Leukemia

Leukemia
Classification and external resources

A Wright's stained bone marrow aspirate smear from a patient with precursor B-cell acute lymphoblastic leukemia.
ICD-10 C91-C95
ICD-9 208.9
ICD-O: 9800-9940
DiseasesDB 7431
MeSH D007938

Leukemia (American English) or leukaemia (British English) (from the Greek leukos λεύκος - white, and haima αίμα - blood[1]) is a type of cancer of the blood or bone marrow characterized by an abnormal increase of immature white blood cells called "blasts". Leukemia is a broad term covering a spectrum of diseases. In turn, it is part of the even broader group of diseases affecting the blood, bone marrow and lymphoid system, which are all known as hematological neoplasms.

In 2000, approximately 256,000 children and adults around the world developed some form of leukemia, and 209,000 died from it.[2] About 90% of all leukemias are diagnosed in adults.[3]

Contents

Classification

Four major kinds of leukemia
Cell type Acute Chronic
Lymphocytic leukemia
(or "lymphoblastic")
Acute lymphoblastic leukemia (ALL) Chronic lymphocytic leukemia (CLL)
Myelogenous leukemia
(also "myeloid" or "nonlymphocytic")
Acute myelogenous leukemia (AML)
(or Myeloblastic)
Chronic myelogenous leukemia (CML)

Clinically and pathologically, leukemia is subdivided into a variety of large groups. The first division is between its acute and chronic forms:

Additionally, the diseases are subdivided according to which kind of blood cell is affected. This split divides leukemias into lymphoblastic or lymphocytic leukemias and myeloid or myelogenous leukemias:

Combining these two classifications provides a total of four main categories. Within each of these four main categories, there are typically several subcategories. Finally, some rarer types are usually considered to be outside of this classification scheme.

Signs and symptoms

Damage to the bone marrow, by way of displacing the normal bone marrow cells with higher numbers of immature white blood cells, results in a lack of blood platelets, which are important in the blood clotting process. This means people with leukemia may easily become bruised, bleed excessively, or develop pinprick bleeds (petechiae).

White blood cells, which are involved in fighting pathogens, may be suppressed or dysfunctional. This could cause the patient's immune system to be unable to fight off a simple infection or to start attacking other body cells. Because leukemia prevents the immune system from working normally, some patients experience frequent infection, ranging from infected tonsils, sores in the mouth, or diarrhea to life-threatening pneumonia or opportunistic infections.

Finally, the red blood cell deficiency leads to anemia, which may cause dyspnea and pallor.

Some patients experience other symptoms, such as feeling sick, having fevers, chills, night sweats, feeling fatiguedand other flu-like symptoms. Some patients experience nausea or a feeling of fullness due to an enlarged liver and spleen; this can result in unintentional weight loss. Blasts affected by the disease may come together and become swollen in the liver or in the lymph nodes causing pain and leading to nausea. [15]

If the leukemic cells invade the central nervous system, then neurological symptoms (notably headaches) can occur. All symptoms associated with leukemia can be attributed to other diseases. Consequently, leukemia is always diagnosed through medical tests.

The word leukemia, which means 'white blood', is derived from the disease's namesake high white blood cell counts that most leukemia patients have before treatment. The high number of white blood cells are apparent when a blood sample is viewed under a microscope. Frequently, these extra white blood cells are immature or dysfunctional. The excessive number of cells can also interfere with the level of other cells, causing a harmful imbalance in the blood count.

Some leukemia patients do not have high white blood cell counts visible during a regular blood count. This less-common condition is called aleukemia. The bone marrow still contains cancerous white blood cells which disrupt the normal production of blood cells, but they remain in the marrow instead of entering the bloodstream, where they would be visible in a blood test. For an aleukemic patient, the white blood cell counts in the bloodstream can be normal or low. Aleukemia can occur in any of the four major types of leukemia, and is particularly common in hairy cell leukemia.[16]

Causes

No single known cause for any of the different types of leukemia exists. The known causes, which are not generally factors within the control of the average person, account for relatively few cases.[17] The different leukemias likely have different causes.

Leukemia, like other cancers, results from mutations in the DNA. Certain mutations can trigger leukemia by activating oncogenes or deactivating tumor suppressor genes, and thereby disrupting the regulation of cell death, differentiation or division. These mutations may occur spontaneously or as a result of exposure to radiation or carcinogenic substances.[18]

Among adults, the known causes are natural and artificial ionizing radiation, a few viruses such as Human T-lymphotropic virus, and some chemicals, notably benzene and alkylating chemotherapy agents for previous malignancies.[19][20][21] Use of tobacco is associated with a small increase in the risk of developing acute myeloid leukemia in adults.[19] Cohort and case-control studies have linked exposure to some petrochemicals and hair dyes to the development of some forms of leukemia. A few cases of maternal-fetal transmission have been reported.[19] Diet has very limited or no effect, although eating more vegetables may confer a small protective benefit.[17]

Viruses have also been linked to some forms of leukemia. Experiments on mice and other mammals have demonstrated the relevance of retroviruses in leukemia, and human retroviruses have also been identified. The first human retrovirus identified was Human T-lymphotropic virus, or HTLV-1, which is known to cause adult T-cell leukemia.[22]

Some people have a genetic predisposition towards developing leukemia. This predisposition is demonstrated by family histories and twin studies.[19] The affected people may have a single gene or multiple genes in common. In some cases, families tend to develop the same kind of leukemia as other members; in other families, affected people may develop different forms of leukemia or related blood cancers.[19]

In addition to these genetic issues, people with chromosomal abnormalities or certain other genetic conditions have a greater risk of leukemia.[20] For example, people with Down syndrome have a significantly increased risk of developing forms of acute leukemia (especially acute myeloid leukemia), and Fanconi anemia is a risk factor for developing acute myeloid leukemia.[19]

Whether non-ionizing radiation causes leukemia has been studied for several decades. The International Agency for Research on Cancer expert working group undertook a detailed review of all data on static and extremely low frequency electromagnetic energy, which occurs naturally and in association with the generation, transmission, and use of electrical power.[23] They concluded that there is limited evidence that high levels of ELF magnetic (but not electric) fields might cause childhood leukemia. Exposure to significant ELF magnetic fields might result in twofold excess risk for leukemia for children exposed to these high levels of magnetic fields.[23] However, the report also says that methodological weaknesses and biases in these studies have likely caused the risk to be overstated.[23] No evidence for a relationship to leukemia or another form of malignancy in adults has been demonstrated.[23] Since exposure to such levels of ELFs is relatively uncommon, the World Health Organization concludes that ELF exposure, if later proven to be causative, would account for just 100 to 2400 cases worldwide each year, representing 0.2 to 4.9% of the total incidence of childhood leukemia for that year (about 0.03 to 0.9% of all leukemias).[24]

Diagnosis

Diagnosis is usually based on repeated complete blood counts and a bone marrow examination following observations of the symptoms, however, in rare cases blood tests may not show if a patient has leukemia, usually this is because the leukemia is in the early stages or has entered remission. A lymph node biopsy can be performed as well in order to diagnose certain types of leukemia in certain situations.

Following diagnosis, blood chemistry tests can be used to determine the degree of liver and kidney damage or the effects of chemotherapy on the patient. When concerns arise about visible damage due to leukemia, doctors may use an X-ray, MRI, or ultrasound. These can potentially view leukemia's effects on such body parts as bones (X-ray), the brain (MRI), or the kidneys, spleen, and liver (ultrasound). Finally, CT scans are rarely used to check lymph nodes in the chest.

Despite the use of these methods to diagnose whether or not a patient has leukemia, many people have not been diagnosed because many of the symptoms are vague, unspecific, and can refer to other diseases. For this reason, the American Cancer Society predicts that at least one-fifth of the people with leukemia have not yet been diagnosed.[16]

Mutation in SPRED1 gene has been associated with a predisposition to childhood leukemia.[25] SPRED1 gene mutations can be diagnosed with genetic sequencing.

Treatment

Most forms of leukemia are treated with pharmaceutical medication, typically combined into a multi-drug chemotherapy regimen. Some are also treated with radiation therapy. In some cases, a bone marrow transplant is useful.

Acute lymphoblastic

Management of ALL focuses on control of bone marrow and systemic (whole-body) disease. Additionally, treatment must prevent leukemic cells from spreading to other sites, particularly the central nervous system (CNS) e.g. monthly lumbar punctures. In general, ALL treatment is divided into several phases:

Chronic lymphocytic

Decision to treat

Hematologists base CLL treatment on both the stage and symptoms of the individual patient. A large group of CLL patients have low-grade disease, which does not benefit from treatment. Individuals with CLL-related complications or more advanced disease often benefit from treatment. In general, the indications for treatment are:

Typical treatment approach

CLL is probably incurable by present treatments. The primary chemotherapeutic plan is combination chemotherapy with chlorambucil or cyclophosphamide, plus a corticosteroid such as prednisone or prednisolone. The use of a corticosteroid has the additional benefit of suppressing some related autoimmune diseases, such as immunohemolytic anemia or immune-mediated thrombocytopenia. In resistant cases, single-agent treatments with nucleoside drugs such as fludarabine,[28] pentostatin, or cladribine may be successful. Younger patients may consider allogeneic or autologous bone marrow transplantation.[29]

Acute myelogenous

Many different anti-cancer drugs are effective for the treatment of AML. Treatments vary somewhat according to the age of the patient and according to the specific subtype of AML. Overall, the strategy is to control bone marrow and systemic (whole-body) disease, while offering specific treatment for the central nervous system (CNS), if involved.

In general, most oncologists rely on combinations of drugs for the initial, induction phase of chemotherapy. Such combination chemotherapy usually offers the benefits of early remission and a lower risk of disease resistance. Consolidation and maintenance treatments are intended to prevent disease recurrence. Consolidation treatment often entails a repetition of induction chemotherapy or the intensification chemotherapy with additional drugs. By contrast, maintenance treatment involves drug doses that are lower than those administered during the induction phase.[30]

Chronic myelogenous

There are many possible treatments for CML, but the standard of care for newly diagnosed patients is imatinib (Gleevec) therapy.[31] Compared to most anti-cancer drugs, it has relatively few side effects and can be taken orally at home. With this drug, more than 90% of patients will be able to keep the disease in check for at least five years,[31] so that CML becomes a chronic, manageable condition.

In a more advanced, uncontrolled state, when the patient cannot tolerate imatinib, or if the patient wishes to attempt a permanent cure, then an allogeneic bone marrow transplantation may be performed. This procedure involves high-dose chemotherapy and radiation followed by infusion of bone marrow from a compatible donor. Approximately 30% of patients die from this procedure.[31]

Hairy cell

Decision to treat
Patients with hairy cell leukemia who are symptom-free typically do not receive immediate treatment. Treatment is generally considered necessary when the patient shows signs and symptoms such as low blood cell counts (e.g., infection-fighting neutrophil count below 1.0 K/µL), frequent infections, unexplained bruises, anemia, or fatigue that is significant enough to disrupt the patient's everyday life.

Typical treatment approach
Patients who need treatment usually receive either one week of cladribine, given daily by intravenous infusion or a simple injection under the skin, or six months of pentostatin, given every four weeks by intravenous infusion. In most cases, one round of treatment will produce a prolonged remission.[32]

Other treatments include rituximab infusion or self-injection with Interferon-alpha. In limited cases, the patient may benefit from splenectomy (removal of the spleen). These treatments are not typically given as the first treatment because their success rates are lower than cladribine or pentostatin.[33]

T-cell prolymphocytic

Most patients with T-cell prolymphocytic leukemia, a rare and aggressive leukemia with a median survival of less than one year, require immediate treatment.[34]

T-cell prolymphocytic leukemia is difficult to treat, and it does not respond to most available chemotherapeutic drugs.[34] Many different treatments have been attempted, with limited success in certain patients: purine analogues (pentostatin, fludarabine, cladribine), chlorambucil, and various forms of combination chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone CHOP, cyclophosphamide, vincristine, prednisone [COP], vincristine, doxorubicin, prednisone, etoposide, cyclophosphamide, bleomycin VAPEC-B). Alemtuzumab (Campath), a monoclonal antibody that attacks white blood cells, has been used in treatment with greater success than previous options.[34]

Some patients who successfully respond to treatment also undergo stem cell transplantation to consolidate the response.[34]

Juvenile myelomonocytic

Treatment for juvenile myelomonocytic leukemia can include splenectomy, chemotherapy, and bone marrow transplantation.[35]

Epidemiology

In 2000, approximately 256,000 children and adults around the world developed a form of leukemia, and 209,000 died from it.[2] This represents about 3% of the almost seven million deaths due to cancer that year, and about 0.35% of all deaths from any cause.[2] Of the sixteen separate sites the body compared, leukemia was the 12th most common class of neoplastic disease, and the 11th most common cause of cancer-related death.[2]

About 245,000 people in the United States are affected with some form of leukemia, including those that have achieved remission or cure. Approximately 44,270 new cases of leukemia were diagnosed in the year of 2008 in the US.[3] This represents 2.9% of all cancers (excluding simple basal cell and squamous cell skin cancers) in the United States, and 30.4% of all blood cancers.[37]

Among children with some form of cancer, about a third have a type of leukemia, most commonly acute lymphoblastic leukemia.[3] A type of leukemia is the second most common form of cancer in infants (under the age of 12 months) and the most common form of cancer in older children.[38] Boys are somewhat more likely to develop leukemia than girls, and white American children are almost twice as likely to develop leukemia than black American children.[38] Only about 3% cancer diagnoses among adults are for leukemias, but because cancer is much more common among adults, more than 90% of all leukemias are diagnosed in adults.[3]

History

Leukemia was first observed by pathologists Rudolf Virchow in 1845. Observing an abnormally large number of white blood cells in a blood sample from a patient, Virchow called the condition Leukämie in German, which he formed from the two Greek words leukos (λευκός), meaning "white", and aima (αίμα), meaning "blood". Around ten years after Virchow's findings, pathologist Franz Ernst Christian Neumann found that one deceased leukemia patient's bone marrow was colored "dirty green-yellow" as opposed to the normal red. This finding allowed Neumann to conclude that a bone marrow problem was responsible for the abnormal blood of leukemia patients.

By 1900 leukemia was viewed as a family of diseases as opposed to a single disease. By 1947 Boston pathologist Sydney Farber believed from past experiments that aminopterin, a folic acid mimic, could potentially cure leukemia in children. The majority of the children with ALL who were tested showed signs of improvement in their bone marrow, but none of them were actually cured. This, however, led to further experiments.

In 1962, researchers Emil J. Freireich Jr. and Emil Frei III used combination chemotherapy to attempt to cure leukemia. The tests were successful with some patients surviving long after the tests.[39]

Research directions

Significant research into the causes, prevalence, diagnosis, treatment, and prognosis of leukemia is being performed. Hundreds of clinical trials are being planned or conducted at any given time.[40] Studies may focus on effective means of treatment, better ways of treating the disease, improving the quality of life for patients, or appropriate care in remission or after cures.

In general, there are two types of leukemia research: clinical/translational research and basic science research. Clinical/translational research focuses on studying the disease in a defined and generally immediately patient-applicable way, whereas basic science research studies the disease process at a distance and the results from such studies are generally less immediately useful to patients with the disease.[41]

Treatment through gene therapy is currently being pursued. One such approach turns T cells into cancer-targeting attackers. As of August 2011, a year after treatment, two of the three patients are cancer-free.[42]

Society and culture

Leukemias are often romanticized in 20th century fiction. It is presented as a pure, clean disease, whose innocent, beautiful, and spiritually sensitive victims tragically die young. As such, it is the cultural successor to tuberculosis.[43]

In pregnancy

Leukemia is rarely associated with pregnancy, affecting only about 1 in 10,000 pregnant women.[44] How it is handled depends primarily on the type of leukemia. Nearly all leukemias appearing in pregnant women are acute leukemias.[45] Acute leukemias normally require prompt, aggressive treatment, despite significant risks of pregnancy loss and birth defects, especially if chemotherapy is given during the developmentally sensitive first trimester.[44] Chronic myelogenous leukemia can be treated with relative safety at any time during pregnancy with Interferon-alpha hormones.[44] Treatment for chronic lymphocytic leukemias, which are rare in pregnant women, can often be postponed until after the end of the pregnancy.[45][44]

See also

References

  1. ^ Leukemia, in Mosby’s Medical, Nursing &Allied Health Dictionary, Fourth Edition, Mosby-YearBook, Inc.,1994, p. 903
  2. ^ a b c d Mathers, Colin D, Cynthia Boschi-Pinto, Alan D Lopez and Christopher JL Murray (2001). "Cancer incidence, mortality and survival by site for 14 regions of the world.". Global Programme on Evidence for Health Policy Discussion Paper No. 13 (World Health Organization). http://www.who.int/entity/healthinfo/paper13.pdf. 
  3. ^ a b c d "Leukemia Facts & Statistics." The Leukemia & Lymphoma Society. Retrieved 2009-07-02.
  4. ^ Jameson, J. N. St C.; Dennis L. Kasper; Harrison, Tinsley Randolph; Braunwald, Eugene; Fauci, Anthony S.; Hauser, Stephen L; Longo, Dan L. (2005). Harrison's principles of internal medicine. New York: McGraw-Hill Medical Publishing Division. ISBN 0-07-140235-7. 
  5. ^ Finding Cancer Statistics » Cancer Stat Fact Sheets »Chronic Lymphocytic Leukemia National Cancer Institute.
  6. ^ Colvin GA, Elfenbein GJ (2003). "The latest treatment advances for acute myelogenous leukemia". Med Health R I 86 (8): 243–6. PMID 14582219. 
  7. ^ Novartis
  8. ^ Patients with Chronic Myelogenous Leukemia Continue to Do Well on Imatinib at 5-Year Follow-Up Medscape Medical News 2006.
  9. ^ Updated Results of Tyrosine Kinase Inhibitors in CML ASCO 2006 Conference Summaries.
  10. ^ Else M, Ruchlemer R, Osuji N (2005). "Long remissions in hairy cell leukemia with purine analogs: a report of 219 patients with a median follow-up of 12.5 years". Cancer 104 (11): 2442–8. doi:10.1002/cncr.21447. PMID 16245328. 
  11. ^ Matutes, Estella. (1998) "T-cell prolymphocytic leukemia, a rare variant of mature post-thymic T-cell leukemias, has distinct clinical and laboratory characteristics and a poor prognosis." Cancer Control Journal Volume 5 Number 1.
  12. ^ Valbuena JR, Herling M, Admirand JH, Padula A, Jones D, Medeiros LJ (March 2005). "T-cell prolymphocytic leukemia involving extramedullary sites". Am. J. Clin. Pathol. 123 (3): 456–64. doi:10.1309/93P4-2RNG-5XBG-3KBE. PMID 15716243. http://www.medscape.com/viewarticle/501092. 
  13. ^ Elaine Sarkin Jaffe, Nancy Lee Harris, World Health Organization, International Agency for Research on Cancer, Harald Stein, J.W. Vardiman (2001). Pathology and genetics of tumours of haematopoietic and lymphoid tissues. World Health Organization Classification of Tumors. 3. Lyon: IARC Press. ISBN 92-832-2411-6. http://books.google.com/?id=XSKqcy7TUZUC. 
  14. ^ Reference list is found at image description page in Wikimedia Commons
  15. ^ "Leukemia". Columbia Electronic Encyclopedia, 6th Edition. http://web.ebscohost.com/ehost/detail?vid=4&hid=113&sid=3db24ea4-7094-4d8a-be87-b76d351e6932%40sessionmgr13&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=mih&AN=39018085. Retrieved 4 November 2011. 
  16. ^ a b American Cancer Society (2010). "How is Leukemia Diagnosed?". Detailed Guide: Leukemia - Adult Chronic. American Cancer Society. http://www.cancer.org/docroot/cri/content/cri_2_4_3x_how_is_leukemia_diagnosed_62.asp. Retrieved 4 May 2010. 
  17. ^ a b Ross JA, Kasum CM, Davies SM, Jacobs DR, Folsom AR, Potter JD (August 2002). "Diet and risk of leukemia in the Iowa Women's Health Study". Cancer Epidemiol. Biomarkers Prev. 11 (8): 777–81. PMID 12163333. http://cebp.aacrjournals.org/content/11/8/777.long. 
  18. ^ "Do We Know What Causes Leukemia". Detailed Guide: Leukemia. American Cancer Society. 2010. http://www.cancer.org/docroot/CRI/content/CRI_2_4_2X_Do_we_know_what_causes_leukemia_62.asp. Retrieved 18 May 2010. 
  19. ^ a b c d e f Wiernik, Peter H. (2001). Adult leukemias. New York: B. C. Decker. pp. 3–15. ISBN 1-55009-111-5. 
  20. ^ a b Robinette, Martin S.; Cotter, Susan; Van de Water (2001). Quick Look Series in Veterinary Medicine: Hematology. Teton NewMedia. p. 105. ISBN 1-893441-36-9. 
  21. ^ Stass, Sanford A.; Schumacher, Harold R.; Rock, William R. (2000). Handbook of hematologic pathology. New York, N.Y: Marcel Dekker. pp. 193–194. ISBN 0-8247-0170-4. 
  22. ^ Leonard, Barry (1998). Leukemia: A Research Report. DIANE Publishing. p. 14. ISBN 0788171895. http://books.google.com/?id=VfFCVvX9btYC&printsec=frontcover&dq=leukemia&q. 
  23. ^ a b c d Non-Ionizing Radiation, Part 1: Static and Extremely Low-Frequency (ELF) Electric and Magnetic Fields (IARC Monographs on the Evaluation of the Carcinogenic Risks). Geneva: World Health Organisation. 2002. pp. 332–333, 338. ISBN 92-832-1280-0. http://monographs.iarc.fr/ENG/Monographs/vol80/index.php. 
  24. ^ "WHO | Electromagnetic fields and public health". http://www.who.int/mediacentre/factsheets/fs322/en/index.html. Retrieved 2009-02-18. 
  25. ^ Pasmant E, Ballerini P, Lapillonne H et al. SPRED1 disorder and predisposition to leukemia in children. Blood 2009; 114:1131.
  26. ^ Hoffbrand AV, Moss PAH, and Pettit JE, "Essential Haematology", Blackwell, 5th ed., 2006.
  27. ^ National Cancer Institute. "Chronic Lymphocytic Leukemia (PDQ) Treatment: Stage Information". http://www.cancer.gov/cancertopics/pdq/treatment/CLL/HealthProfessional/page2. Retrieved 2007-09-04. 
  28. ^ Eichhorst BF, Busch R, Hopfinger G, Pasold R, Hensel M, Steinbrecher C, Siehl S, Jäger U, Bergmann M, Stilgenbauer S, Schweighofer C, Wendtner CM, Döhner H, Brittinger G, Emmerich B, Hallek M, German CLL Study Group. (2006). "Fludarabine plus cyclophosphamide versus fludarabine alone in first-line therapy of younger patients with chronic lymphocytic leukemia". Blood 107 (3): 885–91.. doi:10.1182/blood-2005-06-2395. PMID 16219797. 
  29. ^ Gribben JG (January 2008). "Stem cell transplantation in chronic lymphocytic leukemia". Biol. Blood Marrow Transplant. 15 (1 Suppl): 53–8. doi:10.1016/j.bbmt.2008.10.022. PMC 2668540. PMID 19147079. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=2668540. 
  30. ^ American Cancer Society (6 July 2009). "Typical Treatment of Acute Myeloid Leukemia". Detailed Guide: Leukemia - Acute Myeloid (AML). American Cancer Society. http://www.cancer.org/docroot/CRI/content/CRI_2_4_4x_Treatment_of_Acute_Myeloid_Leukemia_AML.asp. Retrieved 4 May 2010. 
  31. ^ a b c Fausel C (October 2007). "Targeted chronic myeloid leukemia therapy: seeking a cure". J Manag Care Pharm 13 (8 Suppl A): 8–12. PMID 17970609. http://www.amcp.org/data/jmcp/pages%208-12.pdf. 
  32. ^ "Cladribine in a weekly versus daily schedule for untreated active hairy cell leukemia: final report from the Polish Adult Leukemia Group (PALG) of a prospective, randomized, multicenter trial -- Robak et al. 109 (9): 3672 -- Blood". http://bloodjournal.hematologylibrary.org/cgi/content/abstract/bloodjournal;109/9/3672. Retrieved 2007-09-10. 
  33. ^ "Filgrastim for Cladribine-Induced Neutropenic Fever in Patients With Hairy Cell Leukemia -- Saven et al. 93 (8): 2471 -- Blood". http://bloodjournal.hematologylibrary.org/cgi/content/full/93/8/2471. Retrieved 2007-09-10. 
  34. ^ a b c d Dearden CE, Matutes E, Cazin B (September 2001). "High remission rate in T-cell prolymphocytic leukemia with CAMPATH-1H". Blood 98 (6): 1721–6. doi:10.1182/blood.V98.6.1721. PMID 11535503. http://www.bloodjournal.org/cgi/pmidlookup?view=long&pmid=11535503. 
  35. ^ "JMMLfoundation.org". JMMLfoundation.org. http://www.jmmlfoundation.org/modules.php?name=Content&pa=showpage&pid=8/. Retrieved 2010-08-29. 
  36. ^ "WHO Disease and injury country estimates". World Health Organization. 2009. http://www.who.int/healthinfo/global_burden_disease/estimates_country/en/index.html. Retrieved 2009-11-11. 
  37. ^ Horner MJ, Ries LAG, Krapcho M, Neyman N, et al. (eds).. "SEER Cancer Statistics Review, 1975–2006". Surveillance Epidemiology and End Results (SEER). Bethesda, MD: National Cancer Institute. http://seer.cancer.gov/csr/1975_2006/. Retrieved 2009-11-03. "Table 1.4: Age-Adjusted SEER Incidence and U.S. Death Rates and 5-Year Relative Survival Rates By Primary Cancer Site, Sex and Time Period" 
  38. ^ a b James G. Gurney, Malcolm A. Smith, Julie A. Ross (1999) Cancer Incidence and Survival among Children and Adolescents, United States SEER program 1975-1995, chapter on Leukemia Cancer Statistics Branch, National Cancer Institute, available online from the SEER web site
  39. ^ Patlak, Margie. "Targeting Leukemia: From Bench to Bedside". Breakthroughs in Bioscience. The Federation of American Societies for Experimental Biology. http://opa1.faseb.org/pdf/leukemia.pdf. Retrieved 20 May 2010. 
  40. ^ http://www.clinicaltrials.gov/ct2/results?term=leukemia
  41. ^ "Understanding Clinical Trials for Blood Cancers". Leukemia and Lymphoma Society. http://www.leukemia-lymphoma.org/attachments/National/br_1162487596.pdf. Retrieved 19 May 2010. 
  42. ^ Jaslow, Ryan. "New Leukemia Therapy Destroys Cancer by Turning Blood Cells into "Assassins"". CBSnews.com HealthPop section. http://www.cbsnews.com/8301-504763_162-20091135-10391704.html. Retrieved 11 August 2011. 
  43. ^ Sontag, Susan (1978). Illness as Metaphor. New York: Farrar, Straus and Giroux. pp. 18. ISBN 0-374-17443-1. 
  44. ^ a b c d Shapira T, Pereg D, Lishner M (September 2008). "How I treat acute and chronic leukemia in pregnancy". Blood Rev. 22 (5): 247–59. doi:10.1016/j.blre.2008.03.006. PMID 18472198. 
  45. ^ a b Koren G, Lishner M (2010). "Pregnancy and commonly used drugs in hematology practice". Hematology Am Soc Hematol Educ Program 2010: 160–5. doi:10.1182/asheducation-2010.1.160. PMID 21239787. 

External links