Leukemia

Oncology

Clinicals - History

Fact Explanation
Age and sex of the patient Leukemia is a group of malignant disease involving leukocyte forming cells in the bone marrow, characterized by defective proliferation and differentiation of these cell lines. These can be of lymphoid or myeloid origin. In acute leukemia the affected cell lines lack differentiation so that there is increased blast cells. In chronic leukemia cell lines may morphologically differentiate but have defective function. Leukemias are generally named according to the cell line involved and degree of cell differentiation. E.g; Acute lymphocytic leukemia, Chronic myeloid leukemia. The increased proliferation of these cell lines lead to suppression of other cell line production in bone marrow giving rise to the array of clinical features seen in leukemia.
Malignancies such as acute lymphocytic leukemia(ALL) is commonly seen in children. Acute myeloid leukemia(AML), chronic lymphocytic leukemia(CLL), chronic myeloid leukemia(CML) etc. are most commonly encountered in adults. ALL has poor prognosis if it is in an adult male. CLL and CML has a male predominance.
Age and sex of the patient
Leukemia is a group of malignant disease involving leukocyte forming cells in the bone marrow, characterized by defective proliferation and differentiation of these cell lines. These can be of lymphoid or myeloid origin. In acute leukemia the affected cell lines lack differentiation so that there is increased blast cells. In chronic leukemia cell lines may morphologically differentiate but have defective function. Leukemias are generally named according to the cell line involved and degree of cell differentiation. E.g; Acute lymphocytic leukemia, Chronic myeloid leukemia. The increased proliferation of these cell lines lead to suppression of other cell line production in bone marrow giving rise to the array of clinical features seen in leukemia.
Malignancies such as acute lymphocytic leukemia(ALL) is commonly seen in children. Acute myeloid leukemia(AML), chronic lymphocytic leukemia(CLL), chronic myeloid leukemia(CML) etc. are most commonly encountered in adults. ALL has poor prognosis if it is in an adult male. CLL and CML has a male predominance.
Fever Fever is a common symptom of leukemia. Classic pyrexia of unknown origin can be seen these patients. But infections should be excluded first because they can be fatal for these patients. Fever
Fever is a common symptom of leukemia. Classic pyrexia of unknown origin can be seen these patients. But infections should be excluded first because they can be fatal for these patients.
Malaise Is also a constitutional symptom of cancer. Malaise
Is also a constitutional symptom of cancer.
Loss of weight This is a constitutional symptom associated with cancer. Loss of weight
This is a constitutional symptom associated with cancer.
Frequent infections Occur due to neutrophil counts seen in patients with acute leukemia or blast phase of chronic leukemia. These patients are at risk of developing various infections such as pneumonia, otitis media, pharyngitis, infections of skin, perianal region and oral cavity etc. caused by bacteria, virus or fungi. Frequent infections
Occur due to neutrophil counts seen in patients with acute leukemia or blast phase of chronic leukemia. These patients are at risk of developing various infections such as pneumonia, otitis media, pharyngitis, infections of skin, perianal region and oral cavity etc. caused by bacteria, virus or fungi.
Symptoms of anemia such as fatigue, weakness/tiredness shortness of breath, palpitations, dizzy or feeling light headed, chest pain etc. These symptoms may occur in the presence of significant anemia. Anemia occurs due to suppressed red blood cell production in the bone marrow. Symptoms of anemia such as fatigue, weakness/tiredness shortness of breath, palpitations, dizzy or feeling light headed, chest pain etc.
These symptoms may occur in the presence of significant anemia. Anemia occurs due to suppressed red blood cell production in the bone marrow.
Bleeding manifestations Is a symptom commonly associated with lymphoid tumors and also in other hematological malignancies. Bleeding manifestations
Is a symptom commonly associated with lymphoid tumors and also in other hematological malignancies.
Night sweats Arise due to thrombocytopenia secondary to marrow failure. Patients may present with easy bruising, bleeding gums, nose, small red spots on skin or heavy menstrual bleeds. Night sweats
Arise due to thrombocytopenia secondary to marrow failure. Patients may present with easy bruising, bleeding gums, nose, small red spots on skin or heavy menstrual bleeds.
Anorexia Is also a constitutional symptom associated with leukemia. Anorexia
Is also a constitutional symptom associated with leukemia.
Abdominal discomfort May arise in the presence of splenomegaly and/or hepatomegaly. Abdominal discomfort
May arise in the presence of splenomegaly and/or hepatomegaly.
Back pain or Joint pain and swelling This can occur with tumor infiltration of spine and joints. Back pain or Joint pain and swelling
This can occur with tumor infiltration of spine and joints.
Exposure to radiation Past history of exposure high dose radiation is shown to be associated with development of leukemias. Exposure to radiation
Past history of exposure high dose radiation is shown to be associated with development of leukemias.

Clinicals - Examination

Fact Explanation
Pallor This is a sign of anemia. Pallor
This is a sign of anemia.
Jaundice Seen in patients with autoimmune hemolytic anemia complicating CLL. CLL patients have 5-10% increased risk of developing autoimmune complications and commonest of them is autoimmune hemolysis. Jaundice
Seen in patients with autoimmune hemolytic anemia complicating CLL. CLL patients have 5-10% increased risk of developing autoimmune complications and commonest of them is autoimmune hemolysis.
Gum hypertrophy Is seen with acute myeloid leukemia with neoplastic cell infiltration of the gum Gum hypertrophy
Is seen with acute myeloid leukemia with neoplastic cell infiltration of the gum
Petichiae or purpura or ecchymoses Bleeding manifestations result due to thrombocytopenia associated with leukemia or with the development of disseminated intravascular coagulation. Petichiae or purpura or ecchymoses
Bleeding manifestations result due to thrombocytopenia associated with leukemia or with the development of disseminated intravascular coagulation.
Palpable lymph nodes Lymphadenopathy is seen when leukemia cells infiltrate the lymph nodes. These lymph nodes will be enlarged, rubbery,firm and usually involve more than one group of nodes. Palpable lymph nodes
Lymphadenopathy is seen when leukemia cells infiltrate the lymph nodes. These lymph nodes will be enlarged, rubbery,firm and usually involve more than one group of nodes.
Skin changes Leukemia cutis is a condition which occurs due to leukemic cell infiltration of the skin. It appears as a rash which may or may not accompany other features of leukemia. Acute febrile neutrophilic dermatosis or Sweet's syndrome is a paraneoplastic syndrome that is associated with malignancy. When it comes to leukemia it is commonly seen with acute myelogenous leukemia. This condition presents with acute onset of fever and raised, erythematous, well-demarcated, painful papules and plaques, which are typically seen on the upper extremities, face and neck. Can be associated with other systemic symptoms.Adult T cell leukemia is a rare malignancy which can also present with cutaneous manifestations. Skin changes
Leukemia cutis is a condition which occurs due to leukemic cell infiltration of the skin. It appears as a rash which may or may not accompany other features of leukemia. Acute febrile neutrophilic dermatosis or Sweet's syndrome is a paraneoplastic syndrome that is associated with malignancy. When it comes to leukemia it is commonly seen with acute myelogenous leukemia. This condition presents with acute onset of fever and raised, erythematous, well-demarcated, painful papules and plaques, which are typically seen on the upper extremities, face and neck. Can be associated with other systemic symptoms.Adult T cell leukemia is a rare malignancy which can also present with cutaneous manifestations.
Hepatomegaly Occurs with neoplastic cell infiltration of the liver. Hepatomegaly
Occurs with neoplastic cell infiltration of the liver.
Splenomegaly Occurs with neoplastic cell infiltration of the spleen. Splenomegaly
Occurs with neoplastic cell infiltration of the spleen.
Orchidomegaly Is an uncommon manifestation due to neoplastic cell infiltration of the testes. Orchidomegaly
Is an uncommon manifestation due to neoplastic cell infiltration of the testes.
Cranial nerve palsy or features of meningism These arise when the neoplastic cells infiltrate the central nervous system. Cranial nerve palsy or features of meningism
These arise when the neoplastic cells infiltrate the central nervous system.
Features of Down's syndrome Children with Down syndrome has 10-20 fold increased for development of ALL and AML. Features of Down's syndrome
Children with Down syndrome has 10-20 fold increased for development of ALL and AML.
Other signs of anemia such as presence of rapid thready pulse, cardiac flow murmurs etc. These signs indicate of a hyperdynamic circulation and are found in severe anemia. Patient may also develop cardiomegaly and heart failure later. Other signs of anemia such as presence of rapid thready pulse, cardiac flow murmurs etc.
These signs indicate of a hyperdynamic circulation and are found in severe anemia. Patient may also develop cardiomegaly and heart failure later.

Investigations - Diagnosis

Fact Explanation
Complete blood count with blood picture White cell counts will often be high but can even be normal or low. Red cell count platelet count and hemoglobin level will usually be low. In acute leukemia blast cells will be seen in blood smear. In chronic myeloid leukemia the whole spectrum of myeloid cells (i.e. neutropils, basophils, eosinophils and myelocytes) will be increased in the blood film. Lymphocytes will be increased in chronic lymphocytic leukemia. Complete blood count with blood picture
White cell counts will often be high but can even be normal or low. Red cell count platelet count and hemoglobin level will usually be low. In acute leukemia blast cells will be seen in blood smear. In chronic myeloid leukemia the whole spectrum of myeloid cells (i.e. neutropils, basophils, eosinophils and myelocytes) will be increased in the blood film. Lymphocytes will be increased in chronic lymphocytic leukemia.
Bone marrow aspiration and biopsy Bone marrow samples are obtained by aspiration and trephine biopsy. These samples can be examined by staining and light microscope or analyzed by cytogenetic or immunohistochemistry studies. Bone marrow aspiration and biopsy
Bone marrow samples are obtained by aspiration and trephine biopsy. These samples can be examined by staining and light microscope or analyzed by cytogenetic or immunohistochemistry studies.
Chest X ray Is a basic test done to detect mediastinal lymph node involvement. Chest X ray
Is a basic test done to detect mediastinal lymph node involvement.
Ultra sound scan of abdomen Done to assess liver and spleen. Ultra sound scan of abdomen
Done to assess liver and spleen.
Computed tomography of chest and abdomen Done to detect lymph node involvement in chest and abdomen. Computed tomography of chest and abdomen
Done to detect lymph node involvement in chest and abdomen.
Cytogenetic analysis Abnormalities that are looked for includes balanced translocations, deletions of chromosomes, abnormalities of chromosome number etc. Testing for bcr-abl translocation helps to distinguish Philadelphia chromosome positive ALL, which has poor prognosis and Philadelphia chromosome positive CML which has a better prognosis. Cytogenetic analysis
Abnormalities that are looked for includes balanced translocations, deletions of chromosomes, abnormalities of chromosome number etc. Testing for bcr-abl translocation helps to distinguish Philadelphia chromosome positive ALL, which has poor prognosis and Philadelphia chromosome positive CML which has a better prognosis.
Immunohistochemical studies Can differentiate the cell line origin of leukemia cells. Absence of myeloperoxidase staining and presence of terminal deoxynucleotidyl transferase (TdT) is essential for diagnosis of ALL. Flow cytometry can be used to further detect lymphoid antigens such as CD3 or CD19. CD13, CD33, CD34, CD11c are some myeloid antigens that can be detected. Immunohistochemical studies
Can differentiate the cell line origin of leukemia cells. Absence of myeloperoxidase staining and presence of terminal deoxynucleotidyl transferase (TdT) is essential for diagnosis of ALL. Flow cytometry can be used to further detect lymphoid antigens such as CD3 or CD19. CD13, CD33, CD34, CD11c are some myeloid antigens that can be detected.
Lumbar puncture Done to detect CNS involvement if clinical evidence raise suspicion of CNS infiltration. Lumbar puncture
Done to detect CNS involvement if clinical evidence raise suspicion of CNS infiltration.
Coagulation studies Pctivated partial thromboplastin time (aPTT), Prothrombin time (PT), fibrinogen levels and fibrin degradation products(D-dimer). Done when there are bleeding manifestations or clinically suspected disseminated intravascular coagulation (DIC). In case of DIC, PT and aPTT will be elevated; platelet count and fibrinogen level decreased and D-dimer level increased. Coagulation studies
Pctivated partial thromboplastin time (aPTT), Prothrombin time (PT), fibrinogen levels and fibrin degradation products(D-dimer). Done when there are bleeding manifestations or clinically suspected disseminated intravascular coagulation (DIC). In case of DIC, PT and aPTT will be elevated; platelet count and fibrinogen level decreased and D-dimer level increased.
Lactic dehydrogenase level (LDH) Is elevated in conditions where there is increased cell lysis, like in cancer. Lactic dehydrogenase level (LDH)
Is elevated in conditions where there is increased cell lysis, like in cancer.
Serum uric acid level Will be elevated in leukemia and levels will rise further in response to chemotherapy due to increased cell turn over. Serum uric acid level
Will be elevated in leukemia and levels will rise further in response to chemotherapy due to increased cell turn over.
Blood/ urine or other appropriate culture Done if there is suspicion of infections. Antibiotic sensitivity should also be performed. Early detection and prompt treatment of infections is very important in these patients to prevent fatal outcomes. Blood/ urine or other appropriate culture
Done if there is suspicion of infections. Antibiotic sensitivity should also be performed. Early detection and prompt treatment of infections is very important in these patients to prevent fatal outcomes.

Investigations - Management

Fact Explanation
Liver enzyme tests Done to assess liver function prior to initiation of chemotherapy and for liver function monitoring during chemotherapy. Liver enzyme tests
Done to assess liver function prior to initiation of chemotherapy and for liver function monitoring during chemotherapy.
Serum creatinine Done to assess renal function prior to initiation of treatment. Serum creatinine
Done to assess renal function prior to initiation of treatment.
Serum electrolytes Done to assess renal function. Serum electrolytes
Done to assess renal function.
Fasting blood sugar Done to detect presence of diabetes mellitus if clinically suspected. Fasting blood sugar
Done to detect presence of diabetes mellitus if clinically suspected.
Electrocardiogram Done if the patient has features of cardiac disease or a history of ischaemic heart disease. Electrocardiogram
Done if the patient has features of cardiac disease or a history of ischaemic heart disease.
2D Echocardiogram Done to assess cardiac function and anatomy in patients with features of cardiac disease, such as murmur,cardiomegaly etc. 2D Echocardiogram
Done to assess cardiac function and anatomy in patients with features of cardiac disease, such as murmur,cardiomegaly etc.

Management - Supportive

Fact Explanation
Infection control Educate patient regarding risk of infections and importance of avoiding situations that could transmit infections. Employ barrier nursing, proper hand washing. It is important to look for infections, do appropriate investigations and treat any known infection promptly. Infection control
Educate patient regarding risk of infections and importance of avoiding situations that could transmit infections. Employ barrier nursing, proper hand washing. It is important to look for infections, do appropriate investigations and treat any known infection promptly.
Managing bleeding problems If the patient has an overt bleeding manifestation or has symptoms and signs of a central nervous system bleed, do clotting screen and CT/MRI of brain if in doubt. Correct the hemostatic defect immediately with platelets, fresh frozen plasma(FFP) etc. If the patient has hyperviscosity syndrome due to very high white cell counts, leukocyte reduction may have to be considered before transfusion. If patient has extensive bleeding in to skin, venepuncture sites etc or develops acute renal failure suspect disseminated intravascular coagulation(DIC). Do a clotting screen, fibrinogen level and D-dimers level. Find and treat the cause of DIC. Replace platelets, fibrinogen(with cryoprecipitate) and coagulation factors(with FFP). Activated protein C has shown to reduce motality in some cases. In acute promyelocytic leukemia which is the commonest leukemia associated with DIC, use of all trans retinoic acid reduce risk of DIC. Managing bleeding problems
If the patient has an overt bleeding manifestation or has symptoms and signs of a central nervous system bleed, do clotting screen and CT/MRI of brain if in doubt. Correct the hemostatic defect immediately with platelets, fresh frozen plasma(FFP) etc. If the patient has hyperviscosity syndrome due to very high white cell counts, leukocyte reduction may have to be considered before transfusion. If patient has extensive bleeding in to skin, venepuncture sites etc or develops acute renal failure suspect disseminated intravascular coagulation(DIC). Do a clotting screen, fibrinogen level and D-dimers level. Find and treat the cause of DIC. Replace platelets, fibrinogen(with cryoprecipitate) and coagulation factors(with FFP). Activated protein C has shown to reduce motality in some cases. In acute promyelocytic leukemia which is the commonest leukemia associated with DIC, use of all trans retinoic acid reduce risk of DIC.
Managing tumor lysis syndrome This is caused by massive destruction of white cells leading to accumulation of potassium and urate which leads to acute renal failure. Prevention is based on encouraging high fluid intake with allopurinol pre-cytotoxics, and recombinant uricase can be tried. Managing tumor lysis syndrome
This is caused by massive destruction of white cells leading to accumulation of potassium and urate which leads to acute renal failure. Prevention is based on encouraging high fluid intake with allopurinol pre-cytotoxics, and recombinant uricase can be tried.
Leukapheresis Involves filtration of excess white cells by a special machine and return of the rest of cells and plasma to body. This is used to treat hyperviscosity syndrome which is due to massively increased leukocyte counts leading to thrombi formation in brain, heart, lungs etc by leukostasis. This methos reduces lekocyte counts immediately but the effect lasts only a short time. Leukapheresis
Involves filtration of excess white cells by a special machine and return of the rest of cells and plasma to body. This is used to treat hyperviscosity syndrome which is due to massively increased leukocyte counts leading to thrombi formation in brain, heart, lungs etc by leukostasis. This methos reduces lekocyte counts immediately but the effect lasts only a short time.
Education of patient and family Patient and the family should be educated regarding the diagnosis, staging, prognosis, available treatment options for leukemia and their complications etc. These information should help the patient to take informed decisions regarding the treatment for their condition and also improve compliance. They should also be educated regarding potential complications (e.g; risk of infections), how to recognize them and the importance of seeking immediate medical attention. Patient and family should be encouraged to raise their concerns and seek advice. Any doubts present should be clarified. If the patient is a child parents should be made aware of risks of chemotherapy and radiotherapy in the long term, including the risk of secondary cancer. Education of patient and family
Patient and the family should be educated regarding the diagnosis, staging, prognosis, available treatment options for leukemia and their complications etc. These information should help the patient to take informed decisions regarding the treatment for their condition and also improve compliance. They should also be educated regarding potential complications (e.g; risk of infections), how to recognize them and the importance of seeking immediate medical attention. Patient and family should be encouraged to raise their concerns and seek advice. Any doubts present should be clarified. If the patient is a child parents should be made aware of risks of chemotherapy and radiotherapy in the long term, including the risk of secondary cancer.
Counselling and support to family and patient Diagnosis of cancer is a very stressful event to both the patient and the family. Referral to psychologist and counseling should be offered to them. Introduction to support groups and other similar individuals will help them to adjust and respond appropriately to the new changes in life. Counselling and support to family and patient
Diagnosis of cancer is a very stressful event to both the patient and the family. Referral to psychologist and counseling should be offered to them. Introduction to support groups and other similar individuals will help them to adjust and respond appropriately to the new changes in life.

Management - Specific

Fact Explanation
Chemotherapy In acute leukemia the treatment is given in phases as for remission induction, consolidation, central nervous system prophylaxis and maintenance. Remission induction aims to clear the circulation of blast cells and reduce number of blasts in the marrow to normal numbers. Drugs are given as combination regimes and includes chemotherapeutic agents such as vincristine, prednisolone, L-asparaginase, daunorubicin etc. Consolidation aims at clearing 'hidden' blast cells for relapse prevention. CNS prophylaxis aims to clear the blast cells 'hidden' in the CNS(given as intrathecal treatment or high dose intravenous treatment). Maintenance therapy is given in the long term as low dose after consolidation is complete. Chronic myeloid leukemia is usually treated with tyrosine kinase inhibitors(TKI) such as imatinib, which is a specific BCR/ABL tyrosine kinase inhibitor. Hydroxycarbamide can be tried in those intolerant or unresponsive to imatinib. Omacetaxine can be given to treat CML that is resistant to TKIs in use due to presence of T315I mutation. Patients in blast crisis are treated as for acute leukemia. Some of them may benefit from imatinib treatment. Alkylating agents such as chlorambucil, cyclophosphamide together with purine analogs such as fludarabine, pentostatin or corticosteroids or monoclonal antibody rituximab are used to treat cronic lymphocytic leukemia(CLL) to reduce lymphocyte counts and improve marrow function. Chemotherapy
In acute leukemia the treatment is given in phases as for remission induction, consolidation, central nervous system prophylaxis and maintenance. Remission induction aims to clear the circulation of blast cells and reduce number of blasts in the marrow to normal numbers. Drugs are given as combination regimes and includes chemotherapeutic agents such as vincristine, prednisolone, L-asparaginase, daunorubicin etc. Consolidation aims at clearing 'hidden' blast cells for relapse prevention. CNS prophylaxis aims to clear the blast cells 'hidden' in the CNS(given as intrathecal treatment or high dose intravenous treatment). Maintenance therapy is given in the long term as low dose after consolidation is complete. Chronic myeloid leukemia is usually treated with tyrosine kinase inhibitors(TKI) such as imatinib, which is a specific BCR/ABL tyrosine kinase inhibitor. Hydroxycarbamide can be tried in those intolerant or unresponsive to imatinib. Omacetaxine can be given to treat CML that is resistant to TKIs in use due to presence of T315I mutation. Patients in blast crisis are treated as for acute leukemia. Some of them may benefit from imatinib treatment. Alkylating agents such as chlorambucil, cyclophosphamide together with purine analogs such as fludarabine, pentostatin or corticosteroids or monoclonal antibody rituximab are used to treat cronic lymphocytic leukemia(CLL) to reduce lymphocyte counts and improve marrow function.
Radiotherapy CNS irradiation is given in acute leukemia for CNS prophylaxis. Radiation therapy is also used in chronic leukemia for relief from lymhadenopathy or splenomegaly or bone pain. Whole body low dose of radiation is some times given to clear leukemia cells prior to stem cell transplant. Radiotherapy
CNS irradiation is given in acute leukemia for CNS prophylaxis. Radiation therapy is also used in chronic leukemia for relief from lymhadenopathy or splenomegaly or bone pain. Whole body low dose of radiation is some times given to clear leukemia cells prior to stem cell transplant.
Stem cell transplant(SCT) SCT is the only treatment which provides cure for a number of leukemias. Before the transplant procedure, the patient is usually given a high doses of chemotherapy and/or whole body radiation therapy to clear the leukemia cells. Then the patient receives a transplant of stem cells to restore bone marrow cells. These stem cells are obtained either from peripheral blood or the bone marrow. If taken from blood it is called periheral blood stem cell transplant (PBSCT) or if taken from the bone marrow, a bone marrow transplant(BMT). The stem cells can be an allogeneic stem cell transplant (ASCT) or an autologous stem cell transplant. For an allogeneic transplant, the stem cells are obtained from a HLA matched sibling or a HLA matched unrelated donor. Taking umbilical cord stem cells is another option. In an autologous stem cell transplant, the patient's own stem cells are used. These are harvested from the patient's bone marrow or peripheral blood and are stored while the person is treated with high-dose chemotherapy and/or radiation. After that these are transplanted.
Non-myeloablative transplant is an option for older patients who cannot tolerate a standard allogeneic transplant that uses high doses of chemotherapy. These patients are given lower doses of chemotherapy and radiation that do not completely destroy the cells in bone marrow. After this the patient receives the allogeneic stem cells that establish a new immune system and destroy the leukemia cells(graft-versus-leukemia effect).
Stem cell transplant(SCT)
SCT is the only treatment which provides cure for a number of leukemias. Before the transplant procedure, the patient is usually given a high doses of chemotherapy and/or whole body radiation therapy to clear the leukemia cells. Then the patient receives a transplant of stem cells to restore bone marrow cells. These stem cells are obtained either from peripheral blood or the bone marrow. If taken from blood it is called periheral blood stem cell transplant (PBSCT) or if taken from the bone marrow, a bone marrow transplant(BMT). The stem cells can be an allogeneic stem cell transplant (ASCT) or an autologous stem cell transplant. For an allogeneic transplant, the stem cells are obtained from a HLA matched sibling or a HLA matched unrelated donor. Taking umbilical cord stem cells is another option. In an autologous stem cell transplant, the patient's own stem cells are used. These are harvested from the patient's bone marrow or peripheral blood and are stored while the person is treated with high-dose chemotherapy and/or radiation. After that these are transplanted.
Non-myeloablative transplant is an option for older patients who cannot tolerate a standard allogeneic transplant that uses high doses of chemotherapy. These patients are given lower doses of chemotherapy and radiation that do not completely destroy the cells in bone marrow. After this the patient receives the allogeneic stem cells that establish a new immune system and destroy the leukemia cells(graft-versus-leukemia effect).
Splenectomy Is done for symptomatic relief in patients with massive enlarged spleens, not shrunk by chemotherapy or radiation. It may also improve platelet and red cell counts and lower the need for transfusions. Splenectomy
Is done for symptomatic relief in patients with massive enlarged spleens, not shrunk by chemotherapy or radiation. It may also improve platelet and red cell counts and lower the need for transfusions.

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