Leukemia (peds): Difference between revisions
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{{Peds top}} [[leukemia]] | |||
==Background== | ==Background== | ||
*Most common cancer in children (33% of all malignancies) | *Most common cancer in children (33% of all malignancies) | ||
===[[acute lymphocytic leukemia|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== | ==Clinical Features== | ||
===Bone marrow infiltration and failure=== | |||
*Pallor, [[fatigue]], easy bleeding, [[fever]], infection | |||
*Bone pain/[[arthralgia]] | |||
* | *[[Hepatomegaly]] or splenomegaly | ||
===[[Leukostasis and hyperleukocytosis|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]] | |||
**[[Neutropenic enterocolitis (typhlitis)]] | |||
*[[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== | ==Differential Diagnosis== | ||
''Leukemias will often involve >1 cell line; other conditions restricted to single line'' | ''Leukemias will often involve >1 cell line; other conditions restricted to single line'' | ||
*Aplastic anemia | *[[Aplastic anemia]] | ||
*Iron deficiency anemia | *Iron deficiency [[anemia]] | ||
*Viral infection (EBV, CMV, Parvo) | *Viral infection ([[EBV]], [[CMV]], [[parvovirus B19|Parvo]]) | ||
*Immune thrombocytopenia | *Immune [[thrombocytopenia]] | ||
*Rheumatologic diseases | *Rheumatologic diseases | ||
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*CBC with manual differential | *CBC with manual differential | ||
**If suggestive of leukemia also order: | **If suggestive of leukemia also order: | ||
***Chemistry, Ca, Phos, Mg, Uric acid, | ***Chemistry, Ca, Phos, Mg, Uric acid, [[LFTs]], LDH, coags, T+S, UCG (if applicable) | ||
***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster | ***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster | ||
***CXR | ***[[CXR]] | ||
***Consider [[DIC]] labs | |||
==Management== | ==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 results in 30-50K increase in platelet count | **0.1 unit/kg [[platelets]] results in 30-50K increase in platelet count | ||
**Risk of spontaneous ICH is extremely low until platelets <5K | **Risk of spontaneous ICH is extremely low until platelets <5K | ||
**Transfuse if: | **Transfuse if: | ||
***Asymptomatic with platelets <10K | ***Asymptomatic with platelets <10K | ||
***Invasive procedures require platelets >50K | ***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== | ==See Also== | ||
*[[Oncologic emergencies]] | |||
*[[Leukemia]] | |||
==References== | ==References== |
Revision as of 23:31, 28 November 2019
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
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.