this may indicate the cancerous cells invading the Central Nervous System
- Enlarged lymph nodes
Physical Examination –
- A detail physical examination may reveal some trigger points which point towards the risk of having leukemia
- These trigger points are enlarged cervical / axillary lymph nodes, Hepatomegaly (enlarged Liver), Speelomegaly (enlarged Spleen)
Blood Test – A complete blood count test (CBC) will reveal the abnormal growth of blood cells
Biopsy - Lymph node biopsy can be done to detect the type of leukemia in certain conditions
Bone Marrow Test-
- In this test the cells from the bone marrow will be examined
- This test is helpful to detect the exact type of leukemia
- This is the most accurate and confirmatory test
How Is Leukemia Treated:-
The treatment for leukemia majorly depends on what type of leukemia is a person suffering from. The age and medical condition of patient too plays an important role while deciding the treatment routine. Still the basic treatment protocol that is followed for treating leukemia consists of –
- Radiations (RT)
- Multi drug regimen
- Stem cell transplant
- Targeted therapy
Treatment of Acute Leukemia:-
- The treatment of acute leukemia has to be vigorous as this type worsens fast
- The standard treatment protocol for acute leukemia include chemotherapy, radiations and multi drug treatment (usage of steroids)
- The treatment of acute leukemia is done in 4 phases –
- Phase 1 – This aims at rapid killing of tumor cells. This treatment is usually done in hospital setting
- Phase 2 Or Remission – High dose of chemotherapy is given continuously but on an outpatient (OPD) basis. The patient may has to take the chemotherapy in hospital but usually patient is discharged the same day
- Phase 3- This phase includes chemotherapy and radiation in combination. This prevents the metastasis (spread) of malignant cells
- Phase 4- This includes the laboratory investigations, scans and physical examinations of patient to ensure that the leukemia is not recurring
Treatment of Chronic Leukemia:-
- Chronic leukemia remains silent in many of the cases
- Thus the treatment of this leukemia is started when the disease actually shows its symptoms
- the treatment protocol of CLL depends upon its below mentioned 5 stages –
- Stage 0:- In this stage there are too many lymphocytes present in the blood stream but the disease is silent and shows no symptoms. Thus at this stage no treatment is given but the patient is monitored very closely to keep an eye if the disease is progressing.
- Stage I:- In this stage the lymph nodes of the patient swell due to presence of numerous lymphocytes in blood. In this stage close monitoring is done along with required dose of chemotherapy.
- Stage II:- Excessive lymphocytes in the blood causes the lymph nodes to swell along with Hepatomegaly (enlargement of liver) and Spleenomegaly (enlargement of spleen). This stage also chemotherapy along with close monitoring is done.
- Stage III:- Anemia shows up in this stage as the overcrowding of lymphocytes prevents the red blood cells from functioning properly. In this stage usually multi drug regimen with chemotherapy is given.
- Stage IV:- In this stage, anemia, hepatomegaly, spleenomegaly, swollen lymph nodes are associated with heavy loss of platelets. This stage requires intensive chemotherapy with multi drug regimen. Some patients may need bone marrow transplant.
Side Effects Of Treatment of Leukemia:-
- Low blood cells count - Normal blood cells decrease in leukemia. The chemotherapy given during the course further hampers the growth of blood cells adding to this. Patient may land into severe deficiency of platelets, red blood cells and white blood cells.
- Recurrent Infections - Due to the deficiency of white blood cells, the patient gets more prone to various recurrent infections.
- Graft Versus Host Disease - Patient undergoing stem cell transplant or bone marrow transplant is at a risk of Graft Versus Host Disease (GVHD). This risk advances with the age. In GVHD; donor’s immune cells attack patient’s normal cells. This can be mild, moderate or even life threatening.
Various other common side effects include -
- Hair loss
- Oral ulcers
The prognosis of Leukemia depends upon its specific type, whether it is acute or chronic, age of patient, presence and severity of anemia and thrombocytopenia, metastasis (spread) of malignant cells and its infiltration in lymph nodes and bone marrow.
In children, almost 90% suffering from leukemia get cured. 80 to 90% of adults attain remission. Those 40% who survive another 5 years gets completely cured.
After Care For Leukemia Survivor:-
- Physical Examinations And Investigations:- Physician may ask the patient for a follow up immediately in the next month of the treatment getting over. These follow ups should never be missed as they are done to keep an eye if the disease is recurring.
- Dietary Supplements:- Severe deficiencies occur while treating leukemia. These have to be replenished with the help of proper diet and supplements. This includes multivitamins, minerals and any other herbal products.
Leukemia Treatment Costing In India Versus Other Nations:-
The chemotherapy and radiation treatment for leukemia costs depends upon the number of cycles required and stage of cancer. The treatment cost in western countries is almost 10 times more than that of in India.
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• Is leukemia hereditary?
Leukemia is caused by mutation in genes. These genetic abnormalities are not often inherited in the families. So, leukemia is not a hereditary disease.
• What is the first sign of Leukemia?
The most initial sign of leukemia includes fatigue, fever and unexplained weight loss.
• Which leukemia is most fatal?
Acute Lymphoid Leukemia is considered to be fatal as it worsens within few months.