Difference between revisions of "Leukemia (peds)"

 
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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)
  
===ALL===
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===[[acute lymphocytic leukemia|ALL]]===
 
*3/4 of pediatric leukemias
 
*3/4 of pediatric leukemias
 
*5-year survival 75%-80%
 
*5-year survival 75%-80%
 
*Peak incidence 3-5yr old
 
*Peak incidence 3-5yr old
  
===AML===
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===[[AML]]===
 
*1/5 of pediatric leukemias
 
*1/5 of pediatric leukemias
 
*Worse prognosis
 
*Worse prognosis
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===[[Leukostasis and hyperleukocytosis|Hyperleukocytosis]]===
 
===[[Leukostasis and hyperleukocytosis|Hyperleukocytosis]]===
 
*Clinically significant when WBC > 200K in AML, >300K in ALL
 
*Clinically significant when WBC > 200K in AML, >300K in ALL
*Cerebral circulation: [[headache]], [[altered mental status]], [[visual changes]], [[seizure]], [[CVA]]
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*Cerebral circulation: [[headache]], [[altered mental status]], [[visual disturbances]], [[seizure]], [[CVA]]
 
*Pulmonary circulation: [[shortness of breath]], [[hypoxemia]]
 
*Pulmonary circulation: [[shortness of breath]], [[hypoxemia]]
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===Complications===
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*[[Tumor lysis syndrome]]
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*[[Neutropenic fever]], [[Sepsis]], overall increased risk of [[infection]]
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**[[Neutropenic enterocolitis (typhlitis)]]
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*[[Leukostasis and hyperleukocytosis]]
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*[[Hyperviscosity syndrome]]
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*[[Thromboembolism]]
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*Treatment-related complications
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**Chemotherapy-induced [[nausea and vomiting]]
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**[[Cytokine release syndrome]]
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**Chemotherapeutic drug extravasation
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**[[Differentiation syndrome]] ([[retinoic acid syndrome]]) in APML
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**[[Stem cell transplant complications]]
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**Catheter-related complications
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**Tunnel infection
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***Exit site infection
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***CVC obstruction (intraluminal or catheter tip thrombosis)
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***Catheter-related venous thrombosis
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***Fracture of catheter lumen
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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*[[Aplastic anemia]]
 
*[[Aplastic anemia]]
 
*Iron deficiency [[anemia]]
 
*Iron deficiency [[anemia]]
*Viral infection ([[EBV]], [[CMV]], Parvo)
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*Viral infection ([[EBV]], [[CMV]], [[parvovirus B19|Parvo]])
 
*Immune [[thrombocytopenia]]
 
*Immune [[thrombocytopenia]]
 
*Rheumatologic diseases
 
*Rheumatologic diseases
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***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
 
***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
 
***[[CXR]]
 
***[[CXR]]
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***Consider [[DIC]] labs
  
 
==Management==
 
==Management==
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***Invasive procedures require platelets >50K
 
***Invasive procedures require platelets >50K
  
===[[Hyperleukocytosis]]===
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===[[Leukostasis and Hyperleukocytosis]]===
 
*Aggressive IV hydration
 
*Aggressive IV hydration
 
*Urinary alkalinization (pH 7-7.5)
 
*Urinary alkalinization (pH 7-7.5)
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==See Also==
 
==See Also==
*[[oncologic emergencies]]
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*[[Oncologic emergencies]]
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*[[Leukemia]]
  
 
==References==
 
==References==

Latest 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

Hyperleukocytosis

Complications

Differential Diagnosis

Leukemias will often involve >1 cell line; other conditions restricted to single line

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

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

  1. Horton TM and Steuber CP. Overview of the presentation and diagnosis of acute lymphoblastic leukemia in children and adolescents. UpToDate.