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
 
**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 tx required)
 
  
==Diagnosis==
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===[[acute lymphocytic leukemia|ALL]]===
*Signs/symptoms due to bone marrow infiltration and failure
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*3/4 of pediatric leukemias
**Pallor, fatigue, easy bleeding, fever, infection
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*5-year survival 75%-80%
**Bone/joint pain
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*Peak incidence 3-5yr old
**Hepatomegaly or splenomegaly
 
*Hyperleukocytosis
 
**Clinically significant when WBC > 200K in AML, >300K in ALL
 
**Cerebral circulation: HA, AMS, visual changes, sz, CVA
 
**Pulmonary circulation: SOB, hypoxemia
 
  
==DDx==
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===[[AML]]===
*Leukemias will often involve >1 cell line, other conditions restricted to single one
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*1/5 of pediatric leukemias
#Aplastic anemia
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*Worse prognosis
#Iron deficiency anemia
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*More complications (more intense chemo treatment required)
#Viral infection (EBV, CMV, Parvo)
 
#Immune thrombocytopenia
 
#Rheumatologic diseases.
 
  
 +
==Clinical Features==
 +
===Bone marrow infiltration and failure===
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*Pallor, [[fatigue]], easy bleeding, [[fever]], infection
 +
*Bone pain/[[arthralgia]]
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*[[Hepatomegaly]] or splenomegaly
  
==Work-Up==
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===[[Leukostasis and hyperleukocytosis|Hyperleukocytosis]]===
*CBC
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*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===
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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==
 +
''Leukemias will often involve >1 cell line; other conditions restricted to single line''
 +
*[[Aplastic anemia]]
 +
*Iron deficiency [[anemia]]
 +
*Viral infection ([[EBV]], [[CMV]], [[parvovirus B19|Parvo]])
 +
*Immune [[thrombocytopenia]]
 +
*Rheumatologic diseases
 +
 
 +
==Evaluation<ref>Horton TM and Steuber CP.  Overview of the presentation and diagnosis of acute lymphoblastic leukemia in children and adolescents.  UpToDate.</ref>==
 +
*CBC with manual differential
 
**If suggestive of leukemia also order:
 
**If suggestive of leukemia also order:
***Chemistry, Ca, Phos, Mg, Uric acid, LFT, LDH, coags, T+S, CXR
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***Chemistry, Ca, Phos, Mg, Uric acid, [[LFTs]], LDH, coags, T+S, UCG (if applicable)
 +
***Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
 +
***[[CXR]]
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***Consider [[DIC]] labs
  
==Treatment==
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==Management==
*Transfusion
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===[[Transfusion]]===
**Options
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*Options
***Irradiated: for very immunosuppressed (to prevent graft vs host)
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**Irradiated: for very immunosuppressed (to prevent graft vs host)
***Leukocyte-reduced: for pts likely to receive multiple RBC or plts in future
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**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
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**CMV seronegative: for <1yr old, if might need bone marrow transplant in future
**Anemia
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*[[Anemia]]
***10 cc/kg of pRBCs raises Hb by 3 gm/dL
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**10 cc/kg of [[pRBCs]] raises hemoglobin by 3 gm/dL
***Raise Hb to >8
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**Raise hemoglobin to >8
**Thrombocytopenia
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*[[Thrombocytopenia]]
**0.1 unit/kg results in 30-50K increase in plt count
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**0.1 unit/kg [[platelets]] results in 30-50K increase in platelet count
**Risk of spontaneous ICH is extremely low until plt <5K
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**Risk of spontaneous ICH is extremely low until platelets <5K
 
**Transfuse if:
 
**Transfuse if:
***Asymptomatic w/ plt <10K
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***Asymptomatic with platelets <10K
***Invasive procedures require plt >50K
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***Invasive procedures require platelets >50K
*Hyperleukocytosis
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**Aggressive IV hydration
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===[[Leukostasis and Hyperleukocytosis]]===
**Urinary alkalinization (pH 7-7.5)
+
*Aggressive IV hydration
**Allopurinol (for [[Tumor Lysis Syndrome]])
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*Urinary alkalinization (pH 7-7.5)
**Avoid diuretics and pRBC transfusion (plts ok)
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*[[Allopurinol]] (for [[Tumor Lysis Syndrome (TLS)]])
**Give plts if <20K
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*Avoid diuretics and pRBC transfusion (platelets ok)
**Leukapheresis
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*Give platelets if <20K
 +
*Leukapheresis
 +
 
 +
==Disposition==
 +
*admit
  
==Source==
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==See Also==
Tintinalli
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*[[Oncologic emergencies]]
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*[[Leukemia]]
  
[[Category:Peds]]
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==References==
 +
<references/>
 +
[[Category:Pediatrics]]
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[[Category:Heme/Onc]]

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.