10-17 Leukemia - Living Life on Your Feet Not on Your Knees

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17. A Teaching Case of Leukemia (Update 22 Septr 2021)
 The following descending column of headings in order of appearance in the chapter, for your guide in the reading.

Chronic Lymphocytic Leukemia (CLL)

Preventing or dealing with anemia

Blood transfusion

prevent unnecessary blood loss 

Splenectomy

Chemo and Monoclonal Antibody Therapy

Bone marrow and stem cell transplants

I have hands-on experience with Chronic Lymphocytic Leukemia (CLL). The patient, then in his 40s learned of his CLL 20 years ago, on a blood test that showed high white blood cell count (WBCt) almost completely of lympho(cyte)s. CLL is a leukemia that goes years sans symptom or sign except for high WBC so he was advised not to rush to get treated.
   Seven years passed and the WBC count rose to nearly 150,000 per microliter whole blood (20 times normal upper limit) with anemia shown by hematocrit (Hct) below 30% (normal 40 to 47%). Symptoms were surprisingly few.

Preventing or dealing with anemia is important. He tolerated the anemia to the extent he could fly international with hematocrit a little below 30%. (Not generally advisable)
   Anemia in CLL is from lymphocytes in bone marrow spacing out red blood cell production. One wants to sensibly prevent or keep the anemia not severe by eating healthily —-eating red meat for its iron and by taking supplements of high vitamins B12, folic acid and vitamin C. 

   Learning to live comfortably with anemia needs knowledge that the symptoms are due mostly to the low fluid blood-space volume which causes sudden low Blood Pressure and rapid pulse when standing up. Keep well hydrated with fluids and salt, and the low RBC will be acceptable for normal activities. But such a low RBC gives little tolerance for exercise, for high altitude and other low oxygen situation. Use electrolyte fluid intake – sports drink or Coke or Pepsi, and a high fluid intake per day and do not avoid salt. Another problem may be the oxygen-carrying supply for the heart's coronary arteries. So be sure of a good coronary artery reserve, and, in persons at risk, check the coronary artery circulation. And by all means keep your breathing-air from being overloaded with carbon monoxide (CO high in smokers). 

Blood transfusion ideally should come from close family relative not high risk for HIV or hepatitis. If possible, know your donor and have donors who want to help you and are on hand to directly transfer a unit or 2 of blood into your system. This means sensitive discussion with spouse, child, sibling, nephew/niece.

  And prevent unnecessary blood loss by only necessary blood sampling and avoiding accident-prone behavior and also watching your food and drink to avoid peptic ulcers of stomach or duodenum (Anti-ulcer diet advice; no drinking alcohol).
   Avoiding blood loss brings blood platelet count to mind. The CLL patient may have a low blood platelet count. Platelets prevent and limit bleeding and their function is sensitive to aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) like Advil or Motrin. Use acetaminophen (Tylenol) instead of other NSAIDS or aspirin.

Splenectomy is a treatment in CLL because the spleen becomes hyperactive in reaction to the abnormal cells and the hyperactivity may inhibit or shorten red blood cell life adding to the anemia that occurs in CLL. Another bad effect of the defective spleen is that it causes other WBC and immunoglobulin levels to get low, and that leads to easy infection with bacteria.
   The spleen gets very large and becomes a burden and a source of excess cardiac work that can throw an older patient into heart failure. If evidence of hyperactive spleen is found (enlarged organ, shortened RBC life, low platelet count, or Coombs positive blood test) a splenectomy will prolong survival in good life quality. Finally the very large spleen can rupture from even minor bumps. The patient I observed developed a spleen 9x normal size and it lacerated from a minor fall and he had to get an emergency splenectomy in 2008. He nearly died in the ICU but after a week of good care he got better and since then he has had a good quality of life remission from his CLL and he is still standin’ happily in June 2021.  In some cases of CLL, the spleen seems to be the main source of the leukemia so splenectomy may give a long remission as happened in this case.

Chemo and Monoclonal Antibody Therapy: The combination of the chemo agent fludaribine and the monoclonal antibody rituximab has given high rates of complete and partial remissions. The addition of the chemo agent cyclophosphamide (Cytoxan) on many studies shows a small but significant advantage. More recently, very good results also seen with Bendamustine and Rituximab. This therapy is often, by experts, delayed until the CLL starts showing bad signs and symptoms. A WBCt mostly lympho count over 100,000 is an indication for chemotherapy.

Bone marrow and stem cell transplants: Now, with younger age CLL, the transplants are being tried more and getting a 50% cure rate. But risk to life is significant in marrow transplant because of the need to completely destroy the recipient's own marrow. So with a relatively mild leukemia like CLL a bone marrow transplant is not wise until patient is at end of other treatments. One should sign up for a transplant donor because it may take years to find compatible donor. (If you have a willing donor close DNA relative, cherish her or him)

You can be productive and happy if you do it right. Reading http://physiciansnotebook.blogspot.com and Slim Novels at http://adventuresofkimi.blogspot.com can help. And one learns to enjoy life even taking more risks than usual.

END OF CHAPTER. To read next click 10.18 Deathwatches