Nursing Care of a Patient with B-Cell Acute Lymphoblastic Leukemia

TON - August 2011 VOL 4, NO 5 — August 23, 2011

Jayshree Shah, NP

Case Presentation

Chief complaint: Generalized arthralgia for 5 months.

History of present illness: A 35-year-old Hispanic man presented in November 2009 with generalized arthralgias that progressed to continuous shoulder and knee pain. Primary care physician evaluation revealed the complete blood count to be abnormal: complete blood count revealed a white cell count of 83,000/μL, a hemoglobin count of 17.9 g/dL, and a platelet count of 155/μL. In addition, biopsy revealed hypercellular bone marrow with involvement by a B-cell lymphoblastic leukemia. He was referred for emergent evaluation by a hematologist.

Flow cytometry revealed 80% to 90% abnormal cells expressing CD34, CD19, dim CD22, CD10, TdT, CD38, and HLA-DR, CD20(-). Fluorescence in situ hybridization for the Philadelphia chromosome fusion protein was negative. Full cytogenetics revealed a male karyotype with a translocation between the long arm of chromosome 1 and the short arm of chromosome 9 and addition to the long arm of chromosome 13 (deletion 13q) was observed in 6 metaphases. Five metaphases showed t(1;9) unbalanced translocation between the long arm of chromosome 1 and the short arm of chromosome 19. Three metaphases showed t(1;9) and der(9)t(1;9). Six metaphases showed a normal male karyotype. The t(1;19)(q23;p13.3) is reported to be associated with B-cell acute lymphoblastic leukemia (B-ALL). Translocations resulting in partial deletion of the short arm of chromosome 9 also are reported in ALL. The final diagnosis was B-ALL.

A baseline computed tomography scan revealed no enlarged lymphadenopathy in the chest, abdomen, and pelvic area. Multigated acquisition scan revealed the left ventricular ejection fraction to be 71%, which is within normal limits. The patient was treated with dexamethasone 40 mg for 4 days until induction chemotherapy was initiated. Induction consisted of hyperfractionated cyclophosphamide/vincristine/doxorubicin/dexamethasone (Hyper-CVAD) for 2 cycles of part A and B every 21 days with side effects related to mucositis, headaches, nausea, and fatigue. The patient also received intrathecal chemotherapy for 3 doses consisting of cytarabine and methotrexate during the induction.

Medical history: Unremarkable.
Surgical history: Spinal disc surgery (unknown date).
Family history: Mother alive with coronary artery disease and type 2 diabetes mellitus; father alive with coronary artery disease; 1 full sister who is not a human leukocyte antigen match and 2 half sisters. No family history of cancer.
Social history: Patient is currently married and has 1 daughter. He works for a drinking establishment in New York City. Denies tobacco use and consumes moderate amount of alcohol.
Medications: Dexamethasone 40 mg x 4 days, allopurinol 300 mg x 10 days, ciprofloxacin 500 mg twice daily, acyclovir 400 mg twice daily.
Allergies: No known drug allergies.
Physical examination:
General: Muscularly built Hispanic man, well dressed and well nourished accompanied with wife; no acute distress but appeared to be quite anxious.
Vital signs: Temperature: 98.2°F; heart rate: 96 beats/min; blood pressure: 151/83 mm Hg; central venous oxygen saturation: 99%; height: 67 inches; weight 166 lb.
Head, ears, eyes, nose, throat: No pallor; icterus.
Oropharynx: Clear.
Neck: Supple without jugular venous distension; no thyroid masses.
Chest: Clear to auscultation.
Cardiac: Regular rate and rhythm; no murmurs.
Abdomen: Soft, nondistended; no palpable masses. Spleen not appreciated.
Extremities: No edema.
Skin: No rashes.
Neurologic: Grossly nonfocal.
Lymphatic: Not palpable.
Laboratory values: White blood cell: 92.4/μL; hemoglobin: 15.6 g/dL; platelets: 131/μL.

Oncology nurses have an array of skills in and knowledge of cancer. As oncology nurse practitioners, it is vital that we help patients understand their cancer diagnosis. Often people think of solid cancers and liquid tumors as the same tumor type, which they are not. The problem for patients with liquid tumors is that their disease is not visible or palpable. When a cancer is of the blood, we must help them grasp the idea that they have leukemia. Only then can we discuss the treatments they will be receiving and the tests we will be performing, which in this case included frequent blood counts and bone marrow biopsies.

Nursing Interventions

For this patient, we started with teaching him the basics of reading a complete blood count and chemistry results, and educating him about the types of intensive chemotherapy he would be receiving as an inpatient and as an outpatient. It was very important that he understand the chemotherapy schedule, especially when to expect his counts to nadir, because of the risk for infection resulting from a severely suppressed immune system. As the oncology nurse practitioner, my role involved collaborating and coordinating with the physician, pharmacists, caretakers and family members, social worker, transplant team, and other nurses in the inpatient and outpatient setting to make sure the plan would be carried out to the best capability.

Chemotherapy education began with an explanation of the hyperfractionated cyclophosphamide/vincristine/doxorubicin/ dexamethasone (Hyper-CVAD) regimen. This regimen requires the patient to receive chemotherapy as both an inpatient and an outpatient. This patient would be scheduled to be admitted for 5 days every 21 days for part A chemotherapy followed by 4 days for part B chemotherapy. Part A chemotherapy consists of cyclophosphamide 300 mg/m2 over 3 hours every 12 hours for 6 doses on days 1 through 3, with mesna at the same total dose as cyclophosphamide but given by continuous infusion starting with cyclophosphamide and ending 6 hours after the last dose; vincristine 2 mg intravenous (IV) days 4 and 11; doxorubicin 50 mg/m2 IV day 4; and dexamethasone 40 mg days 1 through 4 and 11 through 14. Part B chemotherapy consists of highdose methotrexate 200 mg/m2 IV over 2 hours followed by 800 mg/m2 IV over 24 hours on day 1; leucovorin rescue starting 24 hours after completion of methotrexate infusion at 15 mg oral every 6 hours for 8 doses; until methotrexate levels are lower than 0.1 μM; cytarabine 3 g/m2 over 2 hours every 12 hours 4 times on days 2 and 3. In addition, we discussed the need to offer intrathecal (IT) chemotherapy central nervous system (CNS) prophylaxis. CNS prophylaxis is given according to the expected patient risk, based on previous multivariate analysis for prognostic factors for CNS leukemia. Patients are considered at high risk for CNS disease if the lactate dehydrogenase level is >600 U/L (normal laboratory reference level, 25 to 225 U/L). CNS prophylaxis is given with methotrexate 12 mg IT on day 2 and cytarabine 100 mg IT on day 8 of each cycle for 16 IT treatments for high-risk patients, 4 IT treatments for low-risk patients, and 8 IT treatments for patients of unknown risk.1

We also reviewed the antibiotic prophylaxis regimen, which would include ciprofloxacin 500 mg by mouth twice daily, acyclovir 400 mg by mouth twice daily, and fluconazole 200 mg daily. Supportive care with a granulocyte colony-stimulating factor would include pegfilgrastim 6 mg2 every 21 days for up to 8 cycles. We also discussed the option of having a peripherally inserted central catheter (PICC) to provide easier venous access because he was anticipated to require multiple blood and platelet transfusions, especially during the nadir timeframe. The patient agreed, and a PICC line was inserted during his first admission. We made a calendar so the patient could visualize the chemotherapy cycles, which provided the necessary understanding of the plan. We also had the multidisciplinary team review and edit any changes to plan accordingly.

To conclude the discussion, we reviewed the anticipated symptoms, which included chemotherapy-induced nausea and vomiting, mucositis, alopecia, dermatologic changes, myelosuppression, chemotherapy-induced peripheral neuropathy, and fatigue. This information also was reviewed with the patient’s caregivers. Helping this patient through the side effects and adverse events he would likely experience during his intensive chemotherapy regimen required collaboration among multiple healthcare personnel: pharmacists, social workers, and inpatient and outpatient nurses.

Conclusion

Our main goal for this patient was for him to achieve lifelong remission. Upon finishing his second part B cycle of Hyper-CVAD, a bone marrow biopsy was performed to assure he was in remission. The biopsy revealed, however, that he had residual leukemia cells thus prompting us to direct him to the transplant service. At the time of diagnosis, human leukocyte antigen typing was performed to identify future matches if he should need to have an allogeneic transplant. His disappointment associated with the lack of complete remission made the patient choose to have an allogeneic transplant done as soon as possible. The bone marrow transplant registry was able to find a donor for him, and an allogeneic transplant was performed 2 weeks later. He is currently disease free and remains ever so grateful for having such a great team of multidisciplinary professionals be part of his care.

Reference

1. Kantarjian HM, O’Brien S, Smith TL, et al. Results of treatment with hyper-CVAD, a dose-intensive regimen, in adult acute lymphocytic leukemia. J Clin Oncol. 2000; 18:547-561.

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