Leukemia (peds)

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This page is for pediatric patients. For adult patients, see: leukemia

Background

  • Most common cancer in children (33% of all malignancies)
  • Most without cause but increased incidence with paternal age, maternal fetal loss, higher birthweight, familial clusters, and some genetic syndromes (Down syndrome)

ALL

  • 3/4 of pediatric leukemias
  • 5-year survival 75%-80%
  • Peak incidence 2-5yr old
  • Usually B lineage

AML

  • 1/5 of pediatric leukemias
  • Worse prognosis
  • More complications (more intense chemo treatment required)

Clinical Features

Presentation

  • Hepatomegaly and/or splenomegaly with weight loss, abdominal distension or abdominal pain
  • Lymphadenopathy
  • Fever
  • Bleeding (petechiae, purpura), low platelet count, anemia
  • MSK pain, limp, refusal to bear weight
  • Larger anterior mediastinal mass could cause SVC syndrome

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:
      • Review of peripheral smear
      • Chemistry, Ca, Phos, Mg, Uric acid, LFTs, LDH, coags, T+S, UCG (if applicable)
      • Viral titers cytomegalovirus, EBV, HIV, HBV, varicella zoster
      • CXRto look for mediastinal mass
      • Consider DIC labs, coag studies

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 for further workup including bone marrow biopsy and LP

See Also

References

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