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{{PediatricPage|leukemia}}
==Background==
==Background==
*Most common cancer in children (33% of all malignancies)
*Most common cancer in children (33% of all malignancies)
*ALL
*Most without cause but increased incidence with paternal age, maternal fetal loss, higher birthweight, familial clusters, and some genetic syndromes (Down syndrome)
**3/4 of pediatric leukemias
 
**5-year survival 75%-80%
===[[acute lymphocytic leukemia|ALL]]===
**Peak incidence 3-5yr old
*3/4 of pediatric leukemias
*AML
*5-year survival 75%-80%
**1/5 of pediatric leukemias
*Peak incidence 2-5yr old
**Worse prognosis
*Usually B lineage
**More complications (more intense chemo treatment required)
 
===[[AML]]===
*1/5 of pediatric leukemias
*Worse prognosis
*More complications (more intense chemo treatment required)


==Clinical Features==
==Clinical Features==
*Signs/symptoms due to bone marrow infiltration and failure
 
**Pallor, fatigue, easy bleeding, fever, infection
===Presentation===
**Bone/joint pain
*Hepatomegaly and/or splenomegaly with weight loss, abdominal distension or abdominal pain
**Hepatomegaly or splenomegaly
*Lymphadenopathy
*Hyperleukocytosis
*Fever
**Clinically significant when WBC > 200K in AML, >300K in ALL
*Bleeding (petechiae, purpura), low platelet count, anemia
**Cerebral circulation: HA, AMS, visual changes, seizure, CVA
*MSK pain, limp, refusal to bear weight
**Pulmonary circulation: SOB, hypoxemia
*Larger anterior mediastinal mass could cause SVC syndrome
 
===Bone marrow infiltration and failure===
*Pallor, [[fatigue]], easy bleeding, [[fever]], infection
*Bone pain/[[arthralgia]]
*[[Hepatomegaly]] or splenomegaly
 
===[[Leukostasis and hyperleukocytosis|Hyperleukocytosis]]===
*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===
*[[Tumor lysis syndrome]]
*[[Neutropenic fever]], [[Sepsis]], overall increased risk of [[infection]]
**[[Neutropenic enterocolitis (typhlitis)]]
*[[Leukostasis and hyperleukocytosis]]
*[[Hyperviscosity syndrome]]
*[[Thromboembolism]]
*Treatment-related complications
**Chemotherapy-induced [[nausea and vomiting]]
**[[Cytokine release syndrome]]
**Chemotherapeutic drug extravasation
**[[Differentiation syndrome]] ([[retinoic acid syndrome]]) in APML
**[[Stem cell transplant complications]]
**Catheter-related complications
***Tunnel infection
***Exit site infection
***CVC obstruction (intraluminal or catheter tip thrombosis)
***Catheter-related venous thrombosis
***Fracture of catheter lumen


==Differential Diagnosis==
==Differential Diagnosis==
''Leukemias will often involve >1 cell line; other conditions restricted to single line''
''Leukemias will often involve >1 cell line; other conditions restricted to single line''
*Aplastic anemia
*[[Aplastic anemia]]
*Iron deficiency anemia
*Iron deficiency [[anemia]]
*Viral infection (EBV, CMV, Parvo)
*Viral infection ([[EBV]], [[CMV]], [[parvovirus B19|Parvo]]), [[HIV]]
*Immune thrombocytopenia
*Immune [[thrombocytopenia]]
*Rheumatologic diseases
*Rheumatologic diseases


==Diagnosis==
==Evaluation<ref>Horton TM and Steuber CP.  Overview of the presentation and diagnosis of acute lymphoblastic leukemia in children and adolescents.  UpToDate.</ref>==
*CBC
*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
***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
***[[CXR]]to look for mediastinal mass
***Consider [[DIC]] labs, coag studies


==Management==
==Management==
*[[Transfusion]]
===[[Transfusion]]===
**Options
*Options
***Irradiated: for very immunosuppressed (to prevent graft vs host)
**Irradiated: for very immunosuppressed (to prevent graft vs host)
***Leukocyte-reduced: for patients likely to receive multiple RBC or platelets in future
**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
**CMV seronegative: for <1yr old, if might need bone marrow transplant in future
**Anemia
*[[Anemia]]
***10 cc/kg of [[pRBCs]] raises Hb by 3 gm/dL
**10 cc/kg of [[pRBCs]] raises hemoglobin by 3 gm/dL
***Raise Hb to >8
**Raise hemoglobin to >8
**[[Thrombocytopenia]]
*[[Thrombocytopenia]]
**0.1 unit/kg results in 30-50K increase in platelet count
**0.1 unit/kg [[platelets]] results in 30-50K increase in platelet count
**Risk of spontaneous ICH is extremely low until platelets <5K
**Risk of spontaneous ICH is extremely low until platelets <5K
**Transfuse if:
**Transfuse if:
***Asymptomatic with platelets <10K
***Asymptomatic with platelets <10K
***Invasive procedures require platelets >50K
***Invasive procedures require platelets >50K
*Hyperleukocytosis
 
**Aggressive IV hydration
===[[Leukostasis and Hyperleukocytosis]]===
**Urinary alkalinization (pH 7-7.5)
*Aggressive IV hydration
**Allopurinol (for [[Tumor Lysis Syndrome (TLS)]])
*Urinary alkalinization (pH 7-7.5)
**Avoid diuretics and pRBC transfusion (platelets ok)
*[[Allopurinol]] (for [[Tumor Lysis Syndrome (TLS)]])
**Give platelets if <20K
*Avoid diuretics and pRBC transfusion (platelets ok)
**Leukapheresis
*Give platelets if <20K
*Leukapheresis
 
==Disposition==
*Admit for further workup including bone marrow biopsy and LP


==See Also==
==See Also==
*[[Oncologic emergencies]]
*[[Leukemia]]


==References==
==References==
 
<references/>
[[Category:Pediatrics]]
[[Category:Pediatrics]]
[[Category:Heme/Onc]]
[[Category:Heme/Onc]]

Latest revision as of 17:20, 17 January 2026

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.
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