Treatment of leukemia

May 28, 2018 02:15 | Disease Treatment
For a long time, the treatment of acute leukemia was limited to the use of symptomatic agents. With the introduction of X-ray therapy, attempts were made to treat acute leukemia with X-rays, but soon abandoned this method, as the latter exacerbated the disease and accelerated the course of the process. In the future, blood transfusion was used to treat acute leukemia.

A milder action with leukemia is caused by transfusion of erythrocyte mass.

Currently in our country is a comprehensive method of treating leukemia, the basic principles of which are early onset and continuity. Evaluation of the results of treatment is made on the basis of clinical and hematological improvement. Remissions can be complete and partial.

Complete remission - absolute normalization of clinical and hematological parameters. In the bone marrow punctate, not more than 7% of immature pathological forms are found.

Partial remission - normalization of clinical parameters and partial normalization of peripheral blood of patients. In the bone marrow punctate, the content of immature pathological forms is possible up to 30%.

Clinical improvement is associated with the elimination of a number of clinical symptoms( a decrease in the size of the liver, spleen, lymph nodes, disappearance of hemorrhagic syndrome, etc.).

Hematologic improvement - partial normalization of only peripheral blood parameters( hemoglobin growth, Decrease in the number of immature forms, etc.).

For the treatment of acute leukemia, hormones and antimetabolites( 6-mercaptopurine and methotrexate) are currently used. These preparations can be combined in various combinations depending on the form and period of the disease.

In leukopenic forms of the disease with indistinctly expressed hyperplastic manifestations( weak enlargement of the liver, spleen and lymph nodes) shows the gradual inclusion of drugs( at first hormones, then antimetabolites).With tumor and generalized forms of acute leukemia, the combined use of drugs( hormones and antimetabolites) is shown more. At the onset of clinical-hematologic remission, hormones and antimetabolites are used as maintenance therapy, more often their combination.

Hormonal preparations have been widely used in the practice of treating leukemia prednisone, prednisolone, triamsinolone, etc.

The question of daily doses of hormonal drugs has not yet been resolved. Some researchers recommend the use of large doses of drugs, others - small. A number of researchers indicate the possibility of severe complications in overdose of hormonal drugs( diabetic syndrome, stomach and bowel ulcers, osteoporosis, sepsis, necrosis).

Currently, pediatricians adhere to moderate doses of hormonal drugs( maximum 50-100 mg per day).

Duration of treatment with hormonal drugs can not be limited to certain terms. Most researchers recommend treating patients with these doses of drugs before the onset of persistent clinical and hematologic improvement. In this case, do not immediately interrupt treatment with hormones, but you need to gradually reduce the daily dose. After achieving clinico-hematologic remission, a maintenance dose is prescribed.

The least toxic compounds of folic acid were introduced into the practice of leukemia treatment.

Folic acid antagonists are more effective in treating leukemia in children than in adults. In children, remission occurs frequently( up to 60%) and continues often up to 6-8 months. In the treatment of folic acid antagonists very often because of the toxicity of the drug occur side effects: necrosis of the mucous membranes of the oral cavity and gastrointestinal tract, diarrhea, vomiting, jaundice, oppression of bone marrow hematopoiesis, up to aplastic anemia.

Folinic acid, proposed for the elimination of toxic effects, removing side effects, simultaneously significantly reduces, and sometimes completely eliminates the therapeutic effect.

Many authors widely use 6-mercaptopurine( purinethol) in the treatment of leukemia in children. Clinical and hematological remission is observed quite often( up to 25-30%).

Initially, the proposed daily dose of 6-mercaptopurine 2.5 mg / kg is currently accepted by all clinicians. Depending on the individual characteristics of the patient and the severity of the disease, the dose may vary from 1.5 to 5 mg / kg. In children, it is recommended to start treatment with small doses( 1.5-2 mg / kg).In the future, in the absence of side effects, you can go to the full daily dose. The duration of treatment depends on its results, usually the improvement under the influence of treatment with 6-mercaptopurine occurs rather slowly( not earlier than 3 weeks).

Subsequently maintenance therapy of 1 / 2-1 / 3 of a daily dose is recommended. Treatment with 6-mercaptopurine is usually performed in combination with hormonal drugs or without them with pronounced resistance to the latter. In addition to hormones and chemotherapeutic drugs, other therapeutic measures are carried out.

1) Transfusion of erythrocyte mass in an amount from 30 to 100 ml, preferably one-group. The introduction is carried out dropwise 1-3 times a week, depending on the indications( the degree of anemia, the severity of the patient's condition, the temperature reaction).When the hemorrhagic syndrome shows the introduction of platelet mass.

2) The introduction of plasma is useful in conditions of toxicosis and expressed hemorrhagic syndrome.

3) Antibiotics( penicillin, streptomycin, biomycin, terramycin, tetracycline, etc.) should be administered with a pronounced temperature response or suspected complications and concomitant diseases.

4) Along with this, with leukemias, it is necessary to prescribe large doses of ascorbic acid.

5) Routine and vikasol should be taken with hemorrhagic forms. When exacerbating the hemorrhagic syndrome intravenously, it is necessary to inject plasma and 10% calcium chloride solution.

In the treatment of acute leukemia, some medicinal agents used for chronic leukemia( embichin, milerane, urethane) are contraindicated, as they exacerbate the course of acute leukemia. X-ray therapy, also contraindicated in acute leukemia, is used only for mediastinal tumors, which cause severe choking with a threat to the life of patients. Small doses of X-rays are used in the treatment of chloroleukemia. Also, the treatment of patients with acute leukemia with radioactive isotopes is contraindicated.

All the above methods of therapy, of course, extend the life of the patient and soften the course of the disease.

Most domestic hematologists believe that there is no need to "hurry" with therapeutic intervention in chronic leukemia, because all the existing medicines, while not being radical, can only speed up the process. In general, this situation can be extended to children with chronic leukemia. The pediatrician should deeply assess the condition of the child before initiating an "active" therapy with powerful chemotherapeutic or radiotherapy. It should not be forgotten that all modern means of treating chronic leukemia differ not only in affecting proliferating cells, but also in healthy tissues. The tactics of the doctor with this form of the disease should be to some extent expectant. If the child's condition is satisfactory, the temperature is normal, the liver, spleen and lymph nodes are slightly enlarged, and the red blood counts are high enough, so this patient, despite the increased number of leukocytes, needs only general restorative treatment. Noticeable worsening of the condition, frequent and high temperature rises, a significant increase in the spleen, a tendency to decrease hemoglobin and the number of red blood cells are an indication to the beginning of treatment. Treatment of chronic leukemia, according to EA Kost, justly, "is a great art on which the patient's life expectancy depends."

The derivatives of chloroethylamines( embichin and novembichin) and milerane( myelosan) are most common in the treatment of chronic leukemia in adults and children. Significantly less often pediatricians use urethane. There are separate reports on the treatment of chronic leukemia in children with triethylenethiophosphoramide( tiotef).

AF Tour recommends the following procedure for the use of embihin. The latter is administered intravenously with blood or saline at a rate of 0.1 mg per kg of body weight and embichine number 7, which acts milder - 0.15 mg per kg of body weight. Treatment begins with a 1 / 3-1 / 2 dose, bring it through 2-3 injections to the full. All for the course of treatment up to 10-12, less often 15-20 injections. The drug is administered 3 times a week. The therapeutic effect comes after 10-15 injections. Treatment with embihin can be combined with X-ray irradiation. Remission in this case lasts from several months to a year.

Further treatment can be performed on an outpatient basis in 2 weeks or 1-3 months after the first signs of a relapse( increase in the number of leukocytes, worsening of the leukocyte formula).

In the terminal period of the disease in the presence of cachexia, leukopenia and severe anemia, embichin is contraindicated. As side effects in the treatment with embichin, nausea, vomiting, leukopenia and deep lesions of organs in the form of necrobiotic processes may appear.

Mileran( myelosan) is less toxic and has pronounced antileukemic activity. It is considered the best drug in the treatment of chronic myeloid leukemia. Children with chronic leukemia are prescribed mileran at the rate of 0.06 mg per 1 kg of weight, which is 2-4 mg( maximum 6 mg) per day for 2-3 doses. The duration of treatment with milerane is 2-6 months. The main treatment is stopped when the clinical-hematologic remission comes.

Given the ability of milleran to cause leukopenia, thrombocytopenia, and in some cases pancytopenia, the main treatment is discontinued when the number of white blood cells is close to 30,000-20,000 per mm3;further maintenance therapy( 1 mg of the drug 2-3 times a week) continues. Sometimes already in the period of maintenance therapy the number of white blood cells in patients suddenly falls below 10 000. In such cases, stop treatment with milerane and resume only with the increase in the number of white blood cells. In each individual case, an individual approach to the patient is necessary, taking into account the characteristics of the reaction of its hematopoietic system, the form and period of the disease.

6-mercaptopurine is also used in the treatment of chronic leukemia during the blast crisis along with hormonal drugs. The duration of treatment depends on the result.

Tiotef is recommended to give per os at 5-10 mg per day until signs of clinical improvement appear.

Hormonal preparations( prednisolone, prednisone, triamsinolone, etc.) are used during the period of hemocytoblastic exacerbation of chronic leukemia in the same dose.

Radiation therapy in children should be performed with extreme caution because of the danger of aggravation. A more common and safe method is local irradiation, which is usually combined with transfusion of erythrocyte mass.

Indications for discontinuation of treatment: progressive decrease in the number of leukocytes, thrombocytopenia, hemorrhagic manifestations, high fever. Treatment of relapses should be started as late as possible. Contraindications to treatment: acute leukemia, anemia, significant rejuvenation of white blood( hemocytoblast exacerbation).
The indication for treatment with radioactive phosphorus is the presence of forms of chronic myelogenous leukemia, in which there is a pronounced resistance to treatment with chemotherapeutic drugs or X-rays.

Radioactive phosphorus is given on an empty stomach at a dose of 0.1-1.5 in 100 ml of 20% glucose solution at intervals of 8-10 days. When treating with radioactive phosphorus, adequate nutrition with the addition of ascorbic acid and liver drugs, abundant drinking is necessary. However, during the first 3-4 days from the start of treatment, food that is rich in phosphorus( eggs, meat, fish, caviar, cheese) is usually restricted. Remissions resulting from treatment with radioactive phosphorus continue for 2-12 months. This treatment is contraindicated in acute and subacute forms of leukemia, and it is not recommended for chronic leukemia, accompanied by severe anemia and thrombocytopenia, manifestations of hemorrhagic syndrome.

In addition to the above treatment methods, transfusions of erythrocyte mass( 50-100 ml) are applied again after 4-10 days, depending on the patient's condition and the phase of the disease. Transfusion of plasma is used in severe cases, accompanied by toxicosis and expressed hemorrhagic manifestations.

Transfusion of platelet and leukocyte mass is performed with pronounced thrombocytopenia and leukopenia. Antibiotics are prescribed in the treatment of patients with chronic leukemia strictly according to indications( with fever and with suspected involvement of concomitant disease).Along with medical and radiotherapy, treatment and diet are necessary.

In children with chronic leukemia, joining various types of infectious and colds can aggravate the course of the process. Physiotherapeutic procedures are contraindicated for these children. The question of preventive vaccinations should be decided individually. It is desirable to organize summer holidays for children in the area where the child lives permanently.

Thus, only by applying a set of measures can you improve the condition of patients and significantly prolong their lives.

We also recommend that you read the articles Treatment of acute leukemia and Treatment of chronic leukemia