INTRODUCTION : Leukemia is a broad term given to group of malignant disorder of

bone marrow .In children, two forms of leukemia are generally recognized : AML( acute
Myelogenous leukemia and ALL (acute Lymphoblastic leukemia). The ALL (Acute
Lymphoblastic Leukemia) is the most common type of leukemia accounting for 80%of all
pediatrics leukemias. It is about 3-4 per 100,000 children below 15yrs of age. It is said that
boys are more affected than girls.

DEFINITION : Leukaemia is a malignant progressive disease in which the bone marrow

and other blood-forming organs produce increased numbers of immature or abnormal
leucocytes. These suppress the production of normal blood cells, leading to anaemia and
other symptom.

TYPES
1.Myeloid: Leukaemia that starts in myeloid cells is called myeloid, myelogenous, or
myeloblastic leukaemia.

2. Lymphoid: Leukaemia that starts in lymphoid cells is called lymphoid, lymphoblastic, or

lymphocytic leukaemia. Lymphoid leukaemia cells may collect in the lymph nodes, which
become swollen.

3. Acute myeloid leukemia (AML) affects myeloid cells and grows quickly. Leukemic blast
cells collect in the bone marrow and blood.

4. Acute lymphoblastic leukemia (ALL) affects lymphoid cells and grows quickly.
Leukemic blast cells usually collect in the bone marrow and blood.It is of two types –B ALL
& T ALL.

5. Chronic myeloid leukemia (CML) affects myeloid cells and usually grows slowly at
first. Blood tests show an increase in the number of white blood cells, The abnormal blood
cells work okay. There may be a small number of leukemic blast cells in the bone marrow.

6. Chronic lymphocytic leukemia (CLL) affects lymphoid cells and usually grows slowly.
Blood tests show an increase in the number of white blood cells, The abnormal cells work
almost as well as the normal white blood cells.

CASE PRESENTATION ON :Pre B ALL(Precursor B Cell Acute Lymphoblastic

leukemia)

DEFINITION OF PRE B ALL: It is form of lymphoid Leukemia in which too many

B-cell lymphoblasts (Immature white blood cell) are found in the blood and bone marrow. It
is the most common type of ALL.
PRECIPITATING FACTORS:

In book In patient
 Expose to radiation and certain chemical Ideopathic
chemicals
 Having a sibling with leukemia
 HTLV-1 Virus
 Genetic abnormalities
 Chromosomal translocation
 Ideopathic

PATHOPHYSIOLOGY: In leukemias, a clone of malignant cells may arise at any

stage of maturation, that is, in the lymphoid, myeloid, or pluripotential stage. The cause for
this clonal expansion is poorly understood in most cases, but it appears to involve some
rearrangement of the DNA. External factors, such as alkylating drugs, ionizing radiation, and
chemicals, and internal factors, such as chromosomal abnormalities, lead to DNA changes.
Chromosomal rearrangements may alter the structure or regulation of cellular oncogenes. For
instance,in the B-cell lymphocytic leukemias, chromosomal translocations may put the genes
that normally regulate heavy and light chain immunoglobulin synthesis next to the genes that
regulate normal cellular activation and proliferation. This s results in proliferation of
lymphoblast. As the population of cells expands, the bone marrow starts to fail. Pancytopenia
is typical and results in part from the physical replacement of normal marrow elements by the
immature cells. In addition, the abnormal cells may secrete factors that inhibit
hematopoiesis.

As the bone marrow becomes replaced, the abnormal cells spill into the circulation and
infiltrate other organ such as the liver, the spleen, and the eye. The occular manifestations
may be secondary to direct infiltration of the leukemic cells, as a result of abnormal systemic
hematological parameters, opportunistic infections iatrogenic complications arising from
chemotherapy.
Predisposing factors: Precipitating factors:
Etiology
 Age :unknown  Expose to radiation and
 Gender certain chemical chemicals
 Race  Having a sibling with
 Family history leukemia
 HTLV-1 Virus
 Genetic abnormalities
Somatic mutation in the DNA  Chromosomal translocation

Activate oncogenes/ deactativate tumor suppressor

gene

Activate oncogene/ deactivate tumor-suppressor gene

Malignant transformation of lymphoid stem cell

Uncontrolled proliferation of lymphoblast in the bone marrow

Lymphoblast replace the normal marrow elements

Decreased production of normal blood cell

ONSET: The onset of leukemia varies from acute to insidious. In most instances, the child
displays remarkably few symptoms. For example, leukemia may be diagnosed when a minor
infection, such as a cold, fails to completely disappear. The child is pale, listless, irritable,
febrile, and anorexic. Parents often suspect some underlying problem when they observe the
weight loss, petechiae, bruising without cause, and continued complaints of bone and joint
pain.
At other times leukemia is diagnosed after an extended history of signs and symptoms
mimicking such conditions as rheumatoid arthritis or mononucleosis. In some cases, the
diagnosis of leukemia accompanies some totally unrelated event, such as a routine physical
examination or injury.

The history not only yields valuable medical information regarding the subsequent course of
the illness but also bears heavily on the parents' emotional reaction to the diagnosis . In most
instances, the diagnosis is an unexpected revelation of catastrophic proportion.

CLINICAL MANIFESTATION :

In book In patient
General : General:
 Extreme fatigue or weakness  Extreme fatigue and weakness
 Anorexia  Anorexia
 Malaise  Malaise

Bone marrow infiltration

 Anaemia, pallor, lathergy Bone marrow infiltration
 Neutropenia, infection, Shortness of  Anaemia, pallor
breath, Coughing and fever  Neutropenia, coughing ,fever
 Thrombocytopenia, bruising, petchiae,
nose bleeding, purpura, Melena,
Hematuria, Excessive bleeding after a
minor operation like dental extraction or
any minor injury

Reticuloendothelial infiltration Reticuloendothelial infiltration

 Hepatospleenomegaly  Swelling of side of neck
 Lymphadenopathy-Swelling of abdomen,
face, arms, underarms, side of neck,
groin, Swelling above the collar bone

CNS infiltration
 Headaches, seizures, balance problems
 Vomiting

Others
 Rashes
 Gum problems / Sore in mouth
 abnormal vision
DIAGNOSIS:

In book In patient
 History  History- Fever, Cough and common cold
 Physical examination that arises at 30-15 days interval
 CBC(Neutropenia, thrombocytopenia, 
anaemia)  Physical examination- Fever,common
 Peripheral blood smear shows immature cold and cough, enlarged cervical
blood cells lymphnodes
 Fish(Fluorescent in situ hydration) for  CBC-Hb-7.3%
locating the specific DNA sequences to RBC-2.92 million/microL
identify novel oncogenes Lymphocyte-61.5%
 Bone marrow aspiration and biopsy,that Monocyte-4.6%
shows hypercelluler bonemarrow with Neutrophils-33.2%
primarily blast cell, usually take from the Basophils-0
pelvic bone, to confirm a diagnosis of  Bone marrow aspiration-Excess blast
leukemia. cells >70%
 Lumber puncture or spinal tap to check  Lumber puncture-No infiltration of
the spread of leukemia cells in the fluid blastcells in CSF
that bathes the spinal cord.

MANAGEMENT: (In book)

Theraputic management: Treatment of leukemia involves the use of i.v. and intrathecal
chemotherapeutic agents. Radiation is sometimes used for resistant CNS disease or testicular
relapse. Typically leukemia treatment is divided into phases:

(1) induction, which achieves a complete remission or clinical disappearance of leukemic

cells

(2) intensification, or consolidation therapy, which further decreases the total tumor burden;
and

(3) maintenance, which consists of further chemotherapy to ensure the disease stays in
remission. Although the combination of drugs and possibility of irradiation may vary
according to the institution, the patient's prognostic or risk characteristics, and the type of
leukemia being treated, the following general principles for each phase are consistently
employed.

(1)Remission Induction : Almost immediately after confirmation of the diagnosis, induction

therapy is begun and lasts for 4-5 weeks. A complete remission is determined by the absence
of clinical signs & symptoms of the disease and the presence of less than 5% blast cells in the
bone marrow.
Because many of the chemotherapy drugs also cause myelosuppression of normal blood
elements, the period immediately after a remission can be critical. The body is defenseless
against invading organisms (especially normal bacterial flora) and susceptible to spontaneous
hemorrhage. Consequently, supportive therapy during this time is essential.

(2)Intensification, or Consolidation Therapy: Intensification, or consolidation, therapy is

used to further decrease the number of leukemic cells in the child's body. The intensification
phase consists of pulses of chemotherapy medications given periodically during the first 6
months of treatment. The specific agents used for intensification therapy depend on the type
of leukemia and the child's risk factors.

(3)Maintenance: The goal of maintenance therapy is to preserve remission and further

reduce the number of leukemic cells. Combined drug regimens have been more successful in
maintaining remissions and preventing drug resistance.

During maintenance therapy, weekly or monthly CBCs are taken evaluate the marrow's
response to the drugs. If myelosuppression becomes severe (usually indicated by an ANC
less than 1000/mm) or if toxic side effects occur, therapy is temporarily stopped or the dose
decreased. Duration of therapy has been based on clinical experience comparing survival
rates for various time intervals and is concerned with preventing deleterious effects of
excessive treatment. Although the optimum time for discontinuing therapy is not known,
current practice is to continue treatment for 2-3 years.all children after cessation of therapy
require regular medical evaluation for surveillance of relapse and long term sequelae of
treatment.

 Central Nervous System Prophylactic Therapy : Children with lukemia are at risk for
invasion of the CNS by the leukemic cells. For this reason. , many children receive CNS
prophylactic therapy. Because of concern regarding late effects of cranial irradiation and
intensive systemic chemotherapy
 Reinduction after Relapse :For many children, additional therapy becomes necessary
when a relapse occurs, as evidenced by the presence of leukemic cells within the bone
marrow. Although remissions may be achieved after more than one relapse, each relapse
indicates an increasingly poor prognosis. However, more long-term second and
subsequent remissions are occurring, and these may have better outlooks than previously
thought.

A site that is resistant to chemotherapy and is responsible for leukemic relapse is the testes. A
minority of males experience relapses during maintenance therapy or have occult disease
after cessation of therapy. Treatment for testicular disease includes bilateral testicular
irradiation, and intensive systemic chemotherapy (Rabin, Gramatges, Margolin, et al., 2016).

 Blood or Marrow Transplantation : BMT has been used successfully in treating some
children with ALL and AML. In general, BMT is not recommended for children with
ALL during the first remission because of the excellent results possible with
chemotherapy.
The indication for BMT are those with ALL who are stratified as high risk or have a poor
early therapy response, Because of the poorer prognosis in children with AML,
transplantation may be considered during the first remission when a suitable donor is
available.

RECOMMENDED TREATMENT REGIMEN FOR LOW-RISK ALL

Remission induction chemotherapy(4-6 weeks)
This is achieved by intensive systemic chemotherapy
Drug’s name Dose Route and frequency
 Vincristine 1.5 mg/m^2(maximum 2mg) IV once week
 Prednisolone 40mg/^2(max 60mg) Orally daily
 Asparginase 10,000 units/m^2/day IM bi-weekly

Intrathecal CNS prophylaxis with triple therapy

 Methotraxate(MTX)
Under 1year 10mg
2-8 years 12.5mg
Over 9 years 15mg
 Hydrocortisone(HC)
Under 1year 10mg Intrathecal
2-8 years 12.5mg
Over 9 years 16mg
 Cystosine arabinoside
Under 1 year 20mg
2-8 years 25mg
Over 9 years 30mg
Systemic continuation/ Maintenance therapy

 6MP 50mg/m^2/day Orally

 MTX 20mg^2/week Orally, IV, IM
 Pulse of MTX +/-
6MP(Mercaptopurin)
given at higher doses
This therapy continued for
2.5 to 3 years
Reinforcement /Late intensification therapy

 Vincristine 1.5mg/m^2(max 2mg) IV every 4 weeks

 Prednisolone 40mg/m^2/day Orally for 7 days every 4
Once a week during weeks
induction and then every
8week for 2 years
(In patient-previously received)
Drug’s name Dose Route and frequency
Remission induction chemotherapy(B.wt-12kg)
Vincristine 0.8mg IV
Methotraxate(MTX) 12mg IV
Daunorubicin 15mg IV and IT(Intrathecal)
L asparaginase 5000IU IV
Intensification or consolidation therapy
6MP 25mg Oral
MTX 12mg IT
Cyclophosphamide 500mg IV
Cytosine Arabinoside IV
L asparaginase 5000IU IV
Vincristine 0.8mg IV

Maintenance therapy
MTX 12mg IV & IT
6MP 25mg Oral
Folinic acid 15mg IV
Daunorubicin 15mg IV
(In current admission )

Drug Dose Route Frequency

Inj. Piperacillin 1gm IV TDS
Tazobactum
@100mg/kg b.wt
Inj. Vancomycin 215mg IV TDS
@20mg/kg b.wt
Inj. Pantoprazole 40mg IV OD
NS Nasal drop 1drop both nostril Nasal 2 hourly
Inf. Paracetamol 10ml IV SOS
Syr. Montelukast 3.5ml Oral TDS
+Levocetrizin
Chlorhexidine 1:1 BD
Mouthwash
Sitz Bath with TDS
Betadine
Nebulisation with 0.63mg 4 hourly
Levosalbutamol
COMPLICATION:
 Metastasis to lymph node, liver, spleen, central nervous system and testicles
 Infection
 Bleeding tendencies

PROGNOSIS: Factors deciding prognosis are as follows:

 Initial WBC count - Children with normal or low WBC count, non-T, non-B ALL and
presence of CALLA-positive antigen have better prognosis.
 Age of the child at diagnosis - Children between the ages of 2 and 9 years have better
prognosis.
 Type of the cell
 Sex of the child
 Karyotyping and analysis – Children with DNA index >1.6 and translocation of
chromosomes 4 and 10 have better prognosis.
 Late effect of treatment lead to increased survival.

No organ is exempt from infiltration, and almost all antineoplastic drugs are used including
radiation therapy, leading to adverse effects and secondary carcinomas. This causes many
problems in children, parents and their family members.

NURSING CARE MANAGEMENT (In patient)

Nursing care of the child with leukemia is directly related to the regimen of therapy.
Myelosuppression drug toxicity, and leukemic infiltration cause secondary complications that
necessitate supportive Physical care.
DAY TO DAY PROGNOSIS :
DAY 1 Vital signs-  Loss of appetite
T-102.2 degree F  Irritability
P-98 beats/min  Nasal congestion
R-38 breaths/min  Breathing difficulty
BP-90/50mmHg  Cough
 Parental anxiety
 Disturbed body image
DAY 2 Vital signs-  Took small frequent meal
T-100 degree F  Mild cough present
P-96 beats/min  Nasal congestion is cleared
R-36 breaths/min  Breathing difficulty is reduced to some extent
BP-96/50mmHg  Parental anxiety is reduced

DAY 3 Vital signs-  Took small frequent food

T-98.8 degree F  Cough is reduced
P-90 beats/min  Breathing difficulty is not present
R-32 breaths/min  Mother is having knowledge about infection
BP-96/54 mmHg prevention

CONCLUSION: Childhood leukemia , the most common type of cancer in children and
teens, is a cancer of the white blood cells. They quickly travel through the bloodstream and
crowd out healthy cells. This increases the body’s chances of infection and other problems.
It’s causes are unknown but have some precipitating factors and predisposing factors. The
treatment are mainly chemotherapeutic drug, radiation and bone marrow transplantation.
Others treatment are symptomatic treatment. Proper medical and nursing care help the child
to minimise the difficulties faced by the child and the family during treatment period.
Complication is mainly metastasis . It’s prognosis depends upon some factors like initial
WBC count, age of the child, type of cell etc.
Assessment Nursing diagnosis Goal Nursing Nursing Evaluation
planning implementation
Assessment Nursing diagnosis Goal Nursing Nursing Evaluation
planning implementation
Assessment Nursing diagnosis Goal Nursing Nursing Evaluation
planning implementation
Assessment Nursing diagnosis Goal Nursing Nursing Evaluation
planning implementation
Assessment Nursing diagnosis Goal Nursing Nursing Evaluation
planning implementation