Childhood leukemia &

lymphomas
Nasreen Asghar
Lecturer at BTSON
Objectives
Today we will learn about Hematological malignancies :
Acute Leukemias

Lymphomas

Types

Causes

Clinical manifestations

Diagnosis

Medical and nursing mangement

Pediatric oncology and hematology

Hematological malignancies:
 Acute lymphoblastic leukemia(ALL)

 Acute non-lymphoblastic (myeloblastic)

leukemia (AML)
 Non-Hodgkin lymphoma

 Hodgkin lymphoma
What is leukemias

 Uncontrolled proliferation of immature blood

cells with a different immunological subtypes
which is lethal within 1 –6 months without
treatment
 The disorder starts in the bone marrow, where
normal blood cells are replaced by leukemic
cells.
Incidence

 Most frequent neoplasm in children (28 – 33%)

 1million children under the age of 16 years
 Incidence peak at 2 – 5 years
 75-80%- acute lymphoblastic leukemia -ALL
15-20% - acute
myelogenous (non-lymphoblastic) leukemia
AML/ ANLL
<5% - undifferentiated
acute leukemia and chronic myelogenous
leukemia -CML
Ethiology

 Unknown
 Higher risk in congenital disorders:
-trisomy 21 (14 times higher) and other
trisomies -Turner syndrome
-
Klinefelter syndrome

-neurofibromatosis type 1
-Fanconi anemia
(high fragility of chromosomes)
-congenital
agammaglobulinemia
 Ionizing radiation (atomic bomb developed
high incidence of leukemia)
 Chemical and drugs:
-benzene
-
chloramphenicol

 Infection (viral , HIV)

 Immunodeficiency
Acute lymphoblastic
leukemia
 Acute lymphocytic leukemia (ALL), also
known as acute lymphoblastic
leukemia, refers to an abnormal growth of
lymphocyte precursors or lymphoblasts.
 80% of leukemias
 Girl – to- boy ratio is 1: 1.2
 Peak incidence 2 – 5 years
Clinical manifestation

 General aspects:

 - the duration of symptoms is days to several

weeks, occasionally – several months
often: low –grade
fever,
 Signs Of Infection,
 Fatigue,
 Bleeding,
 Pallor
CONTI…

 The symptoms depend on the degree of

cytopenia:
- anemia: pallor, fatigue, tachycardia,
dyspnea,
- leukopenia:infections, temperature
elevation
- thrombocytopenia: petechiae, mucosal
bleeding, epistaxes, prolonged menstrual
bleeding
Specific signs and symptoms

 Eye: bleeding, infiltration of local vessels,

 CNS: at time of diagnosis less than 5% have
CNS leukemia with meningeal signs (morning
headache, vomiting, papilla edema,
neurological signs)
 CONTI…

Ear, nose, throat:

-lymph
nodes infiltration
-Mikulicz syndrome (infiltration of
salivary glands and/or tear glands)
Skin:
maculopapular skin infiltration,
often of deep red color (infants)
 CONTI…

 Cardiac involvement:
-leukemic
infiltration or hemorrhage
-tachycardia, low blood
pressure or other signs of cardiac
insufficiency
 Pleura/and pericardium: effusion
 Lymphadenopathy
 Gastrointestinal involvement:
-
hepato- and/or splenomegaly

 Testicular involvement: enlargement of

one or both testes without pain , hard
consistency
 Bone and joint involvement:
-bone pain
initially present in 25 % to 50% of
patients ! -
Laboratory findings

 Red cells:
-hemoglobin – normal/
moderate /markedly low -low
number of reticulocytes
 White blood cell :
- normal/ low/ high
-in
children with high WBC- leukemic blast cells
present
 Platelets:
-usually low
CONTI…
 Coagulopathy:
-in children with hyperleukocytosis
-low levels of prothrombin,
fibrinogen, clotting factors may be present.
 Chemistry:
-the serum uric acid is often high
initially - the serum
potassium level may be high (cell lysis)
-serum hypocalcemia or hypercalcemia (in marked
leukemic bone infiltration)
abnormal liver function
 Bone marrow analysis
 Immunological characterization
 Therapy

 Systematic chemotherapy
 Subdivided into:
-remission induction (4-5 Weeks)
-consolidation with CNS prophylaxis ( 2-4 weeks)
-maintenance phase(2-5 yrs)
 Radiation therapy
 Platelet transfusion
 RBC transfusion
 Bone marrow transplant
 Stem cell transplant.
Prognosis
 Rate of first remission in ALL: more
than 90%
 80% of children survive without
relapse
Nursing Diagnosis
 Based on the assessment data, major nursing diagnoses for
the patient with ALL may include:
 Risk for infection related to overproduction of immature
WBCs.
 Risk for impaired skin integrity related to toxic effects of
chemotherapy, alteration in nutrition, and impaired
immobility.
 Imbalanced nutrition, less than body requirements,
related to hypermetabolic state, anorexia, pain, and nausea.
 Acute pain and discomfort related to mucositis, leukocyte
infiltration of systemic tissues, fever, and infection.
 Hyperthermia related to infection.
 Fatigue and activity intolerance related to anemia and
infection
Nursing care
 Before treatment:
 Education. The nurse should explain the disease course, treatment,
and adverse effects.
 Infection. The nurse should teach the patient and his family how to
recognize symptoms of infection such as fever, chills, cough,
and sore throat.
 Bleeding. The nurse should educate the patient and the family how
to recognize abnormal bleeding through bruising and Petechiae and
how to stop it with direct pressure and ice application.
 Promote good nutrition. The nurse should explain that
chemotherapy causes weight loss and anorexia, so the patient must
be encouraged to eat and drink high-calorie and high-
protein foods and beverages.
 Rehabilitation. The nurse should help establish and appropriate
rehabilitation program for the patient during remission.
Nursing Care during treatment
 Watch out for meningeal leukemia (confusion, lethargy, headache).
 Prevent hyperuricemia, a possible result of rapid, chemotherapy-
induced leukemia cell lysis through encouraging fluids to 2000 ml
daily.
 Control infection by placing the patient in a private room and
instituting neutropenic precautions.
 Provide thorough skin care by keeping the patient’s skin and
perianal area clean, applying mild lotions and creams to keep skin
from cracking and drying, and thoroughly cleaning skin before all
invasive skin procedures.
 Control mouth ulceration by checking often for obvious ulcers and
gum swelling, and by providing frequent mouth care and saline
rinses.
 Provide Psychological support to parents.
 Manage parental stress.
Acute myelogenous
leukemia
 In acute myeloid leukemia (AML), too many
immature white blood cells (called myeloid
blasts) are made.
 Epidemiology: 15-20% of all leukemias in
children
 Frequency remains stable throughout
childhood with slight increase during
adolescence
 No difference in incidence between boys and
girls
Causes
 Causes of AML is unknown,
 Risks include inherited genetic problems such
as Down syndrome,
 Neurofibromatosis type 1,
 Fanconi anemia,
 inherited bone marrow failure
syndromes (IBMFS)
 radiation
 Identical twin diagnosed with leukemia before
age 6 can develop AML.20-25%
 Clinical presentation

 Fatigue (Tiredness) And Weakness

 Swollen Lymph Nodes
 Infections (Like Bronchitis Or Tonsillitis) That Keep Coming
Back
 Fever
 Night Sweats
 Easy Bruising Or Petechiae (Tiny Red Spots On The Skin
Caused By Easy Bleeding)
 Bone And Joint Pain
 Abdominal Pain (Caused By Abnormal Blood Cells Building
Up In Organs Like The Kidneys, Liver, And Spleen)
Diagnosis
 Blood tests.
 Bone marrow aspiration and biopsy
 Imaging studies.
 Chromosomal tests
Therapy

 Induction/ consolidation/ maintenance

 Stem cell transplantation

Prognosis
 5+year survival rate 50-60 %
Nursing diagnosis
 Risk for infection related to altered WBC
production and immune function
 Ineffective protection related to reduced
platelet count and risk for bleeding
 Impaired oral mucous membrane secondary to
anemia and reduced platelets
 Fatigue related to anemia
 Parental Anxiety related to fear of leukemia
diagnosis
Nursing care
 Place in a private room.
 Limit visitors to immediate family for the present.
 Instruct all staff, the family, and child to carefully wash
hands. Post a sign over the washbasin in the room as a
reminder.
 Record vital signs every 4 hours.
 Avoid invasive procedures unless absolutely necessary.
 Monitor for bleeding every 4 hours, including skin, oral
mucosa, abdominal assessment, body fluids.
 Instruct to perform oral hyygiene every 2 to 4 hours,
using a soft-bristle toothbrush.
Conti…
 Ask the dietitian to work with pt to identify preferred
foods. Instruct to avoid foods that may damage oral
mucosa, such as very hot, very cold, or highly acidic or
spicy foods.
 Provide for periods of rest alternating with activity.
 Teach the parents about the bone marrow biopsy. Allow
time for questions and to verbalize fears.
 Refer to the oncology nurse specialist for further
teaching and support.
Non-Hodgkin lymphoma
(NHL)
 Neoplasia of the lymphatic system and its
precursor cells with genetically disturbed
regulation, differentiation and apoptosis
 B-cell or T-cell may involve
 Incidence 5 –7 % of all neoplasias in childhood
 Peak incidence between 5 and 15 years
 Ratio of boys to girls 2:1
 Burkitt lymphoma (BL): endemic form in Africa
10:100,000 children and sporadic form in Europe
and USA
Etiology

Predisposing factors for NHL:

 Acquired immunodeficiency: autoimmune disorders, HIV

infection
 Congenital B-cell defect, congenital T-cell defect

 Exposure to irradiation

 Drug induced, after immunosuppressive treatment

WHO classification (Types)

Histology Rat Immuno - Main occurence

e phenotype
Burkitt lymphoma 50% B-cell Abdomen
Burkitt-like
lymphoma
Large B-cell 7-8% B-cell
lymphoma
Lymphoblastic 30% Pre-T-cell or Thorax, lymph
lymphoma pre-B-cell nodes, bone
Anaplastic, large 7-8% T-cell Lymph nodes,
cell lymphoma skin, soft tissue,
bone
 Clinical manifestations

Duration of symptoms: usually a few days to weeks

Non-specific symptoms: fatigue, nausea, anorexia, loss of weigth
and/or fever

In relation to localisation of NHL:

 Abdomen:

 especially the ileocecal region, mesentery, retroperitoneum,

ovaries > painfull, spasms, vomiting

 Obstipation, intussusception

 Apendicitis-like

 ascites
CONTI…

Mediastinum:
 Mostly anterior or middle part of mediastinum > cough,

stridor, dyspnea, wheezing

 Edema of the neck and face with marked dyspnea

 Pain of the back or abdomen

 Pleural effusion
Involvement of adenoid and tonsils,
nasopharyngeal lymph nodes, parotid gland
swelling
Peripheral lymph nodes:
 Mostly cervical, supraclavicular and inguinal

 Lymph nodes are firm,

 Other locations:

CNS, cranial and peripheral nerves, skin, muscles,

bone, thorax, gonads, parotid gland, epidural
region→ spinal cord compression
Diagnosis:

 Histological (lymph nodes, peripheral blood, bone

marrow or fluid resulting from pleural effusion or
ascites)
 Morphological, immunophenotypical and molecular
/cytogenetic analyses
 Serum uric acid
 Bone marrow aspiration
 CSF analysis
 Radiological diagnosis
 Ultrasound
 Conventional X-ray
 CT of the thoracic, abdomen and skeletal disease
 MRI for CNS
 PET (positron –emmision tomography)
 Bone scan
NHL
CONTI…
 Stages I + II: 10 – 20% of all NHL
 Stages III+ IV: 80 – 90% of all NHL
Treatment

 Induction therapy should be begun as soon as

possible!
 Tumor lysis syndrome prophylaxis or treatment
 Chemotherapy
 Surgical procedure: total resection in I or II stage with
localized masses only
 Overall long-term survival >80%
Hodgkin Disease
 It involves B-cells only and shows Progressive,
painless enlargement of lymph nodes with
continuous extension between lymph node
region
 Reed-Sternberg cells (Enlarged B-cells)
 Incidence: 5-7% of all neoplasia in childhood
 Boys more than girls
 Rare before 5 years; increasing until the age of
11 years
 Peak incidence between 15 and 35 years of age
Etiology and pathogenesis

Correlation with EBV infection, genetic predisposition,

disturbed cellular immune response
High incidence in patients with SLE, rheumatoid disorders,

, agammaglobulinemia
Clinical presentation

 Painless enlargement of lymph nodes, mostly in the cervical

and supraclavicular regions
 Swollen lymph nodes are firm, and painfull to palpation
 Most common involved lymph nodes: cervical (75%),
supraclavicular(25%), axillary.
 Extranodal involvement: lung, bone, liver
 In mediastinal involvement: a cough, sometimes with
dyspnea, dysphagia and enlargement of the vessels of the
neck .
 Fever higher than 38° C
 Night sweats
 Loss of more than 10% body weight
 Sometimes: pruritus and/or nausea
Laboratory analyses

 Blood
 Bone marrow
 LDH
 Immunological analyse

Stage- Radiological evaluation

 Chest (x-ray, CT)
 Abdomem (usg , CT)
 PET-CT
HL
Staging classification

 I: involvement of a single lymph node region(I) or a

single extralymphatic organ (IE)
 II:two or more lymph node regions on the same side of
the diaphragm (II) or localized involvement of an
extralymphatic organ or site one or more lymph node
regions on the same side of the diaphragm
 III: involvement of lymph node regions on both sides of
the diaphragm (III) which may be accompanied by
involvement of an extralymphatic organ (IIIe) or site, or
both (IIIES)
 IV: diffuse or disseminated process
Treatment

 Procedure depends on stage and histopathology

 Chemo- and radiotherapy

Prognosis
 Stage I/II >90%

 Stage III/IV 70-80%

Nursing Diagnosis for Malignant
Lymphoma

1. Acute Pain related to the injury of biological agents.

2. Hyperthermia related to ineffective thermoregulation
secondary to inflammation.
3. Imbalanced Nutrition Less than Body Requirements
related to nausea, vomiting.
4. Knowledge Deficit related to lack of exposure to
information
5. Risk for Ineffective Airway Clearance related to enlarged
lymph node / airway edema.
Nursing interventions
 Assess respiratory rate, depth, rhythm.
Place the patient in a comfortable position, usually with a
high headboard / or sit up straight to the feet of hanging.
Assist with deep breathing techniques or breathing and lip
/ diaphragm. Abdomen when indicated.
 Assess pain scale
Teach the client relaxation and distraction techniques
Collaboration in the delivery of analgesic drugs.
 Observation of the client's body temperature.
Encourage and provide drinking a lot (in accordance with
the needs of the client's body fluids).
 Collaboration in the provision of antipyretics.
Conti…
 Review the history of nutrition, including food
preferences.
 Observation and record food intake.
Measure weight every day.
 Collaboration in the provision of nutritional
supplements.
 Provide therapeutic communication to clients
and client families.
 Provide information about the disease process
to the client and the client's family.
References
 1.Hockenberry, M and Wilson, D.
(2015) Wong's Nursing Care of
Infants and Children. 10th edition.
Thank you