Literature Summary

Major Literature


Ganzel et al, Blood Reviews 2012

  • Hyperleukocytosis = WBC >100,000
    • 10-30% in ALL
  • Complications associated w/ hyperleukocytosis
    • Leukostasis
      • Increased blood viscosity and/or endothelial activation by blasts secrete cytokines that promote more blast recruitment --> vascular obstruction
      • CNS and lung most commonly affected
        • CNS:  confusion, dizziness, HA, tinnitus, vision change, delirium, ataxia, somnolence, coma, ICH
        • Lung:  SOB, tachypnea, hypoxemia, infiltrates
      • Other organs
        • Acute leg ischemia
        • Renal vein thrombosis
        • Priapism
      • In pediatric ALL, leukostasis most prevalent w/ WBC >400,000
    • TLS
      • Due to high cell turnover
      • HyperUA, hyperPhos, hyperK, hypoCa
    • DIC
      • Due to high cell turnover --> exposes endothelium to high levels of tissue factor --> triggers extrinsic coagulation pathway
  • Why treat?
    • To prevent above complications
    • Chemotherapy can further increase risk of above complications if WBC high
  • How do you treat?
    • Hydration
    • Allopurinol (chemical cytoreduction)
    • Leukapheresis (mechanical cytoreduction)
      • Indications
        • Reduce acute sxs from leukostasis
        • Prevent leukostasis
        • Avoid/Reduce severity of TLS and DIC
      • Efficacy
        • Single cycle can reduce WBC by 20-50%
        • Most authors suggest WBC <100,000 as the goal
        • May reduce early death (mortality in the first 2 weeks) but no effect on cancer remission rates or overall survival
      • Complications
        • HypoCa from citrate toxicity
        • RBC or platelet loss during the procedure
        • Venous access complications (bleed, infection, thrombosis)
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