Medical Management for Acute Lymphocytic Leukemia The goal of treatment is to get the blood counts and the

e bone marrow back to normal. If this occurs and the bone marrow looks healthy under the microscope, the cancer is said to be in remission. The main treatment for acute lymphocytic leukemia (ALL) in adults involves the long-term use of chemotherapy. In the past several years, doctors have begun to use more intensive chemotherapy regimens, which have led to more responses to treatment. But these regimens are also more likely to cause side effects, such as low white blood cell counts. Patients may need to take other drugs to help prevent or treat these side effects. Treatment typically takes place in 3 phases: Induction (or remission induction) Consolidation (intensification) Maintenance

The total treatment usually takes about 2 years, with the maintenance phase taking up most of this time. Treatment may be more or less intense, depending on the subtype of ALL and other prognostic factors. An important part of treatment of ALL is central nervous system (CNS) prophylaxis -- treatment that is meant to ensure the leukemia does not spread to (or remain in) the brain or spinal cord. This is described in more detail below. Induction The initial phase of chemotherapy usually lasts for a month or so. Different combinations may be used, but they typically include the following drugs:

Vincristine Dexamethasone or prednisone Doxorubicin (Adriamycin) or daunorubicin

Treatment to keep the leukemia cells from spreading to the CNS is often started at this time. This is known as CNS prophylaxis. This may include one or more of the following: Chemotherapy injected directly into the spinal fluid (called intrathecal chemotherapy). The drug used most often is methotrexate, but sometimes cytarabine or a steroid such as prednisone may be used as well.

High-dose IV methotrexate Radiation therapy to the brain and spinal cord

Induction chemotherapy can often have serious side effects, including lifethreatening infections. For this reason, close monitoring and supportive care with other drugs such as antibiotics is important. Consolidation (intensification) If the patient goes into remission, the next phase often consists of a fairly short course of chemotherapy, using many of the same drugs that were used for induction therapy. This typically lasts for a few months. Usually the drugs are given in high doses so that the treatment is still fairly intense. CNS prophylaxis may be continued at this time. Maintenance After consolidation, the patient is generally put on a maintenance chemotherapy program of methotrexate and 6-mercaptopurine (6-MP). In some cases, this may be combined with other drugs such as vincristine and prednisone. Maintenance usually lasts for about 2 years. CNS prophylaxis may be continued at this time. Some doctors feel that maintenance therapy may not be needed for some leukemias such as T-cell ALL and mature B-cell ALL (Burkitt leukemia). Surgical Management for Acute Lymphocytic Leukemia Surgery has a very limited role in the treatment of acute lymphocytic leukemia (ALL). Because leukemia cells spread widely throughout the bone marrow and to many other organs, it is not possible to cure this type of cancer by surgery. Aside from a possible lymph node biopsy, surgery rarely has any role even in the diagnosis, since a bone marrow aspirate and biopsy can usually diagnose leukemia. Often before chemotherapy is about to start, surgery is needed to insert a small plastic tube, called a central venous catheter or venous access device (VAD), into a large vein. The end of the tube is just under the skin or sticks out in the chest area or upper arm. The VAD is left in place during treatment to give intravenous (IV) drugs such as chemotherapy and to take blood samples. This lowers the number of needle sticks needed during treatment. It is very important to learn how to care for the device to keep it from getting infected. Nursing Management for Acute Lymphocytic Leukemia
PREVENTING OR MANAGING INFECTION AND BLEEDING MONITORING AND MANAGING POTENTIAL COMPLICATIONS MANAGING MUCOSITIS Although emphasis is placed on the oral mucosa, it is important to realize that the entire gastrointestinal mucosa can be altered, not only by the effects of chemotherapy but also from prolonged administrationof antibiotics. Oral hygiene is very important to diminish the bacteria within the mouth, maintain moisture, and provide comfort. To diminish perinealrectal complications, it is important to cleanse the perinealrectal area thoroughly after each bowel movement. Stool softeners should be used to increase the moisture of bowel movements; however, the stool texture must be monitored so that the softeners can be decreased or stopped if the stool becomes too loose.

 IMPROVING NUTRITIONAL INTAKE The disease process can increase, and sepsis further increases, the patients metabolic rate and nutritional requirements. Nutritional intake is often reduced because of pain and discomfort associated with stomatitis. Small, frequent feedings of foods that are soft in texture and moderate in temperature may be better tolerated. Low-microbial diets are typically prescribed (avoiding uncooked fruits or vegetables and those without a peelable skin). Nutritional supplements are frequently used. Parenteral nutrition is often required to maintain adequate nutrition. EASING PAIN AND DISCOMFORT Recurrent fevers are common in acute leukemia; at times, they are accompanied by shaking chills, which can be severe (rigors). Sponging with cool water may be useful, but cold water or ice packs should be avoided because the heat cannot dissipate from constricted blood vessels. Bedclothes need frequent changing as well. Gentle back and shoulder massage may provide comfort. Nurses need to implement creative strategies that permit uninterrupted sleep for at least a few hours while still administering necessary medications on time. With the exception of severe mucositis, less pain is associated with acute leukemia than with many other forms of cancer. However, the amount of psychologic suffering that the patient must endure can be immense. Patients greatly benefit from active listening. DECREASING FATIGUE AND DECONDITIONING Fatigue is a common and oppressive problem. Nursing interventions should focus on assisting the patient to establish a balance between activity and rest. Patients with acute leukemia need to maintain some physical activity and exercise to prevent the deconditioning that results from inactivity. At a minimum, patients should be encouraged to sit up in a chair while awake rather than staying in bed; even this simple activity can improve the patients tidal volume and enhance circulation. Physical therapy can also be beneficial. MAINTAINING FLUID AND ELECTROLYTE BALANCE Febrile episodes, bleeding, and inadequate or overly aggressive fluid replacement can alter the patients fluid status. Similarly, persistent diarrhea, vomiting, and long-term use of certain antimicrobial agents can cause significant deficits in electrolytes. Intake and output need to be measured accurately, and daily weights should also be monitored. The patient should be assessed for signs of dehydration as well as fluid overload, with particular attention to pulmonary status and the development of dependent edema. Laboratory test results, particularly electrolytes, blood urea nitrogen, creatinine, and hematocrit, should be monitored and compared with previous results. Replacement of electrolytes, particularly potassium and magnesium, is commonly required. Patients receiving amphotericin or certain antibiotics are at increased risk for electrolyte depletion. IMPROVING SELF-CARE Because hygiene measures are so important in this patient population, they must be performed by the nurse when the patient cannot do so. However, the patient should be encouraged to do as much as possible, to preserve mobility and function as well as selfesteem. Patients may have negative feelings, even disgust that they can no longer care for themselves. Empathetic listening is helpful, as is realistic reassurance that these deficits are temporary. As the patient recovers, it is important to assist him or her to resume more self-care. MANAGING ANXIETY AND GRIEF The nurse needs to assess how much information patients want to have regarding the illness, its treatment, and potential complications. This desire should be reassessed at intervals, because needs and interest in information change throughout the course of the disease and treatment. Many patients become depressed and begin to grieve for the losses they feel, such as normal family functioning, professional roles and responsibilities, and social roles, as well as physical functioning. Nurses can assist patients to identify the source of the grief and encourage them to allow time to adjust to the major life changes produced by the illness. Role restructuring, in both family and professional life, may be required. Again, when possible, permitting patients to identify options and to take time making significant decisions regarding such restructuring is helpful.