0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45
Acute Lymphoblastic Leukemia 33■Cardiac evaluation with ECG and determination of cardiac ejection
fraction by scandifferential diagnosis
■Reactive lymphocytosis (e.g., infectious mononucleosis, cytome-
galoviral infection, pertussis); acute myelogenous leukemia; acute
leukemic transformation from another underlying hematologic dis-
order (e.g., myelodysplasia, chronic lymphocytic leukemia; mantle
cell lymphoma; plasmablastic myeloma)management
What to Do First
■Initial medical management
■Following careful physical assessment, patient should be treated for
complications of bone marrow failure (e.g., transfusion of red cells
and/or platelets for anemia or severe thrombocytopenia and treat-
ment of infection with appropriate antibiotics)
■Metabolic status must be assessed and stabilized (i.e., administra-
tion of adequate hydration to avoid complications of tumor lysis);
allopurinol should be used to prevent and treat hyperuricemia, but
should be stopped following initial reduction of the tumor load;
allopurinol should be stopped after day 6–12, depending on the
metabolic parameters. Rasburicase (a recombinant urate-oxidase
enzyme) has been approved for the initial management of pediatric
patients with leukemia, lymphoma, and malignancies anticipated
to result in tumor lysis upon treatment. This agent appears to be
effective in preventing hyperuricemia and may reduce the need for
alkalinization of the urine, thus improving the negative impact of
alkalinization on phosphates in impairing renal function.
■Patient should have central intravenous access for optimal manage-
ment during induction chemotherapy.
■Prophylactic antibiotics & antiviral & antifungal agents should be
considered for the uninfected patient until neutropenia has resolved;
all patients should receive Pneumocystis prophylaxis starting with
the second course of chemotherapy; granulocyte colony-stimulating
factor (G-CSF) is given to patients after waiting at least 24 h after the
last dose of cytotoxic chemotherapy (e.g., day 4 until neutrophils
have recovered to >5,000 after the nadir); caution must be exercised
in selecting prophylactic agents to avoid drug allergies. Furthermore,
caution must be used in understanding the impact of multiple con-
comitant medications on chemotherapy agents used throughout