Virtual Rounds Session 3: Leukemias (Premed Shadowing)

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Throughout each premed virtual shadowing session, you will actively participate by answering and asking questions about the week’s proposed case. Like an in-person shadowing experience, we strive to stimulate students intellectually and ultimately reaffirm their interest in medicine.

Introduction – Leukemias

Cancer is a topic of which is near and dear to the lives of many. When we discuss leukemia as a concept, we are focusing on cancer of the blood and blood components. This can certainly be a challenging topic to learn but rewarding nevertheless.

Case Highlights

A 66 y/o M w/ presents to your clinic with a two month history of LUQ abdominal pain and fatigue. He states that he used to walk his golden retriever 2.5 miles every morning but as of lately, can barely reach the end of the driveway without feeling SOB and light-headedness. He notes that he has lost 20 lbs over the last two months and is not dieting or trying to lose weight. His spouse is present for the interview and states that he often soaks the bed sheets with his sweating each night, which led to her urging him to be seen. He denies recent illness, CP, N/V/D, or HA. He is currently retired and worked for a nuclear power plant for 41 years.

Pathology

There are primarily two ways to classify leukemia:

ACUTE leukemia

• This refers to mature or terminally differentiated cells (not immature or blast cells), which are often in excess.
  • Mature cells generally have clumped chromatin with the nucleus taking up less of the cell as compared to immature blast cells.
• Ex: ALL (acute lymphoid leukemia), AML (acute myeloid leukemia)

Pictured above: ALL :https://webpath.med.utah.edu/HEMEHTML/HEME018.html

CHRONIC leukemia

• This means immature cells or blast cells (myeloblasts, lymphoblasts, etc.)
  • Immature or blast cells generally have fine, lacey chromatin, a high nucleus to cytoplasmic ratio, and presence of nucleoli
• Ex: CML (chronic myeloid leukemia), CLL (chronic lymphoid leukemia)

Pictured below: CLL:https://www.stepwards.com/?page_id=1011

In terms of risk factors or exposures of which place one at risk for developing leukemia, we might consider:

• Occupational or lifestyle exposures
  • Solvents, smoking, radiation
• Prior radiation or chemotherapy
• Genetic conditions such as Down Syndrome or other myelodysplastic syndromes

To diagnose leukemia, we often take into consideration the clinical picture of the patient (ex. Fatigue, weight loss, bruising, abdominal pain, etc.) coupled with laboratory or other diagnostic tests. A complete blood count (CBC) with differential may show an elevated white blood cell count (leukocytosis), perhaps with signs of anemia and the presence of immature cells. Additional tests we can consider are a bone marrow biopsy, Fluorescence In Situ Hybridization (FISH), flow cytometry, and PCR to detect abnormalities present.

Treatment is often specific to the type of leukemia as well as the type of mutation present. Many drugs target specific known mutations that lead to the development of abnormal cancer cells. For instance, the drug imantinib is a tyrosine kinase inhibitor which targets the mutation t(9;22) in CML which leads to an abnormally functioning tyrosine kinase.

Take home points

1. Leukemia is a complex topic of which can be divided into acute and chronic leukemias.
2. Acute leukemias are composed primarily of large amounts of immature or blast cells.
3. Chronic leukemias are typically differentiated or mature cells BUT in excess. These cells are typically not functional, despite the large number of them. This can lead to bleeding and infections as a result.
4. Exposures to radiation, solvents, chemotherapy, or smoking coupled with a history of weight loss, bleeding, and fatigue can point us in the direction of leukemia.
5. Treatment for leukemia is often specific to the type of leukemia itself in order to target mutations of which lead to the abnormal cells.

Watch the virtual shadowing session here:

Virtual Rounds Session 3: Leukemias (Premed Shadowing)

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