Leukaemia

Leukaemia in pediatric

1. Leukemia
Surendra Sharma
Associate Professor
Amity College of Nursing
Amity University, Haryana

2. DEFINITION
Leukemiaisamalignantdiseaseofblood
formingorgansofthebodythatresultsin
uncontrolledgrowthofimmaturewhitebloodcells.
Theleukemiaprocessinthebonemarrowwiththe
productionofnormalredcell,whitecellandplatelets
(Wongs,2005).
Itisleukemiaaredisordersofuncontrolled
proliferationofleucocyteandtheirprecursorsinthe
bonemarrowwithinfilterationoflymphnodes,
spleenliverandotherbodyorgans(Mosby’sClinical
Nursing).

3. INCIDENCE
28700 new cases of leukemia occur yearly
Approximately 26500 occur in adults
2200 in children
21600 deaths in childrens approximately.
Etiology
The exact causative agent is unknown
Virus
Rediation
Chemical and drug exposure
Genetic

4. Pathophysiology
Acutelymphoyticleukemiaismaliguane
disorderarisingfromasinglelymphoidstemcell,
withimpairedmaturationandaccumulationofthe
maligentcellsinthebonemarrow.
Diagnosisisconfirmedbybonemarrow
aspirationorbiopsy,whichtypicallyshowsdifferent
stagesoflymphoiddevelopment.
From,veryimmatureatalmostcells.
Thedegreeofimmaturityisaguidetothe
prognosis,thegreaterthenumberofimmature
cells,thepoorerwillbetheprognosis.

5. CATEGORIES OF CHILDHOOD LEUKEMIA
Acute Iumphocytic leukemia (AIL)
1. Standard risk all
2. High risk all
T cell ALL
B cell ALL
Acute Nonlymphocytic leukemia (ANLL)
Granhlocytic
Myelocytic
Myelogenous
Monoblastic
Chronic myelocytic leukemia (CML)
Adult form
Chronic phase
blast crisis
Juvenile form
Congenital leukemia

6. Clinical manifestations
Anemia from decreased RBCs
Infection from neutropenia
Bleeding from decreased platelet production
Fever
Weakening of the bone
Fractures
Spleen, liver, lymphglanss demonstrate marked
infiltration, enlargement
Eventually fibrosis
Leukemic cells may also invade the testes,
kidney, prostate, ovaries, GIT tract and lungs

7. Diagnostic evaluation
•Historycollection
•Physicalexamination
•Peripheralbloodsmear(immatureformsof
leukocytes)
•Bonemarrowaspirationorbiospsy.
•Lumparpunctureisperformedtodetermineif
thereisanyCNSinvolvement.
Management (Therapeutic)
Treatment ofleukemiainvolvestheuseof
chemotherapeuticagents,withorwithoutcronial
eradicationinfourphases:
1. Induction therapy
2. CNS prophylactic therapy
3. Intensification therapy
4. Maintenance therapy

8. Inductiontherapy
Inductionofremissionaimsateradicationofall
leukemiablastcells,whichpermitsthereturnof
normalhemetopoisis.Anumberofgeneticordrug
combinationsareused.
Themostcommon dugisprenizoloneand
vincristilemanyotherdrugcombinationssuchasL-
aspanginaseandcyclophosphemidewithsteroidsare
alsousedforchemotherapy.
Maintenancetherapy
Acompleteremissionimputesaclinical
haemtologicalandbonemarrowremission.For
remissiontherapydrugslike,metro percate
cyclophosphemideand6merceptoparilecodeused.
Alsoduringmaintenancetherapy,periodicCBSare
takentoevaluatethebonemarrow’sresponsetothe
drugs.

9. CNS prophylactic therapy
TreatmentoftheCNSconsistsofprophylactictherapy
usingintrathecalchemotherapywithmethotrexate,cytarbine
andhydrocortisone.SometimesMetrotrexateaswellas
cytarabinemaybegivenassingleagentsintrathecally.
Intensificationorconsolidationtherapy
Aftercompleteremissionisobtained,aperiodof
intensifiedtreatmentisadministeredtocradicateresidual
leukemiccells,thisisfollowedbydelayedintensificationto
preventemergence ofresistantleukemia clones.
Chemotherapy includinghighdoseorintermedicatedose
methotrexate,cytarbineisadministeredoveraperiodof
severalmonths.
Nursingmanagement
Givepsychologicalsupporttothefamilymembers
Encouragechildtotalkaboutfeelings
Helpfamilyastheyencouragechildtoexpressfeelings
Givepainrelieftherapy
Avoidpressureonpainfulareas
Keepfreshaircirculatinginroom

10. ACUTE LYMPHOCYTIC LEUKEMIA (ALL)
DEFINITION
ALLisabroadtermdescribingagroupof
malignantdiseasesinwhichnormalbonemarrow
elementsarereplacedbyabnormalimmature
lymphocytesknownasblastcells.
INCIDENCE ANDETIOLOGY
98%childrensufferingfromleukemiahaveacute
typeofthedisease.
Mostlyin2–5yearsold
Boththeagegroups
Approximately3,000newcaseseachyearinthe
US.
Viruses
Radiation
Exposureofcertaintoxicchemicals
Drugssuchasbenzeneandagenticpredisposition
MostlyunknownALLcasesetiology

11. PATHOPHYSIOLOGY
Acute lymphocytic leukemia develops
Single lymphoid cell
Transformation and proliferates uncontrollably
Bone marrow of an individual with ALL the invasion of
these malignant lymphoblast or immature white cells cause
“Crowding out”
Normal red blood cell, platelets and white blood cells
Pancytopenia (Reduction in the number of RBCs and WBCs
and platelets)
Immunosuppression

12. CLINICAL MANIFESTATIONS
Bone marrow
depression
Increased
metabolism
Enlargement of organs
infiltrate by blast
cells
Blast cells crowd
out healthy, WBCs,
RBCs, platelets
1 23 Weight
loss
BonesSpleenLiverGlandsKidney
Proliferation of immature white blood cells (Blasts)
1.Decreased WBCs (decreased immunifunction)
2.Decreased RBCs (decreased Oxygen carrying capacity)
3.Patients platelets (decreased clotting capacity)
Pathotlysilogy leading to clinical manifestations in ALL
Source (Polts Nickil, P. No. 926).

13. Enlargement of organs infiltrated by blast cells
Bones
•Bone pain
•Migratory joint pain and swelling
Spleen
•Splenomegaly
•Abdominal fulness
Liver
•Hepatomegly

14. Glands
1. Lymphadenopathy
2. Tenderness
Kidney
Kidney enlargement
Usually no overt signs or symptoms
1. Decreased immune function signs and symptoms
Fever
Infection especially pulmonary, urinary tract
Blood
2. Decreased O2 carrying capacity
Anaemia
Weakness
Malaise
Pallor
Dyspnea
Tachycardia
3. Decreased clotting capacity
Increased bruising/petechiae
Nose bleeds
Bleeding from gums
Haemorrhage

15. Diagnosis
BMA(Bondmarrowaspiration)
25%ofabnormallymphoblastsinthebone
marrowisdiagnostic
Bloodcountandageatdiagnosisarethemost
importantprognosticsignsinALL.
BestprognosisisWBClessthan5000/mm3and
theageof2–9years.
WorstprognosisWBCof50000/mm3younger
than2yearsandolderthan10years.
Lemparpunctureisdonetoassessforthe
presenceofCNSdisease.
ChestX-rayisobtainedtodetectamediastinal
mass.
Laboratoryfindingswillshowliverorkidney
involvement.

16. Treatment
IfincludesALLtreatedwithsystemicchemotherapy and
includesthreephases:
1.IndicationPhases
Thegoalistheinductionphaseistoreducethetumor
burdentoanundetectablelevel,astateknownas
remission.
 Inremissionthereisnoevidenceofleukemiaon
physicalexam,bonemarrowevaluation.
 PeripheralbloodcountsintheCSForanyother
extramedullarysite.
 95%ofchildrenwithALLachieveremission
during inductionwhichusuallylastsfourweeks.
 Remissioninductionisachievedby
treatingthechildwiththechemotherapeutic
agents,oncoin, lesparaginase and
predinisonechildren.
 Presentingsymptomssuchasanaemia,infection
orbleedingaretreatedatthetimeofdiagnosis.
 Elevationoftheuricacid
 Acuterenalfailure,thisiscalledtumour

17. Treatment
Ailopurinolisalsogiventoaidintheexcretionof
uricacidthroughthekidneys,preventingrenal
obstructionandfailure.
WBC high50000 orgreaterorextensive
lymphadenopathy.
Radiationtherapy
2. Consolidation phase
 Itiseradicatinganyresidualleukemiccellsand
startspromptlyonceremissionisattained.
 Chemotherapyisfrequentlygiveninhighdoses
requiringhospitalizationduringthisphaseof
treatment.
 ITCinrathecallymedicationsisfrequentand
radiationtherapytothebrainmaybegivenforCNS
prophylaxis ortreatment.
 Childrenwhohaveextremedullarydiseasewill
receiveradiationtothosesitesatthistime.
 Sixmonthsintensethisphase

18. 3. Maintenance phase
 Itfollowsconsolidationandmaintainscontrolof
theleukemiawithmostchemotherapeuticagents
administeredbyoral,IM,IVroutes.
 OccasionalIVinjectionsofvincristineand
lymbar punctureswithITchemotherapymaybe
given.
 Mostcentrescontinuetherapyfor2½to3
yearsafterdiagnosis.
 Todayremissioncanbeinducedin95%of
children.
And5yearssurvivalratesarenownearly80%.
Thecompletionofchemotherapyisagoalthatmany
caregiversandchildrenlookforwardtowithahopeto
returntoa“normallife”again.
 Itisalsometwithhighanxietyandfearthatifno
furthertherapyisgiventhechildwillpromptlyrelapse.
 Thefamilyneedstobeassumedthatthereisno
significantadvantagetocontinuingtherapybeyond
thisperiod.
 Bonemarrow transplantisatreatmentoptionfor

19. Nursingdiagnosis
1.Riskforinfectionrelatedtoneutropeniafromthe
diseaseprocessandtreatment
Intervention
Followthestrictasepectictechniqueforhand
washingprocedure.
Monitorthevitalsignsfrequentsforsignsof
infection.
Administerantibioticsasordered.
Tominimizeexposuretoinfectiveorganism.

20. 2. Risk for injury related to thrombocytopenia
Intervention
 Monitorsusceptiabilitytobleeding
 Assessforsignsofbleedingincluding
petechiaquaandbruishing
 Monitorurineandstoolforsignsofoccult
bleeding
 Dotheplatietcountdaily
 Decreasedplatietcountbruising,petelachiae
andbloodinurineorstoolcanindicatebleeding
 Monitorforsignsofhemorrhage(DecreasedBP,
tachycardia,pallor,diaphoresisrestlessness)
 Avoidskinpunctureswhenpossible.Apply
pressureifpuncturesnecessaryfor5–10
minutes
 Childrenwithplateletcountsbelow20000/mm3
areatriskforspontaneousbleeding

21. 3.Painrelatedtodiagnosis,diseaseprocessand
treatment
Assessthepainfulareasforlocation,severity
andsignsofinfection.
Providepainmedication
Providepsychologicalsupport
Giveplaytherapy
Followthedoctorsorder
4.Imbalancednutrition:lessthanbodyrequirement
relatedtolossofappetitenausea,vomitingand
mucositis
 Givesmallamountoffoodfrequently
 Encouragehighproteinandhighcaloriediet
 Givepatientlikefood
 Administerantiemeticsasorderedtodecrease
nausea

22. ACUTE MYELOGENOSUS LEUKEMIA
ANIListhesecondtypeofleukemiarecognized.
ChildrenwithAMLhaveapoorerprognosisthanthose
withALL.70to85%ofchildrenwiththistypeof
leukemiawillachieveremissio,butonly30–40%will
becomelongtermsurvivors.
Incidenceandetiology
15to45%approximatelyofchildhoodleukemia.
Etiologyisnotknown.
Riskfactorssuchasexposuretoradiationtherapy
andchemotherapy forthetreatmentofa
previouscancer,exposuretobenzeneandgenetic
predispositioninchildrenwithdownsyndrome
andfanconisanaemiacanbenamed.

23. Pathophysiology
ALLmalignantmyeloidblastscrowdoutthe
normalWBC,plateletsandredbloodcellscausing
neutropenia and immunosuppression,
thrombosytopeniaandanaemia.
Clinical manifestation
Resembling the flu, i.e.,
Fever
Fatigue
Malise
Anorexia
Bleeding and severe hemorrhage
DIC (Disaminated intravascular cogulation)
AML and ALL clinical manifestations are same
Difficulty in walking
Incontinuence of urine and stool caused by spinal
cord compression
Enlargement of the liver, spleen
Lymphadenopathy occurs less often

24. Diagnosis
Bonemarrowaspiration>25%,malignantmyeloid
blastsconfirmsthediagnosisofAML.
Treatment(Medical)
Systemicchemotherapy
ThephasesofAMLtreatmentareremission
inductionandcontinuationtherapy
Chemotherapydrugssuchascytarabineandan
anthracyclineagent.
Afterremissionisachievedmanyclinicaltrials
callforacontinuationwithintensehighdose
chemotherapeuticagentssuchascytarabine,
cytoxinanthracyclines
Bonemarrowtransplantation
RadiationtotheheadmaybepartofCNS
therapyandprophylaxis

25. Nursing management
Checkthevitalsigns,decreasetheblood
pressureandincreaseinheartrate.
Watchforbleeding
Provideskincareandpreventskinbreakdown.
Providepaincontrollingmeasures like
modificationinthephysicalenvironment
positioninguseofanalgesicetc.
Providepsychologicalsupporttothepatients
andparents.
Isolatethepatientandrestrictthevisitors
Givelightclothtowearandpreventthe
pressureofbedlines
Usedimlightandcreateminimum sound
environment
Providediversionaltherapieslikeuseofmusic
relaxationtechniquescutaneousstimulationetc.

26. Nursing care plan
1. Highriskforinfectionrelatedtoineffective
immune system.
2. Alteredprotectionrelatedtoelectrolyte
imbalances secondarytotumourlysis.
3. ActivityintolerancerelatedtoimpairedO2
transport.
4. Highriskforinjury(internal)relatedto
inadequate clottingfactors(platelts)
5. Anxietyrelatedtounfamilaritywithnew
diagnosisandtreatmentplan.
Implementation
1. Monitor the vital signs
Prevent constipation and invasive procedures.
obtained blood via finger tips not venipunture.
Inspect skin daily for areas of breakdown.
Monitor blood counts
Inspactoralcavityfororalcandidiasisand
breakdownintheoralmucosallining.
Instruct family about signs and symptoms of
infection.

27. 2. Check the vital signs.
Give adequate rest.
Encourage to play.
Administer packed RBCs as advised by doctor.
Discuss with parent child signs and symptoms of
anaemia, treatment options.
3.Monitor platlet count daily.
Inspectstoolurine,gums, sputum, nasal
secretionforanyevidenceofbleeding.
Minimize/avoid in vasive procedures
4.Provide adequate knowledge to the parents about
diagnosis and treatment.
Introduce family to another family whose child
has similar diagnosis with similar therapy.
Verbally reinforce each day the plan for next 24-48
hours.
Provide written and verbal discharge instructions.

28. CHRONIC LYMPHOCYTIC LEUKEMIA
CLLitischaracterizedbyaproviferationand
accumulationorsmall,abnormal mature
lymphocytesinthebonemarrow.
Itismainlyoccursinadultsespeciallyinolder
adults(65years).

29. CHRONIC MYELOGENOUS LEUKEMIA
Itoccursbetween25–60yearsofage.
Peakincidenceisaroundat45yearsofage.
Etiologyisalsounknown.
Chromosome 22and9isidentifiedinperson
diagnosedwithCML.
Health education
Give extra calories and protein rich diet.
Encourage the child mingle with all children.
Follow the doctor’s order and take the regular
checkup to the children.
Avoid injuries and damage to the body’s.
Explain about the prevention and control of the
further attack to be avoid.