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Leukemia, Lymphoma

Objectives:

  1. Identify the key components of medical history taking relevant to leukemia and lymphoma
  2. Identify key physical exam findings important to the management of patients with leukemia/lymphoma
  3. Review diagnostic and laboratory criteria for leukemias and lymphomas
  4. Review management of leukemia/lymphoma in the inpatient setting and potential complications of therapy
  5. Review diagnostic criteria for Tumor Lysis Syndrome and other oncologic emergencies
  6. Review management of the oncologic patient presenting with fever

Articles:

Additional Resources:

  • Pediatric Heme/Onc interactive cases found via the AAMC MedEdPortal
  • CHOP Open Access Video Series: Hematology and Oncology
    • These are detailed overview lectures on diagnosis, management, and outcomes for patients with a variety of hematology/oncology-related diagnoses including leukemias and lymphomas. Please take note of the publication date as therapies can change quickly!

Self-Assessment:

1. A 3-year-old boy is brought to the office with complaints of fever and pain in the legs. The fever has been intermittent and as high as 101.5°F (38.6°C) for the past 5 days, and the pain in the legs is waking him up at night. He has a negative medical history, and his immunizations are up-to-date. The mother noted that he has had some bruising on the arms and legs, but she accounts for that by his active play. He had a viral infection approximately 3 weeks ago that resolved without treatment. Vital signs include a temperature of 100.8°F (38.2°C), a heart rate of 120 beats/min, a respiratory rate of 24 breaths/min, blood pressure of 100/60 mm Hg, and oxygen saturation of 100% on room air. There is mild cervical lymphadenopathy, and results of the heart and lung examinations are normal. The abdomen is soft, without hepatosplenomegaly. The extremities show mild discomfort, with scattered ecchymoses. Neurologic examination findings are normal. Laboratory studies show a white blood cell (WBC) count of 1,500/μL (1.5 x 109/L), a hemoglobin level of 8.5 g/dL (85 g/L), a hematocrit value of 24%, a platelet count of 75 x 103/μL (75 x 109/L), a reticulocyte count of 0.4%, and a differential count of 5% neutrophils, 85% lymphocytes, 5% eosinophils, and 5% monocytes.

Which of the following is the most likely diagnosis in this patient?

  1. Acute Lymphoblastic Leukemia
  2. Aplastic Anemia
  3. Chronic Lymphocytic Leukemia
  4. Infectious Mononucleosis
  5. Viral Suppression

2. A 14-year-old girl is brought to the emergency department with a history of fatigue, pallor, and bruising. On physical examination the vital signs show a temperature of 100.0°F (37.8°C), a heart rate of 100 beats/min, a respiratory rate of 20 breaths/min, and BP of 110/65 mm Hg. Physical examination shows a pale adolescent in no acute distress. There is mild cervical adenopathy, and the lungs are clear. A grade 2/6 systolic murmur is heard. The abdomen is soft, with the spleen palpable 3 cm below the left costal margin. The liver is 1 cm below the right costal margin. Neurologic examination findings are normal. Extremities show scattered bruising. Laboratory data show a WBC count of 150,000/μL (150 x 109/L); a hemoglobin level of 6 g/dL (60 g/L); a hematocrit value of 18%; a platelet count of 10 x 103/μL (10 x 109/L); a differential count of 95% atypical lymphocytes, 2% monocytes, and 3% neutrophils; a blood urea nitrogen level of 10 mg/dL (3.6 mmol/L); a creatinine level of 0.5 mg/dL (44.2 μmol/L); and a potassium level of 3.0 mEq/L (3.0 mmol/L). The patient is admitted to the hospital, and flow cytometry on a bone marrow aspirate shows pre–B-cell acute lymphocytic leukemia. The girl begins chemotherapy with vincristine, doxorubicin, and prednisone, with planned L-asparaginase on day 4 of therapy. Twenty-four hours after beginning therapy the nurse calls and
says that the patient has not urinated in 8 hours. The blood pressure is now 140/90 mm Hg. Laboratory data show a blood urea nitrogen level of 30 mg/dL (10.7 mmol/L), a creatinine level of 2.5 mg/dL (221.0 μmol/L), a phosphorus level of 6 mg/dL (1.9 mmol/L), a calcium level of 7.5 mg/dL (1.9 mmol/L), a lipase level of 100 U/L (1.7 μkat/L), and a potassium level of 5.0 mEq/L (5.0 mmol/L).

Which of the following is the most likely explanation for the change in the patient’s status and laboratory data?

  1. Cardiac Failure
  2. Dehydration
  3. Gastrointestinal bleeding
  4. Pancreatitis
  5. Tumor Lysis Syndrome

3. A 15-year-old boy is brought to the office for routine health care maintenance. He has been generally doing well, but his medical history is significant for acute myelogenous leukemia treated with cytarabine, daunorubicin, etoposide, and mitoxantrone. He has been off therapy and in continuous remission for 7 years and is doing well in school. His physical examination shows no abnormalities. He is Tanner stage 4.

Which of the following is the most appropriate test to perform in this patient?

  1. Echocardiography
  2. Hearing Evaluation
  3. Hemoglobin A1c
  4. Serum Follicle-Stimulating Hormone, Luteinizing Hormone, and Testosterone
  5. Radiographs of the Hips

4. The most urgent complication in a patient with Non-Hodgkin’s Lymphoma that needs to be evaluated at diagnosis and followed closely is:

  1. An elevated WBC > 50,000
  2. A uric acid of 5.0
  3. A mediastinal mass
  4. Complaints of left flank pain

5. A 10-year-old girl presents with cervical lymphadenopathy and dyspnea. She is found to have a large mediastinal mass and pancytopenia. On day 3 of chemotherapy she has a serum potassium level of 6.2 mEq/L (6.2 mmol/L), a serum calcium level of 6.0 mg/dL (1.5 mmol/L), a serum phosphorus level of 7 mg/dL (2.3 mmol/L), and a serum uric acid level of 10 mg/dL (594.9 μmol/L).

Which of the following is the most appropriate management plan for this patient?

  1. Cardiac telemetry and administration of rasburicase
  2. Maintenance fluid hydration and repeat laboratory studies in 24 hours
  3. Measurement of cardiac ejection fraction and administration of allopurinol
  4. Monitoring of urine output and administration of allopurinol
  5. Monitoring of urine pH and administration of rasburicase

6. A 4-year-old boy is brought to the clinic for evaluation of a 2-month history of bone pain and recurrent fever. He is found to have hepatosplenomegaly and pancytopenia. Serum uric acid and potassium levels are within the reference range but there is hypocalcemia and hyperphosphatemia.

Which of the following is the most appropriate initial management for this patient?

  1. Hyperhydration and alkalization to maintain urine pH 6.5 to 7.5
  2. Hyperhydration and allopurinol therapy
  3. Maintenance hydration and allopurinol therapy
  4. Maintenance hydration and calcium carbonate supplementation
  5. Maintenance hydration and parenteral calcium therapy

Find the answers here.