leukemia is one among the common congenital malformations in children. it is also called as cancer of blood cells where immature blood cells are formed due to mutations in progenitor stem cell. This content includes types of leukemia especially categorized in children with description of diagnosis and management.
2. INTRODUCTION
Leukemia is derived from the Greek word Leukos= white
haima/emia= blood
It means uncontrollable proliferation of immature white
blood cells called blasts cells.
3. Definition
Leukemia is a malignant progressive disease in which the bone
marrow and other blood-forming organs produce increased
numbers of immature or abnormal leucocytes. These suppress
the production of normal blood cells, leading to anaemia and
other symptoms.
4. Leukemia inChildren - Statistics
Leukemia constitutes about 30%–50% of all childhood cancers
globally.
In India, annually >10,000 cases of childhood leukemia have been
reported.
Incidence of leukemia in Indian pediatric population was reported
as 34%, of which 73%; 18%; and 4% were Acute lymphoblastic
leukemia(ALL), Acute myeloidleukemia(AML) and Chronic myeloid
leukemia(CML). Respectively.
InALLboys are more affected than girls
7. Classification
Based on severity
Acute leukemia: rapid division of
cells with rapid disease
progression. Onset of symptoms
with in a week. Most common
pediatric cancer
Chronic leukemia: consists of both
mature and immature cells.
typically worsens slowly.
Asymptomatic for many years.
Common in adults than in children
Based on type of cell
Myelogenous/myeloid leukemia:
developed from myeloid
precursors results in development
of abnormal RBC, Platelets and
WBC(eosinophils, basophils,
neutrophils)
Lymphocytic leukemia: developed
from lymphoid precursors results
in development of abnormal WBC
(monocytes and lymphocytes)
8. Pathology of leukemia
Type Cells involved Cytology Statistics
ALL Immature B or T
cells, macrophages
Chromosomal aberration Common in
children (33%)
AML Immature myeloid
WBC’s
Oncogene mutations,
single myeloblast
mutation, cytogenetic
abnormalities
Both adults and
children (80%)
CLL Lymphoid B or T cell Chromosomal
abnormalities
Common over 55
years age
CML Myeloid stem cells Chromosomal
translocation, granulocytes
Rare in children
9.
10. CLINICALFEATURES
General Systemic Effects
1.Fever(60%).
2.Lassitude (50%)
3.Pallor(40%)
Hematologic Effects Arising from Bone Marrow Invasion
1.Anaemia
–pallor,fatigability, tachycardia, dyspnoea &CHF
2.Neutropenia
–fever,ulceration of buccal mucosa andinfection.
3.Thrombocytopenia
–petechial, purpura, easy bruisability, bleedingfrom mucous membrane
and internalbleeding.
12. CLINICAL FEATURES MNEUMONIC – Childhood Cancer
CONTINUOUS FEVER, WEIGHT LOSS
HEADACHES, EARLY MORNING VOMITION
INCREASED SWELLING OR PERSISTENT PAIN IN BONES, JOINTS, BACK OR LEGS
LUMP OR MASS – ABDO, NECK, CHEST, PELVIS, ARMPITS
DEVELOPMENT OF RASH, BLEEDING, BRUISION
CONSTANT / RECURENT INFECTIONS
A WHITISH COLOR BEHIND PUPIL
NAUSEA – PERSISTANT OR VOMITING WITHO OR W/O SEIZURE
CONSTANT TIREDNESS
EYE OR VISON CHANGES
RECURRENT OR PERSISTENT FEVER
13. INVESTIGATIONS
• Blood count
• Haemoglobin: Moderate to markedreduction
• Blood smear: Blasts are present on blood smear. Very few to
none(in patients with leukopenia).
• White blood cell count: Low,normal,or increased
• Thrombocytopenia: 92% of patients have platelet counts
below normal. Very fewto none (in patients withleukopenia).
14. INVESTIGATIONS – Bone Marrow
• Leukemia must be suspected whenthe bone marrow contains
more than 5%blasts.
• The hallmark of the diagnosis of acute leukemia is the blast cell,
are relatively undifferentiated cell with diffuselydistributed
nuclear chromatin, one or more nucleoli and basophilic cytoplasm.
20. MAINTENANCE
• Inj.VCR 1.5 mg/m2 one in a month
• TabPrednisolone 60 mg/m2 for one week
• T.6MP 50 mg/m2 p.odaily
• T.MTX 20 mg/m2 p.owkly
The optimal duration of therapy remainsunknown. Most investigators
continue to treat patients for 2 to 3 years, based on results of older
studies
21. FOLLOWUP
If the patient completes chemotherapy for 2 years without relapse-
stop chemo and follow up.
No relapse within 5 years-can be declared as cured.
• A totalof 10 mg/kg/dayof allopurinol in divideddoses isgiveninall
casesbeforethe commencementof antileukemicdrugs.
• When the blast cellcount is more than 50,000/mm3 or there are large
tumour masses, allopurinol is obligatory,togetherwith a fluidintakeof 2–
3L/m2/day
SUPPORTIVE CARE
22. SUPPORTIVE CARE
• use of packedredcells
• When high feverand possible septicemia occur in the presence of
neutropenia, antibiotic therapy should be startedafter taking appropriate
blood cultures and a chest radiograph.(NEUTROPENIAREGIME)
• Platelettransfusions should beadministered to patients with overt bleeding
or when the plateletcount is below10,000/mm3.
23. ALLOGENIC STEM CELLTRANSPLANTATION
• Usually done in second remission.
• Can be done in first remission in high risk patients
- WBC > 25000,
- philadelphia chromosome positive,
- poor initial response to remission induction.
24. NEWER DRUGS
Monoclonal antibodies :rituximab (CD20), epratuzumab (CD22)
Antimetabolites: clofarabine, nelarabine
Tyrosine kinase inhibitor: imatinib, nilotinib,.
Patients with .0.01% leukemic cells after the end of induction have a worse
prognosis and may require more intensivetherapy.
REMISSION
25. RELAPSE
• Despite current intensive front‐line treatments, 20%of
children withALL experience bone marrowrelapse.
• Relapsemay bean isolatedeventinthebone marrow or may be
combined with relapse in othersites
27. NURSING MANAGEMENT
NURSING ASSESSMENT
Health history: collect data regarding antenatal exposure to
radiation, medications, infections, presence of genetic
abnormalities to child or child sibling, history of organ
transplantation etc
Physical examination: check for petechiae, purpura, bruising,
internal bleeding, pallor, organomegaly, lymphadenopathy etc
Laboratory results: identify child values for complete blood
count and other investigation reports
28. NURSING DIAGNOSES
Risk for infection related to overproduction of immature blast
cells
Risk for decreased cardiac output related to thrombocytopenia
secondary to treatment
Risk for impaired skin integrity related to chemotherapy;
immobility
29. Cont….
Imbalanced nutrition less than body requirements related to
hypermetabolic state anorexia mucositis nausea and pain
Acute pain and discomfort related to mucositis, leukocyte
infiltration of systemic tissues fever and infection
Hyperthermia related to tumor lysis or infection
Fatigue and activity intolerance related to anemia infection
and deconditioning
30. Nursing care planning and goals
The major goals for the patient may include:
Aseptic environment
Absence of pain.
Attainment and maintenance of adequate nutrition.
Activity tolerance.
Ability to cope with the diagnosis and prognosis.
31. NURSING INTERVENTIONS
Infection control and prevention:
Perform handwashing before and after giving care to child
Maintain oral and personal hygiene of child
Avoid rectal thermometer and suppositories
Perineal cleansing after passing stools every time
Recognize symptoms of infection e.g fever, chills, cough,
and sore throat
32. Institute bleeding precautions:
Provide a soft toothbrush for oral hygiene
Avoid invasive procedures (including IM/IV medication)
unless necessary
Avoid aspirin containing drugs and rectal suppositories
Avoid urinary catheterization, if needed then only lesser sized.
Avoid mucosal trauma during suctioning.
Remove all sharp objects around child.
33. Maintain skin integrity
Keep bed linen dry and wrinkle free
Use paper plaster only for procedural adhesion
Inspect skin for any lesions, dryness, and eruptions
Keep skin and perineal area clean
Apply mild lotion or creams to keep skin from drying or
cracking
Maintain hydration by increasing fluid intake
34. Promote good nutrition
Monitor weight of child regularly.
Monitor for nausea and vomiting
Provide high calorie and high protein diet
Provide small feeds and frequent intervals
Administer antiemetics before meal as advised
35. Minimise pain and discomfort:
Assess the characteristics of pain
Manage pain appropriately by pharmacological and non
pharmacological methods like
Massage
Positioning
Cool/heat therapy
Aromatherapy
Guided imagery
