Leukemia (peds)
This page is for pediatric patients. For adult patients, see: leukemia
Background
- Most common cancer in children (33% of all malignancies)
ALL
- 3/4 of pediatric leukemias
- 5-year survival 75%-80%
- Peak incidence 3-5yr old
AML
- 1/5 of pediatric leukemias
- Worse prognosis
- More complications (more intense chemo treatment required)
Clinical Features
Bone marrow infiltration and failure
- Pallor, fatigue, easy bleeding, fever, infection
- Bone pain/arthralgia
- Hepatomegaly or splenomegaly
Hyperleukocytosis
- Clinically significant when WBC > 200K in AML, >300K in ALL
- Cerebral circulation: headache, altered mental status, visual disturbances, seizure, CVA
- Pulmonary circulation: shortness of breath, hypoxemia
Complications
- Tumor lysis syndrome
- Neutropenic fever, Sepsis, overall increased risk of infection
- Leukostasis and hyperleukocytosis
- Hyperviscosity syndrome
- Thromboembolism
- Treatment-related complications
- Chemotherapy-induced nausea and vomiting
- Cytokine release syndrome
- Chemotherapeutic drug extravasation
- Differentiation syndrome (retinoic acid syndrome) in APML
- Stem cell transplant complications
- Catheter-related complications
- Tunnel infection
- Exit site infection
- CVC obstruction (intraluminal or catheter tip thrombosis)
- Catheter-related venous thrombosis
- Fracture of catheter lumen
Differential Diagnosis
Leukemias will often involve >1 cell line; other conditions restricted to single line
- Aplastic anemia
- Iron deficiency anemia
- Viral infection (EBV, CMV, Parvo)
- Immune thrombocytopenia
- Rheumatologic diseases
Evaluation[1]
- CBC with manual differential
- If suggestive of leukemia also order:
- Chemistry, Ca, Phos, Mg, Uric acid, LFTs, LDH, coags, T+S, UCG (if applicable)
- Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
- CXR
- Consider DIC labs
- If suggestive of leukemia also order:
Management
Transfusion
- Options
- Irradiated: for very immunosuppressed (to prevent graft vs host)
- Leukocyte-reduced: for patients likely to receive multiple RBC or platelets in future
- CMV seronegative: for <1yr old, if might need bone marrow transplant in future
- Anemia
- 10 cc/kg of pRBCs raises hemoglobin by 3 gm/dL
- Raise hemoglobin to >8
- Thrombocytopenia
- 0.1 unit/kg platelets results in 30-50K increase in platelet count
- Risk of spontaneous ICH is extremely low until platelets <5K
- Transfuse if:
- Asymptomatic with platelets <10K
- Invasive procedures require platelets >50K
Leukostasis and Hyperleukocytosis
- Aggressive IV hydration
- Urinary alkalinization (pH 7-7.5)
- Allopurinol (for Tumor Lysis Syndrome (TLS))
- Avoid diuretics and pRBC transfusion (platelets ok)
- Give platelets if <20K
- Leukapheresis
Disposition
- admit
See Also
References
- Horton TM and Steuber CP. Overview of the presentation and diagnosis of acute lymphoblastic leukemia in children and adolescents. UpToDate.
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