acute nonlymphocytic leukemia in the elderly
Introduction
Introduction to acute non-lymphocytic leukemia ANLL is an acute non-lymphocytic leukemia secondary to myelodysplastic syndrome or chemotherapy drugs, mainly showing anemia, fever, and hemorrhage. basic knowledge The proportion of illness: the incidence rate of middle-aged and elderly people over 50 years old is about 0.03%--0.07% Susceptible people: the elderly Mode of infection: non-infectious Complications: anemia
Cause
Acute non-lymphocytic leukemia in the elderly
Genetic factors (20%):
Familial leukemia accounts for 0.7% of leukemia, and the incidence of leukemia in the same twin is three times higher than that of other people. B-cell chronic lymphocytic leukemia is familial, congenital diseases such as Fanconi anemia, Down syndrome, Bloom syndrome, etc. The incidence of leukemia is high.
Other blood diseases (10%):
Such as chronic myeloid leukemia, MDS, myeloproliferative diseases such as essential thrombocytosis, myelofibrosis and polycythemia vera, paroxysmal hemoglobinuria, multiple myeloma, lymphoma and other blood diseases may eventually develop into acute Leukemia, especially ANLL.
Ionizing radiation (10%):
X-ray diagnosis and treatment, 32P treatment, the incidence of leukemia in the population of atomic bombs is high.Chemical factors (10%):
Benzene and its derivatives, antineoplastic agents such as alkylating agents and etoposide, and bis-morpholine for the treatment of psoriasis can cause leukemia, especially ANLL.
Virus (20%):
For example, a type C retrovirus, human T lymphocyte virus-I, can cause adult T cell leukemia.
Prevention
Elderly acute non-lymphocytic leukemia prevention
Risk factor
(1) Ionizing radiation After the atomic bomb attack in Hiroshima, Hiroshima, Japan, the incidence of leukemia among survivors was 30 times and 17 times higher than that of unexposed people. The dose of radiation (100-900 cGy) was closely related to the incidence of leukemia. The incidence of leukemia was 3.5 times that of the control group, mostly acute lymphoblastic, acute or chronic myelogenous leukemia, the mother had a history of X-ray exposure during pregnancy, and the increase in the number of X-rays before the pregnancy, the risk of childhood leukemia increased.
(2) chemical factors benzene-induced leukemia has been confirmed: such as the incidence of early shoe-making workers (contact with benzene glue) is 3 to 20 times higher than the normal population, alkylating agents (such as nitrogen mustard, benzene butyl) Acid nitrogen mustard, cyclophosphamide, busulfan, etc. can cause secondary leukemia, especially in tumors with lymphoma or immune system defects. The effect of bis-morpholine-induced leukemia has been reported in recent years. Derivatives of ethylamine have strong chromosomal aberrations. Chloramphenicol and phenylbutazone may also cause leukemia. Leukemia caused by chemical substances is mostly acute leukemia.
(3) Carcinogenic viruses Human leukemia caused by viruses is only found in adult T-cell leukemia (ATL): it is caused by human T lymphocytotrophic virus-I (HTLV-I), which is C The type of RNA retrovirus can be transmitted through sexual transmission, and the blood products can be transmitted laterally to the offspring. From 1984 to 1990, 11 cases of ATL patients were found in China, mostly in coastal areas.
(4) Among the children with genetic factors, one person has acute leukemia, the other one has 25% higher risk of leukemia than normal people, and the leukemia is the same type. The relationship between congenital diseases and leukemia is also compared. Close, such as congenital stupid (Down syndrome) is often prone to leukemia, the incidence of acute leukemia is 20 times higher than normal.
(5) Hematological diseases Some blood diseases may eventually develop into acute leukemia, such as chronic myeloid leukemia, polycythemia vera, essential thrombocytosis, myelofibrosis, myelodysplastic syndrome: paroxysmal nocturnal hemoglobinuria , lymphoma, multiple myeloma, etc.
(6) Others: Other factors that can cause leukemia include gasoline, organic solvents, insecticides, hair dyes, arsenic agents, and coatings.
2. Tertiary prevention
Primary prevention:
1 Eat more fresh fruits and vegetables, reasonable diet, proper physical exercise, and enhance the body's resistance.
2 For the application of radiopharmaceuticals and chemical agents (especially alkylating agents), it is necessary to strictly control the indications and drug dosages to avoid abuse, and at the same time or subsequently give corresponding protective drugs to reduce the occurrence of drug-induced acute leukemia.
3 Take necessary protective measures for people who work in the radioactive environment for a long time, such as wearing anti-radiation isolation suits, regular treatment, supplementing with multivitamins, etc., and keeping and isolating radioactive instruments or articles to avoid surrounding people. radiation.
4 pregnant women should avoid ionizing radiation and unnecessary drug intake during pregnancy.
5 Promote environmental protection and reduce pollution of natural resources (such as water, atmosphere, soil, etc.).
Secondary prevention: Screening for high-risk groups, the elderly should undergo regular physical examinations, in order to find asymptomatic leukemia patients, to provide necessary further examination of suspicious cases, to achieve early detection, early diagnosis, early treatment, the most commonly used examination There are blood routine, white blood cell classification, platelet morphology and bone marrow aspiration, B-ultrasound and so on.
Tertiary prevention: For patients who have been diagnosed with acute leukemia, according to the state of the body, the progress of the disease, the system of regular treatment of various important organ functions, control the condition, improve the quality of life of patients and prolong the survival period.
Complication
Elderly patients with acute non-lymphocytic leukemia Complications anemia
There are mainly anemia, bleeding, infection and so on.
Symptom
Symptoms of acute non-lymphocytic leukemia in the elderly Common symptoms Thrombocytopenia Skin infiltration Intravascular Coagulation Joint pain Respiratory failure Intracranial hemorrhage Qi dynasty snoring Nodular renal failure
The clinical manifestations of acute non-leaching are similar to those of acute drenching. There are four major clinical manifestations, namely: anemia, fever, hemorrhage and infiltration, which are similar to those of acute drenching, and will not be described again, but they are different from acute drenching. And the specificity of each subtype of ANLL is described.
1. At least half of the cases of acute non-leaching cases have bleeding symptoms. The main cause of bleeding is thrombocytopenia, but the possibility of disseminated intravascular coagulation (DIC) may not be neglected, especially in the acute promyelitis of M3 subtype. In the case of cell leukemia, the clinical bleeding symptoms are obvious, the severity and breadth of the bleeding, especially the extensive hemorrhage in many parts, the subcutaneous hemorrhage has developed into a large purple spot by the purpura, and these bleeding phenomena are difficult to explain to the primary disease. It is suspected and excluded from disseminated intravascular coagulation.
2. The symptoms of bone and joint pain are much less than that of ALL, generally less than 20%. Lymph nodes, liver, spleen and other swelling can be seen in half of the cases, but the swelling is lighter than ALL, and the incidence is lower than ALL.
3. About 10% of cases of skin infiltration, the skin flushing, or the disease is blue-purple, nodular, skin lesions are more common in M5 subtype acute monocytic leukemia.
4. The gums are infiltrated, swollen and grayish blue, which is characteristic of mononuclear cell infiltration.
5. At the beginning of the disease, there are fewer central nervous system leukemias than ALL, but in the ANLL peripheral blood high white blood cells, the chance of brain leukemia in mononuclear cell subtypes (M5) will increase.
6. The subperiosteal infiltration of the eyelids can be a green tumor, which pushes the eyeball outward, which is characteristic of ANLL infiltration.
7. In a small number of cases, the peripheral blood showed a high white blood cell count >100×109/L. Such cases are prone to leukostasis, and the leukocyte stasis of the pulmonary capillary bed appears anxious, voice and interstitial infiltration. Severe respiratory failure, showing the performance of respiratory distress syndrome, poor prognosis, white blood cell stasis in the central nervous system, often accompanied by intracranial hemorrhage, often cause death, leukocyte stasis of genitourinary system can occur abnormal penile erection, hyperuricemia Symptoms and kidney failure.
8. Classification
(1) FAB classification: acute non-lymphocytic leukemia is divided into 9 types as follows:
M0 (acute differentiation of acute myeloid leukemia): The original cells are similar to L2 cells under light microscope, with obvious nucleoli, cytoplasmic transparency, basophilic, no azurophilic particles and Auer bodies, myeloperoxidase (MPO) ) and Sudan black B positive cells <3%; under electron microscope, MPO (+); CD33 or CD13 and other myeloid markers can be (+), lymphoid antigens are usually (-), but sometimes CD7+.TdT+; Non-leukemia can express CD7+.TdT+.
M1 (undifferentiated type of acute myeloid leukemia): Undifferentiated granulocytes (type I + type II) account for more than 90% of bone marrow non-young red blood cells, at least 3% of cells are peroxidase stained (+), protoplasmic cytoplasm No particles in the type I, and a few particles in the type II.
M2 (acute differentiation of acute myeloid leukemia): Myeloblasts account for 30% to 89% of bone marrow non-young red blood cells, monocytes <20%, and other granulocytes >10%.
M3 (acute promyelocytic leukemia): Multi-granular promyelocytic cells are predominant in the bone marrow, and such cells are 30% in non-erythroid cells.
M4 (acute granulocyte-monocytic leukemia): primordial cells in the bone marrow account for more than 30% of non-erythroid cells, granulocytes account for 30% to 80% at each stage, and mononuclear cells at each stage are >20%.
In addition to the M4 type of M5Eo, eosinophils 5% in non-erythroid cells.
M6 (acute monocytic leukemia): the original mononuclear cells in the non-erythroid cells of the bone marrow, 80% of the young mononuclear cells and monocytes, if the original monocytes are 80% M5a, <80% is M5b.
M7 (acute erythroleukemia): erythrocytes in the bone marrow 50%, primordial cells in non-erythroid cells (type I + type II) 30%.
M8 (acute megakaryoblastic leukemia): 30% of primitive megakaryocytes in the bone marrow.
In China, M2 is divided into M2a and M2b2, M2a is M2, and M2b is a subtype proposed by China. It is characterized by a marked increase in primordial and promyelocytic cells in the bone marrow, but with abnormal neutrophils. Granulocytes are predominant, their nucleus often has nucleoli, and there is an obvious imbalance in nucleoplasm development. Such cells are >30%.
(2) Immunophenotyping: The immunological expression of CD33 in acute non-leaching cells was positive in the acute cells of acute non-leaching, but the acute lymphoblastic was negative.
CD33 is positive for normal promyelocytic promyelocytic cells, mesenchymal cells and monocytes, CD11b, CD14.CD36 is positive for monocyte cells, CD13 is positive for myeloblasts, and CD13 and nuclear TdT are reported. The prognosis of the positive patients was poor, while the CD15 positivity responded well to chemotherapy. The acute non-lymphocytes were not expressed on the lymphoid antigens CD19, CD20, CD21 and CALLA, and only less than 5% of the acute non-leaching expression of TdT Positive, Ia/HLA-DR is expressed in most acute non-leaching.
(3) cytogenetic classification: acute non-leaching chromosome change M1 has monomer 5, t (6; 9), t (9; 22), M2 has monomer 7. monomer 5, t (8; 21) , t(9;11),del(11),INV(16),t(6;9), M3 shows t(15;17), M4 has monomer 7,t(8;21),t(9) ; 11), del (11), t (6; 9), M4EO see INV (16), M5 has monomer 7, t (9; 11), del (11), INVt (16).
(4) Molecular biology:
Diagnosis can be based on medical history, clinical manifestations, blood tests and bone marrow examinations.
Examine
Examination of acute non-lymphocytic leukemia in the elderly
Peripheral blood
At the time of onset, the peripheral blood leukocyte counts can vary, but the total white blood cell count is less than that of ALL, especially in the M3 subtype acute promyelocytic leukemia. The peripheral blood leukocyte count is about half of the cases <3×109/ L, a small number of cases of peripheral blood can show a significant high white blood cell count (> 100 × 109 / L), easy to see M4 and M5 subtype, peripheral blood can appear leukemia cells, such a rod-like body can be seen in the cytoplasm (Auer Rod) is a granulocyte or mononuclear cell, the peripheral blood leukocyte count is low, and there is no type of non-leukemia leukemia of leukemia cells. In fact, it is rare. Patients often have moderate anemia at the time of diagnosis, and reticulocytes are reduced. Peripheral blood may have nucleated red blood cells, usually young red blood cells, and thrombocytopenia is often obvious. When DIC is complicated, platelets are more reduced.
2. Bone marrow
In most cases, nucleated cell proliferation is markedly active, and a large number of leukemia cells appear. In a small number of cases, the nucleated cell proliferation of bone marrow is reduced. The peripheral blood of such cases also shows a decrease in white blood cell count, and the proportion of leukemia cells in the bone marrow is reduced in myeloid proliferation. Cases are sometimes lower, can be less than 40%, called acute leukemia with low percentage of blast cells, erythroid precursor cells can have megaloblastic changes, especially in cases of erythroleukemia or acute non-leukemia leukemia hematopoietic abnormal syndrome Evolving, erythroid cell proliferation is mostly inhibited in ANLL (except for M6), and megakaryocyte cell lines are also inhibited.
3. Cell chemistry.
4. Blood biochemistry
(1) hyperuricemia: can be seen in half of ANLL cases or when leukemia cells destroy and dissolve.
(2) increased lysozyme: can be seen in monocytic leukemia M4 and M5, lysozyme too high may cause renal tubular damage, clinical need to be vigilant.
(3) Examination of disseminated intravascular coagulation: more patients with DIC than ALL in ANLL, especially those with M3 subtype. Laboratory tests often show thrombocytopenia, but most cases have shown thrombocytopenia due to ANLL diagnosis. Therefore, this parameter has little reference value in leukemia cases complicated with DIC. Fibrinogen is decreased in DIC, prothrombin time is prolonged, fibrin cleavage product is increased, plasma protamine co-coagulation test is positive, and there is 5th. Factor reduction.
(4) Cell colony formation: Colony formation of leukemia cells can be divided into five types, namely:
1 non-growth type;
2 small cluster type;
3 large cluster type;
4 The ratio of clusters to colonies is abnormally increased;
5 clusters, the colony ratio is normal, and the type 1, 3, and 4 have poor response to chemotherapy, but it has also been reported that only type 3 has a poor prognosis.
X-ray examination: chest radiograph shows anterior mediastinal mass accounted for 5% to 10% of cases, thymus enlargement often accompanied by pleural effusion, such cases are common in T cell acute showers.
Diagnosis
Diagnosis and diagnosis of acute non-lymphocytic leukemia
1. Identification of bone marrow metastasis of solid tumors, such as bone marrow metastasis of neuroblastoma. These cells often appear in a pile of rosettes and are differentiated by electron microscopy if necessary.
2. Due to the clinical non-specific symptoms such as fever, joint symptoms, mild anemia should be differentiated from juvenile rheumatoid arthritis or lupus erythematosus, should not abuse the adrenal cortex hormone when the diagnosis is unknown, or it will lead to symptoms Relieve, delay diagnosis.
3. Certain infectious diseases such as infectious mononucleosis, toxoplasmosis, cytomegalovirus infection may have fever, lymphadenopathy and hepatosplenomegaly, and atypical lymphocytes can be seen in peripheral blood. Morphological examination.
4. In addition, the non-leukemia leukemia type in acute drenching should be differentiated from the aplastic anemia, but the bone marrow examination is helpful for the identification of these two types of diseases. The blood uric acid and lactate dehydrogenase in the biochemical aplastic anemia cases are all reduced. And can rise in leukemia.
