Content Reviewers:Antonella Melani, MD, Lisa Miklush, PhD, RNC, CNS, Jannah Amiel, MS, BSN, RN, Jodi Berndt, PhD, RN, CCRN-K, PCCN-K, CNE, CHSE, Gabrielle Proper, RN, BScN, MN
Taylor Oscar is a 64-year-old male who presents to the clinic with a 3-week history of extreme fatigue, bruising, and flu-like symptoms.
Laboratory findings reveal a white blood cell count of 18,000/mm3 with 40 percent blasts, hemoglobin 12.6 g/dL, and platelets 112,000/mm3.
A bone marrow biopsy and aspirate is performed, which confirms a diagnosis of acute myeloid leukemia or AML.
Taylor is emergently admitted to the hematology oncology unit to begin treatment for AML.
Leukemia refers to a group of cancers that can occur when there’s uncontrolled proliferation of non-functional white blood cells, or WBCs, in the bone marrow.
Leukemias are grouped by how quickly the disease develops. Acute leukemia develops very quickly, over days to weeks, so the WBCs don’t mature at all, and usually remain in the earlier “blast” form.
On the other hand, chronic leukemia develops slowly, over many months or years, so the non-functional WBCs have time to mature partially.
Now, leukemias can be further grouped based on the cell type involved. Myeloid leukemias are caused by proliferation of cells from the myeloid cell line, such as monocytes or granulocytes, which include eosinophils, basophils, and neutrophils.
On the other hand, lymphoid leukemias are caused by the proliferation of cells from the lymphoid line, which includes B- and T- cells.
Now, leukemias are thought to be caused by mutations in the precursor blood cells in the bone marrow, leading to uncontrolled proliferation.
There are certain risk factors that have been identified for developing these mutations.
These include exposure to ionizing radiation, previous chemotherapy, smoking, and exposure to chemicals such as benzene.
Other risk factors include a history of antecedent hematologic disorders, including myelodysplastic syndromes, and pre-existing genetic conditions such as Fanconi anemia, Bloom syndrome, xeroderma pigmentosum, Down syndrome, and Li-Fraumeni syndrome.
Another risk factor is age, since ALL is more common in children, while AML and chronic leukemias are more common in adults. Finally, leukemias are slightly more common among males than females.
Clients with leukemia typically present with symptoms like weight loss, weakness, night sweats, and unexplained fever.
As the non-functional WBCs keep proliferating in the bone marrow, they take up a lot of space, so the other normal blood cells growing in the bone marrow get “crowded out.”
Ultimately, this results in complications like cytopenia, including anemia, thrombocytopenia, and leukopenia.
As a consequence, symptoms of leukemia can include pallor and fatigue, because of the anemia; easier bleeding, bruising, and petechiae, because of the thrombocytopenia; and frequent infections, because of the leukopenia.
Other symptoms may include pain and tenderness in the bones due to the increased WBC production.
In addition, these WBCs may start to spill out into the blood. Some of them can deposit in organs and tissues throughout the body, such the liver and spleen, causing hepatosplenomegaly, which often causes a feeling of abdominal fullness; or the lymph nodes causing lymphadenopathy, which often causes mild, but localized pain in the lymph nodes.
The diagnosis of leukemia usually starts with history and physical examination, followed by a complete blood count or CBC, which generally reveals increased WBCs along with cytopenia.
Additionally, a peripheral blood smear may show increased blast cells, myeloblasts in case of AML, and lymphoblasts in case of ALL.
This is usually followed up by a bone marrow biopsy, which also shows an increase in blast cells.
In acute leukemia, the percentage of blast cells in the bone marrow goes up from their normal value of 1 to 2% to greater than 20%!
Treatment is mainly aimed at reducing the number of blast cells which can allow the other blood cells to develop normally, and it generally consists of three chemotherapy phases: induction, which is aimed at inducing remission; consolidation, aimed at eliminating any remaining leukemic cells; and maintenance, aimed at preventing relapse.
The choice of treatment will depend on the client’s age and medical fitness, which generally means those with no severe comorbid conditions, so they can tolerate treatment with intensive chemotherapy.
On the other hand, medically unfit but not frail clients are typically treated with low-intensity chemotherapy.
Finally, frail clients wouldn’t tolerate chemotherapy, so they’re treated with supportive care to help improve their quality of life.
Other treatments for leukemia include radiation therapy, hematopoietic stem cell transplantation and immunotherapy.
Let’s get back to assess our client Taylor. Since being admitted, he has had a central venous access device, or CVAD, inserted for his induction treatment, which he is scheduled to start tomorrow morning.
After entering his room, you ask him how he is doing, and he says he is feeling confused and anxious about his recent diagnosis and beginning treatment so quickly. He appears overwhelmed and is not sure when he will be able to go home.
Upon examination, his lungs are clear to auscultation. He denies shortness of breath at rest, however states that he has been so exhausted during the last few weeks that he has not been able to maintain his usual level of activity.
Often, he feels like he can’t catch his breath when he is up moving for more than a few minutes.
His abdomen is soft and bowel sounds are present in all four quadrants. He has noticeable bruising on his legs bilaterally.