BIBLIOGRAPHY: Datta Parul, Textbook of Pediatric Nursing, edition 4, The medical sciences publishers, 4838/24 Ansari road, Daryaganj, New Delhi, 110002, India INTRODUCTION Leukemia is the most common type of childhood malignancy. It is characterized by persistent and uncontrolled production immature and abnormal WBCs. It is a disease of abnormal proliferation and maturation of bone marrow which interferes with the production of normal RBCs, WBCs and platelets. Leukemia is defined as uncontrolled neoplastic proliferation of leukocyte precursors. According to National Cancer Institute, Leukemia is defined as a cancer that starts in blood-forming tissue, such as the bone marrow, and causes large number of abnormal cells to be produced and enter the bloodstream. 95-98% of childhood leukemia are acute type. 70-75% of acute lymphocytic leukemia. common malignancy of children less than 15 years. peak incidence is four years of age. males are more affected than females. twice more common in white then black in children. The exact cause is unknown. viruses like HPV ,Epstein Barr virus ,human T cell lymphoma leukemia virus (HTLV). Radiations exposure to chemicals and drugs like benzene and Dilantin familial predisposition chromosomal abnormalities like Down syndrome Genetic like Fanconi's anemia ,bloom syndrome ACUTE LYMPHOCYTIC LEUKEMIA Primary disorder of bone marrow in which normal bone marrow elements are replaced by immature or undifferentiated blast cells. develop when lymphoid cell line is affected. characterized by anemia, thrombocytopenia, neutropenia, especially granulocytopenia. the incidence rate is one in 2000 live birth. the peak age of onset is 3 to 7 years and males are more affected than females According to French American British classification on the basis of cell morphology it is classified as L1 L2 L3 According to type of cell it is classified as T cell B cell Pre-B cell Null cell T cell 10 to 15% ,high risk ,seen in older children especially males ,featured as mediastinal mass ,hepatosplenomegaly ,high WBC count ,CNS involvement and has poor prognosis. B cell 1 to 2% children ,aggressive form ,poor prognosis and high-risk type. Pre-B cell Good prognosis and respond well to therapy. Null cell No cellular surface markers (80% ). Great imitator, with vague and varied signs and symptoms, resembling almost any disease. Peripheral blood examination which shows decrease hemoglobin, RBC, hematocrit and platelet count bone marrow analysis in which large number of lymphoblasts and lymphocytes with hypercellular visible. chest X-ray CSF Chemotherapy radiation therapy bone marrow transplantation supportive and symptomatic management Chemotherapy Remission induction chemotherapy Vincristine, Prednisolone, Asparaginase and Adriamycin are given for 4-6 weeks. maintenance therapy or systemic continuation 6 MP (Mercaptopurine) and MTX (Methotrexate) are given for 2.5-3 years. late intensification or THERAPY

1. LEUKEMIA
BY;
ANUSHRI
SRIVASTAVA

2. INTRODUCTION
• Leukemia is the most common type of childhood malignancy.
• It is characterized by persistent and uncontrolled production immature and abnormal WBCs.
• It is a disease of abnormal proliferation and maturation of bone marrow which interferes with
the production of normal RBCs, WBCs and platelets.

3. DEFINITION
• Leukemia is defined as uncontrolled neoplastic proliferation of leukocyte precursors.
• According to National Cancer Institute,
Leukemia is defined as a cancer that starts in blood-forming tissue, such as the
bone marrow, and causes large number of abnormal cells to be produced and enter the
bloodstream.

4. INCIDENCE
• 95-98% of childhood leukemia are acute type.
• 70-75% of acute lymphocytic leukemia.
• common malignancy of children less than 15 years.
• peak incidence is four years of age.
• males are more affected than females.
• twice more common in white then black in children.

5. ETIOLOGY
• The exact cause is unknown.
• viruses like HPV ,Epstein Barr virus ,human T cell lymphoma leukemia virus (HTLV).
• Radiations
• exposure to chemicals and drugs like benzene and Dilantin
• familial predisposition
• chromosomal abnormalities like Down syndrome
• Genetic like Fanconi's anemia ,bloom syndrome
Fanconi anemia is a rare disease that is inherited from
families which affects the bone marrow. it is caused
due to an abnormal gene that damages cells which
keep them from repairing damaged DNA. It results in
decreased production of all types of blood cells
characterized by bleeding, infection, bone problems
like scoliosis, vitiligo, small head.
Bloom syndrome is a rare inherited autosomal recessive
pattern disorder marked by shorter than average height a
narrow face a red skin rash that occurs on sun exposed areas
of the body and an increased risk of cancer it is caused due to
mutation of both copies of the BLM gene in people with
bloom syndrome and each parent carries one mutant copy
and one normal copy

6. PATHOPHYSIOLOGY
.
Uncontrolled
proliferation
of leucocyte
precursors
competition for nutrients, infiltration of organs and replacement of normal cells by leukemic
cells
Bone marrow dysfunction
RBC‘s
Anemia
WBCs
Infection
Platelets
Hemorrhage
Reticulo-
endothelial
system
enlarged lymph
nodes, liver and
spleen
Central nervous
system
Leukemic
meningitis
Generalized
hypermetabolism
Cellular
starvation

7. CLASSIFICATION
LEUKEMIA
ACUTE
ACUTE LYMPHOID
LEUKEMIA
ACUTE MYELOID
LEUKEMIA
CHRONIC
CHRONIC
LYMPHOID
LEUKEMIA
CHRONIC
MYELOID
LEUKEMIA

8. ACUTE LYMPHOCYTIC LEUKEMIA
• Primary disorder of bone marrow in which normal bone marrow elements are replaced by
immature or undifferentiated blast cells.
• develop when lymphoid cell line is affected.
• characterized by anemia, thrombocytopenia, neutropenia, especially granulocytopenia.
• the incidence rate is one in 2000 live birth.
• the peak age of onset is 3 to 7 years and males are more affected than females

9. Classification of acute lymphocytic leukemia
• According to French American British classification on the basis of cell morphology it is
classified as
• L1
• L2
• L3
• According to type of cell it is classified as
• T cell
• B cell
• Pre-B cell
• Null cell

10. • T cell
10 to 15% ,high risk ,seen in older children especially males ,featured as mediastinal
mass ,hepatosplenomegaly ,high WBC count ,CNS involvement and has poor prognosis.
• B cell
1 to 2% children ,aggressive form ,poor prognosis and high-risk type.
• Pre-B cell
Good prognosis and respond well to therapy.
• Null cell
No cellular surface markers (80% ).

11. Clinical manifestation of acute lymphocytic leukemia
• Great imitator, with vague and varied signs and symptoms, resembling almost any disease.
• Fever, anorexia, malaise, weakness, petechiae, purpura, ecchymosis, bleeding,
progressive pallor, decreased activity level, weight loss and muscle wasting.
• Abdominal pain, bone pain, joint pain, sternal tenderness, hepatosplenomegaly,
hematemesis, melena, hematuria, oral infections.
• excessive bleeding from nose spray or minor injury or minor operation like tooth
extraction can be the first alarming feature
• in meningeal leukemia – headache, vomiting, drowsiness, unconsciousness, Convulsions,
cranial nerve involvement, papilledema, blurred or double vision .

12. Diagnostic evaluation of acute lymphocytic anemia
• Peripheral blood examination which shows decrease hemoglobin, RBC, hematocrit and
platelet count
• bone marrow analysis in which large number of lymphoblasts and lymphocytes with
hypercellular visible.
• chest X-ray
• CSF analysis

13. Management of acute lymphocytic anemia
• Chemotherapy
• radiation therapy
• bone marrow transplantation
• supportive and symptomatic management

14. Chemotherapy
• Remission induction chemotherapy
Vincristine, Prednisolone, Asparaginase and Adriamycin are given for 4-6 weeks.
• maintenance therapy or systemic continuation
6 MP (Mercaptopurine) and MTX (Methotrexate) are given for 2.5-3 years.
• late intensification or reinforcement therapy
Provided with vincristine and prednisolone every 4 weeks.
• CNS prophylaxis
• Triple therapy is administered through intrathecal route as anti-leukemic drugs do not penetrate CSF.
• Methotrexate, hydrocortisone and cytosine arabinoside: once a week during induction And then every
eight weeks for two years.
• cranial irradiation can be given in combination with above drugs.
Cranial irradiation is a technique that is used to combat the
occurrence of metastasis to the brain in highly aggressive cancers
that commonly metastasize to brin by using radiation therapy.

15. Complication of Acute lymphoid leukemia
• Infection
• arrhythmias
• urate nephropathy
• bleeding
• heart block

16. 2. Acute Non-lymphocytic leukemia
• Acute non lymphocytic leukemia is also known as acute myeloid leukemia.
• acute non lymphocytic leukemia is an abnormal proliferation of monocytes and
myelocytes in bone marrow.
• it is responsible for about 20% of childhood leukemia.

17. Clinical manifestation of acute non lymphocytic
leukemia
• Anemia, leucopenia And thrombocytopenia
• progressive pallor, Fever, active bleeding, bone pain, GI tract disturbance, gingival swelling
• recurrent infection, splenomegaly, marked lymph adenopathy
• joint pain
• orbital swelling and frequent bruising
• CNS involvement like headache, blurred vision, fundal hemorrhage and Paresis
• Hyper uremia

18. Diagnosis of Acute non-lymphocytic leukemia
• blood examination
• liver function test
• serological test
• bone marrow study

19. Management of acute non lymphocytic leukemia
• Chemotherapy – cytosine arabinoside IV for seven days ,daunorubicin For three days and
maintenance therapy up to two years
• heparin therapy
• supportive treatment like blood, platelet transfusion, I V antibiotic therapy ,cranial
irradiation and bone marrow transplantation
• prolonged disease-free survival has been obtained

20. 3. Chronic myelocytic leukemia
• chronic myelocytic leukemia is characterized by increased number of myeloid cells in all
stages of maturation both in the blood and bone marrow
• it is quite rare in children accounting for 2 to 3% of all leukemia
• Clinical features – Juvenile type chronic lymphocytic leukemia occurs in children below 2
years of age with eczema ,lymph adenopathy ,recurrent bacterial infections ,
hepatosplenomegaly ,thrombocytopenia ,WBC count is less than 1 00 00 0 /mm3 ,Plastic
cells ,Philadelphia chromosome ,discouraging response to chemotherapy ,remarkable
eosinophilia basophilia ,hyperplasia . Philadelphia chromosome forms when chromosome 9 and
chromosome 22 break and exchange portions. this creates
abnormally small chromosome 22 and a new combination of
instructions for your cells that can lead to the development of
chronic myelogenous leukemia.
Eczema is a condition that causes inflamed, itchy,
cracked and rough skin.

21. Diagnosis and management of chronic myelocytic
leukemia
• Diagnosis
• blood examination
• bone marrow analysis
• Management
• same as acute non lymphocytic leukemia

22. Nursing management
• Nursing diagnosis
• Anxiety of parent related to diagnosis of malignant disease
• Risk for infection and bleeding related to abnormal bone functions
• Pain related to infiltration of leukemic cells
• Activity intolerance related to fatigue resulting from disease process
• Altered nutrition less than body requirement related to anorexia ,gingival ulcer
• Alteration of body image related to alopecia