Adult Leukaemias

When someone suffers from any of the leukaemias, they have more white blood cells than is normal, and those cells are not very effective. Because there are so many circulating cells, there is an imbalance between the cells and the liquid they are contained in.

When there are too many cells, the blood has great difficulty circulating because the blood is harder to push round, so that oxygen is not carried to the tissues as effectively as usual.

As the whole of the bone marrow, where the blood cells are produced, is somehow not functioning normally, even the red blood cells that carry oxygen around the body are less efficient than normal, and there is often a degree of iron deficiency anaemia.

White blood cells, as well as red blood cells and platelets, are produced in the bone marrow. There are two separate lines of development of white cells, one called myeloid, which mainly makes neutrophils, the other called lymphoid, which makes lymphocytes.

Leukaemias are divided into acute, which basically means sudden and very aggressive, and chronic, in which the condition develops slowly and is less serious. Leukaemias are therefore called acute lymphoblastic, acute myeloid, chronic lymphocytic or chronic myeloid.

Symptoms and Signs.

The first symptoms or signs of one of the leukaemias depends upon which cells are produced reasonably normally, and which ones are abnormal. An iron deficiency anaemia occurs quite often, if the red blood cells are not able to incorporate iron normally, so fatigue or lack of energy may be one of the first features.

If the great increase in the production of white blood cells ‘smothers’ the production of platelets, which may also function less efficiently than usual, spontaneous bruising or outright bleeding may occur, such as nosebleeds, because of clotting abnormalities. Sometimes a joint is damaged and swells most painfully.

When it is found to be full of blood, doctors question the possibility of leukaemia. In acute myeloid leukaemia, however, there is sometimes a risk of the blood clotting too easily, and this can be the first indication of the disease.

Persistent infections may sometimes be the presenting sign, if there is a low count of certain of the white blood cells (even if others are being produced in very large amounts), all of the cells being functionally deficient.

If there are very large numbers of white cells, the patient may complain of not being able to think or concentrate properly, probably because of poor oxygen delivery to the brain. Whatever the symptoms or signs, clearly the bone marrow is failing to do its job properly.

When a doctor examines a patient suffering from leukaemia, enlarged lymph glands may be felt anywhere in the body, and the spleen may be larger than usual. Under normal circumstances it cannot be felt, as it is tucked under the ribs on the left side, but in leukaemia, an experienced hand can easily feel it.

Sometimes the liver is also swollen. If the leukaemia involves the central nervous system, a nerve palsy may develop, such as can suggest a stroke.

Acute lymphoblastic leukaemia is the one that tends to develop in children, although it can occur in all ages. Acute myeloid leukaemia is more common in older people and in those who have previously had a form of chemotherapy.

Chronic myeloid leukaemia is characterised by a raised level of Philadelphia chromosome (where there is a change of position of genetic material between the long arms of chromosome 9 and 22).

In this condition, patients’ status may alter and the bone marrow may develop myelofibrosis, when fibrous tissue seems to develop in the bone marrow, with the result that blood cells are not formed as much and as well as they should be, but large numbers of white cells are also no longer produced.

In a way one could suggest that the bone marrow has simply become worn out, and the leukaemia has gone into remission, but has left the bone marrow in a rather weak state. I have an elderly lady as a patient who needed regular blood transfusions before she first came to see me, who has done remarkably well and also feels a lot better.Investigations.

Investigations revolve almost entirely around analysing the blood and bone marrow. As the condition is effectively confined to the bone marrow, there is little value in doing any scans. While both the liver, the spleen and groups of lymph glands may become enlarged, they can be assessed by a doctor’s examining hand. However, scans and X-rays may be carried out if the specialist feels they can be of value.

Conventional Treatment.

Treatment of all forms of leukaemia is with specific regimes of chemotherapy, usually a cocktail of drugs. The use of radiotherapy is confined to reducing the swelling of the spleen or groups of lymph glands,

Because the effect of chemotherapy is to try to suppress the rapid growth of cells in the bone marrow, it sometimes overdoes things, in which case the patient’s immune system becomes severely compromised.

This puts the patient at risk of developing a fatal infection, or bleeding to death, which is why Oncologists regularly examine the patient’s blood to see what effect the prescribed treatment is having on the bone marrow. If there is a risk of infection, the patient will be treated with antibiotics, sometimes intravenously in hospital if the situation becomes severe.

In acute lymphoblastic leukaemia, chemotherapy can cause the death of so many cells that the body becomes overwhelmed by all that cellular debris. The patient is then at risk of developing kidney failure, a dangerously high level of potassium in the blood stream (there is a lot of potassium inside cells), which can ‘poison’ the heart, and a raised level of uric acid, which can cause gout.

Appropriate tests and drugs may therefore be needed to deal with any of these situations. Very occasionally, the central nervous system is involved in the whole process, needing chemotherapy into the spinal fluid and sometimes radiotherapy to the brain.

Newer drugs are gradually being introduced to treat some of the leukaemias, which are not considered to be chemotherapy. Interferons are also starting to be used.

Bone marrow transplant is often offered, and the preferred approach is to take a sample of the patients’ own bone marrow when in remission, to be given back at a later stage (autologous transplant). The alternative is to use a matching donor (allograft transplant), but this carries additional risks.

Unfortunately, the heavy doses of chemotherapy that are given to ‘kill off’ the person’s bone marrow sometimes render the person unable to fight off an infection, or the graft may simply not work.