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Acute Leukemia : Diagnosis
   
Western Medicine Chinese Medicine

Medical history: Diagnosing leukemia involves several steps. Your doctor will want a detailed medical and family history to help decide if you are at risk for developing leukemia (for more information, refer to the section on the causes of leukemia). Other information includes the kind and duration of symptoms you are experiencing.

Physical exam: Your doctor will conduct a routine physical exam and will look for the swelling in the liver, the spleen, and lymph nodes.

Investigations:

If your doctor suspects you have leukemia, you will be referred to an oncologist. An oncologist is a doctor who specializes in diagnosing and treating cancer. He will request further blood tests and bone marrow examination. These procedures will help the doctor confirms the diagnosis, determine the type of leukemia, and to decide upon what kind of treatment is necessary.

Blood tests: A sample of blood is examined under a microscope to determine the number and the type of blood cells. Most people with leukemia have too many white blood cells and not enough red blood cells or platelets. If the results of the blood tests are not normal, your doctor may do a bone marrow biopsy.
Bone marrow aspirate and biopsy: A sample of bone and marrow cells is removed by inserting a long, hollow needle into the hipbone. These cells are stained and examined under a microscope. This test can confirm the diagnosis and reveal the type of leukemia.
Marrow is taken by syringe
Bone marrow aspiration and biopsy
Lumbar puncture: A small needle is inserted through the back to take out a sample of the fluid that surrounds the brain and spine. The fluid is then examined under a microscope to see if leukemia cells are present.
Imaging: One or more of the following tests are done to create a picture of the inside of the body and to see how far the leukemia has spread. These tests include X-rays, computed tomography (CT scan), magnetic resonance imaging (MRI), bone scan, and ultrasound.
Immunologic studies: This is an antibody-antigen reaction. An antibody is a protein made by lymphocytes, which is capable of interacting with a foreign substance (antigen), to inactivate it. This study will identify the antigens on the surface of cells. For example, the ALL may be either B-cell subtypes or T-cell subtypes.

Cellular and genetic analysis: The following new tests have improved the diagnosis of different types of leukemia and the measure of disease progression. Currently, these tests are not routinely done outside of the clinical trials.

Flow cytometry also uses the antibody-antigen reaction method. In this test, a sample of bone marrow, lymph node, or blood is treated with special antibodies attached to fluorescent molecules and passed in front of a laser beam. Each antibody sticks only to a certain type of leukemia cell and the laser causes leukemia cells to give off light.
Cytogenetic studies are done to identify defects in the chromosome that may signal the presence of leukemia. The genetic association is especially higher in CLL. In CML, the Philadelphia chromosome is found in more than 90% of all cases.

Deciding on treatment: It is recommended to get a second opinion about the diagnosis and treatment plan. Doing this may help the person to confirm the diagnosis and review the proposed course of treatment. In many centers where leukemia is treated, the person may be asked to participate in clinical trials (treatment studies). Clinical studies help doctors find out whether a new treatment is safe and effective.

 
 

Determining the circumstances and manifestations of a disease through inquiry, and by observing the individual's symptoms are important in TCM. Diagnosis is based on the following four examination techniques.

Through these four techniques a variety of symptoms and signs will be used to identify the individual's disharmony pattern. This is crucial because at the various stages of a disease, a variety of disharmony patterns are present which require different types of therapy. This is why individuals with the same disease are often treated very differently by their TCM practitioner.

A TCM practitioner will not diagnose an individual with acute leukemia. Instead, he or she will diagnose the individual with a disharmony pattern. Particular attention is paid to the following points for differentiation of the various disharmony patterns.

1. Distinguishing the locations of the illness to find out which organs or systems are involved.
2. Distinguishing the nature of illness to decide whether the syndrome is yin, yang, excess or deficiency type.
3. Distinguishing the stage of illness to classify the disease in its acute or remission stages.

Acute leukemia commonly has the disharmony patterns described below:
I Acute Stage of Acute Leukemia

1. Damp and Heat Type
  This often occurs in the early stage of leukemia, and is mainly caused by a mild deficiency of qi, and extreme excess of pathogenic heat. Dampness is produced when the stomach and spleen cannot function properly to transform and transport nutrients. As the dampness accumulates over time, it turns into a heat evil which can inflict damage to the body. Upon examination, the tongue is red and covered with yellow, greasy fur. The pulse is rapid.
2. Noxious Heat Type
  This usually occurs at the time when normal blood cell production of white blood cells, red blood cells and platelets is exhausted due to the overproduction of leukemic cells in the bone marrow and blood. At this stage, noxious heat is extremely excessive, and the remaining vital qi is sparse. Noxious heat and other toxic waste products are produced when the organs hyperfunction and an increase in metabolism is created that results in material consumption of substances such as nutrients and body fluids. As a result, the noxious heat damages the meridians and blood and causes bleeding symptoms. Upon examination, the tongue is red and dry and covered with yellow, dry fur. The pulse feels rolling and rapid.
3. Accumulated Mass Type
  Noxious heat and phlegm evils transform into masses when they stagnate, and block the collaterals (part of the meridian system) in the course of leukemia. Upon examination, the lips and tongue appear pale, and the tip and the margin of the tongue exhibits petechiae. The pulse feels deep and fluttery.
4. Interior Liver-Wind Stir-Up Type
  This usually occurs at the terminal stage of acute leukemia, and develops from the stirring up of interior wind evils. In this stage, the body accumulates excessive noxious heat, which consumes body fluids and damages the blood and meridians. This triggers endogenous pathogenic wind that seriously disturbs the movement of qi and blood. Wind evils affect the liver, which is responsible for helping with the flow of qi and blood. The wind evils are the result of yin deficiency, hyperactivity of liver-yang or excess heat evils. This type can also be caused by phlegm evils blocking the clear orifices such as the mouth. Upon examination, the tongue appears red and dry is coated with little or no fur. The pulse is stringy and rapid.

II Remission Stage of Acute Leukemia

1. Deficiency if Qi and Yin Type
  This occurs in a late stage of leukemia when the body is trying to recover from the damage the disease has inflicted. Qi and yin have been exhausted for a long period and the heart, spleen and body fluid distribution are no longer functioning normally. Upon examination, the tongue appears red and is covered with scanty or scaled fur. The pulse feels deep, thready and rapid.
2. Deficiency of Qi and Blood Type
  This also occurs at the late stage of leukemia where the body is starting to recover. During this stage, vital qi begins to convalesce, and the heat, wind or damp evils start to disperse. The body is getting better from the illness, but the impaired organs, qi and blood are still very weak. Upon examination, the tongue is pale and swollen with indented margins, and covered with a thin, white fur. The pulse sign is deficient and heavy or soft and thready.

Click here to see the development of leukemia from a TCM perspective

III Differentiating acute leukemia from other illnesses

In the clinical diagnosis of TCM, acute leukemia should be differentiated from other similar diseases.

1. Consumptive Disease
  This is a disease caused by insufficiency of vital qi and blood, or organ deficiency. When the individual experiences fever and anemia, it should be distinguished from aplastic anemia, which comes under the category of consumptive disease. In the whole course of this type of disease, there are no nodules or abdominal mass, so it is easy to differentiate.
2. Blood Disorders
  Blood disorders involve spontaneous bleeding diseases such as thrombocytopenia (not enough platelets to clot the blood), abnormal blood vessels and blood coagulation factor deficiencies. These specific blood disorders can be detected in leukemia patients through blood tests.
3. Fever Caused by Exogenous (external) evils
  This type of fever is usually induced by seasonal pathogens. It usually presents with persistent high fever and excessive interior heat. Interior heat is produced when there is a pathological disturbance in the physiological functions of the qi, blood, body fluids and organs. With this type of fever, the individual's blood parameters are normal, and it is easy to recover from the fever. However, leukemia sufferers usually have a persistent low-grade fever, but when it is complicated by infections, the temperature will be high.

Note: If a TCM practitioner suspects there might be a serious problem that Chinese medicine alone cannot treat, he or she will recommend the individual see a western doctor for further follow up.