Notes on Childhood Cancer and Leukemia

Overview of Childhood Cancer

Childhood cancer is known to be the leading cause of death from disease in children beyond the infancy stage. It poses unique challenges and requires specialized treatment approaches. Almost half of all childhood cancers involve blood or blood-forming organs, primarily categorized under Neoplastic Disorders, which include significant conditions such as:

• Leukemia: A type of cancer that affects the blood and bone marrow.

• Lymphomas: Cancers that originate in the lymphatic system, which is part of the immune system.

These cancers necessitate comprehensive care strategies with varying treatment modalities.

Side Effects of Treatment

The treatment for childhood cancers often leads to significant side effects, impacting the patient's overall health and well-being. Key side effects include:

• Infection due to neutropenia: A condition characterized by a low neutrophil count, making patients highly susceptible to infections.

• Bleeding tendencies: Arising from decreased platelet production, which heightens the risk of bleeding and bruising.

• Anemia: Resulting from a decreased number of red blood cells (RBCs), leading to fatigue and weakness.

• Organ enlargement: Particularly severe enlargement of organs such as the spleen, liver, and lymph glands.

Classification of Acute Leukemias

Acute leukemias encompass a broad range of malignant diseases that primarily affect the bone marrow and lymphatic system. These conditions are characterized by significant heterogeneity and complex classifications, which can influence treatment outcomes and prognoses. The main types include

• Acute Lymphoid Leukemia (ALL): This is a predominant form of cancer in children.

• Acute Non-Lymphoid (Myelogenous) Leukemia (ANLL or AML): Less common than ALL but still significant among childhood cancers.

• Stem Cell/Blast Cell Leukemia: Involves the proliferation of immature cells in the bone marrow.

Acute Lymphoblastic Leukemia (ALL)

ALL is the most common form of childhood cancer, with an estimated 4,900 new cases reported annually in the USA. The disease shows a higher incidence among boys and Hispanic populations, with a peak onset age between 2 to 3 years. Early detection and intervention are crucial to improve outcomes.

Pathophysiology of Leukemia

Leukemia is defined as an unrestricted proliferation of immature white blood cells (WBCs) in the blood-forming tissues. This results in:

• Severe enlargement of organs such as the liver and spleen due to the overproduction of WBCs.

• Despite the elevated cell count, the disease typically presents with a low overall leukocyte count, primarily due to an increased number of immature cells (or blasts) that compete for nutrients, ultimately leading to the destruction of normal blood cells.

Clinical Manifestations

Key clinical manifestations of leukemia include:

• Persistent minor infections are indicative of a compromised immune system.

• Physical signs: Patients often present as pale, irritable, and feverish and may show signs of decreased appetite (anorexia).

• Diagnostic approaches:

  • Peripheral blood smear: Shows immature leukocytes and often reflects low blood cell counts.

  • Lumbar puncture: Used to assess involvement of the central nervous system (CNS).

  • Bone marrow aspiration or biopsy: Considered the definitive diagnostic procedure for confirming leukemia.

Therapeutic Management of Leukemia

Therapeutic management typically consists of three phases:

1. Induction Therapy: Lasting 4 to 5 weeks, this phase aims for rapid remission by initiating chemotherapy immediately upon diagnosis.

2. Intensification (Consolidation) Therapy: A focused effort to eradicate residual leukemic cells through periodic chemotherapy over a span of 6 months.

3. Maintenance Therapy: This phase is intended to preserve remission and involves regular CBCs (complete blood counts) weekly or monthly, usually lasting 2 to 3 years before ceasing, while continuing monitoring for relapse.

Hematopoietic Stem Cell Transplantation (HSCT)

HSCT is an advanced therapeutic option that can involve donors who may be relatives or non-relatives. Possible transplants utilize:

• Antigen matched or mismatched peripheral stem cells.

• Umbilical cord blood.

However, risks associated with HSCT include graft-versus-host disease and severe organ damage, hence comprehensive pre-transplant assessments are crucial.

Care Management of Leukemia

Care for children with leukemia extends beyond physical treatment and includes:

• Support for families during diagnostic and therapeutic procedures to help alleviate emotional distress.

• Pain relief measures to enhance the quality of life.

• Precautions when using chemotherapeutic agents to minimize side effects.

• Continuous emotional support is critical for both the patient and their family throughout the treatment process.

Management of Drug Toxicity

Addressing common issues resulting from treatment is vital, which may include

• Nausea/vomiting: Side effects that can significantly impact nutritional intake.

  • give antiemetic control before chemotherapy (30 min to 1 hr)

• Anorexia results in potential weight loss and nutrient deficiencies.

• Mucosal ulceration: leading to pain and potential complications in eating and swallowing.

  • Avoid viscous lidocaine, lemon glycerin swabsand hydrogen peroxide because of drying effects

• Neuropathy: Nerve damage can lead to further complications.

• Hemorrhagic cystitis: A serious side effect requiring attention.

  • if signs of cystitis, such as burning on urination, occur, prompt medical evaluation is needed. Hemorrhagic cystitis warrants a full workup and timely intervention.

  • give IV fluids

• Alopecia: Hair loss is common due to chemotherapeutic regimens.

  • Encourage children to choose wig similar to their own hairstyle

• Mood changes: Psychological support is thus necessary to address emotional fluctuations.

• Moon facies: A rounded facial appearance commonly seen due to steroid use as part of treatment.

Prognosis Factors

The prognosis for childhood leukemia is contingent upon several factors, including

• Initial white blood cell (WBC) count: Higher counts at diagnosis can indicate a poorer prognosis.

• Age at diagnosis: Young age can be favorable, while older children may have a different prognosis.

• Type of cell involved: Specific types of leukemia have distinct behaviors and outcomes.

• Gender: Statistical differences have been noted in outcomes between genders.

• Karyotype analysis: Chromosomal abnormalities influence treatment responses and prognosis.

Note: Without appropriate treatment interventions, acute leukemias can have a fatal trajectory, emphasizing the necessity for timely and effective medical strategies.