AKT · Haematology/Haemato-oncology

Acute leukaemia (ALL & AML)

Malignant proliferation of immature blasts in the marrow → marrow failure (rapid onset)

Overview

Aggressive malignancies of haematopoietic precursors in which immature BLASTS replace the marrow, causing rapid marrow failure (anaemia, neutropenia, thrombocytopenia). Acute lymphoblastic leukaemia (ALL) is commonest in children; acute myeloid leukaemia (AML) predominates in adults. Presentation is over days–weeks with the consequences of cytopenias plus blasts on the film/marrow; it is a haematological emergency (neutropenic sepsis, bleeding, tumour lysis).

Recognise

Rapid onset of marrow failure: anaemia (fatigue/pallor), neutropenia (infections/fever), thrombocytopenia (bruising/bleeding/petechiae); bone pain
Blasts on blood film; ALL — children, lymphadenopathy, hepatosplenomegaly, CNS/testicular involvement; AML — adults, gum infiltration, AUER RODS, DIC (esp. acute promyelocytic leukaemia)
AML may present with DIC (acute promyelocytic leukaemia, APML — t(15;17)); blast crisis can transform from CML

Red flags

Neutropenic sepsis, bleeding from thrombocytopenia/DIC, or tumour lysis syndrome → emergencies
Acute promyelocytic leukaemia (APML) with DIC → urgent (all-trans retinoic acid + supportive); hyperleukocytosis/leukostasis → emergency

Differentials & how to tell them apart

Chronic leukaemiamore indolent, mature cells; CLL (lymphocytosis, smear cells), CML (Philadelphia chromosome, massive splenomegaly)

Aplastic anaemia / marrow failurepancytopenia WITHOUT blasts — marrow distinguishes

Leukaemoid reaction / infectionreactive — no blasts/clonal marrow

Investigations

FBC (cytopenias ± high WCC), blood FILM (blasts; Auer rods in AML), urgent bone marrow (≥20% blasts) with immunophenotyping/cytogenetics; coagulation/fibrinogen (DIC); LDH/urate/U&Es/calcium/phosphate (tumour lysis); LP for CNS involvement (ALL).

Management

Urgent haematology + supportive care (sepsis/transfusion/tumour-lysis prophylaxis) → intensive chemotherapy

1Suspect from rapid marrow failure + blasts on film; arrange urgent bone marrow (≥20% blasts) with immunophenotyping/cytogenetics. Provide supportive care — treat neutropenic sepsis, transfuse, and give tumour-lysis prophylaxis (hydration + allopurinol/rasburicase).Gate: Acute promyelocytic leukaemia (APML, t(15;17)) presents with DIC and is an emergency → all-trans retinoic acid; manage tumour lysis and bleeding urgently.
2Type-specific intensive chemotherapy (CNS prophylaxis in ALL), stem-cell transplant and targeted agents for high-risk/relapsed disease.

Urgent haematology referral + supportive care — treat neutropenic sepsis, transfuse, manage DIC; tumour-lysis prophylaxis (hydration + allopurinol/rasburicase)

Intensive chemotherapy (regimen by type) — ALL and AML protocols; CNS prophylaxis in ALL

APML: all-trans retinoic acid (ATRA) ± arsenic — a haematological emergency — ATRA corrects the DIC and is curative-intent

Stem-cell transplant; targeted agents — for selected high-risk/relapsed disease

Key points

Days-to-weeks of marrow failure (anaemia + neutropenia/infection + thrombocytopenia/bleeding) + BLASTS on film = acute leukaemia → urgent marrow + supportive care + tumour-lysis prophylaxis. ALL = children (CNS/testicular); AML = adults (Auer rods); APML (t(15;17)) presents with DIC → ATRA. Watch neutropenic sepsis and tumour lysis.

Monitor & prognosis

Counts/marrow remission, sepsis/bleeding/tumour-lysis surveillance, treatment toxicity.

Childhood ALL highly curable; adult AML poorer; APML good with ATRA; depends on cytogenetics.

Source: BSH; cross-ref child_health (ALL)