This document provides information about leukemia including: - It defines leukemia as cancer of the blood or bone marrow characterized by abnormal increase of immature white blood cells. - The objectives are to explain hematopoiesis, classify leukemia, list causes and manifestations, and explain management. - Acute lymphoblastic leukemia is the most common childhood leukemia, accounting for 73% of cases. Prognosis depends on factors like age, white blood cell count, and specific genetic abnormalities. - Treatment involves chemotherapy with induction, consolidation, and maintenance phases over 2-3 years, along with supportive care and stem cell transplantation in some cases. Late effects of treatment can include cognitive impairment and secondary cancers.

1. Leukemia
Laxmi Dahal
LECTURER
1
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2. General Objective
At the end of the session, participants will be able
to explain about leukemias.
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3. Specific objectives
At the end of the session, participants will be able
to:
- Explain hematopoiesis.
- Define leukemia.
- Explain the epidemiology of leukemia.
- List the factors predisposing leukemia
- Classify leukemia.
- List the causes of leukemia.
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4. Specific objectives
- Enlist the clinical manifestations of leukemia.
- State the diagnostic criteria of leukemia.
- List the differential diagnosis of leukemia.
- Explain the management of leukemia.
- State the prognosis of leukemia.
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5. Hematopoisis
5
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6. 6
Blast cell
• Blast cells are immature precursors of either
lymphocytes (lymphoblasts), or granulocytes
(myeloblasts).
• They do not normally appear in peripheral blood.
they can be recognized by their large size, and
primitive nuclei .
• Presence of blast cells in blood, signify
ACUTE LEUKEMIA.
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7. Blast cell
7
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8. 8
Definition
• Leuka = white, emia = blood
• Leukemia is a type of cancer of blood or
bone marrow.
• Characterized by an abnormal increase of
immature white blood cells called "blasts".
• Leukemias are the most common cancers
affecting children.
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9. Leukemia in Children
 Acute lymphoblastic leukemia (ALL)
accounts for 73%,
 Acute myeloid leukemia (AML) accounts
for approximately 18%.
 Chronic myeloid leukemia (CML) is rarely
seen, accounting for less than 4%.

10. 10
Epidemiology
–
–
Most common childhood cancer
– 3,000 new cases each year
Demographics:
• Males more commonly than females
• Whites more than blacks.
• More commonly in patients with Down’s
Syndrome.
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11. Incidence
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12. Age Incidence
12
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13. 2/13/2023 13

14. 14
Classification of leukemias
Cell type Acute Chronic
Lymphocytic
leukemia (or
"lymphoblastic")
Acute
lymphoblastic
leukemia(ALL)
Chronic
lymphocytic
leukemia
(CLL)
Myelogenous
leukemia
(also "myeloid" or
"nonlymphocytic")
Acute
myelogenous
leukemia(AML)
(or myeloblastic)
Chronic
myelogenous
leukemia
(CML)
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15. 2/13/2023 15

16. 16
Acute
Lymphoblastic Leukemia
(ALL)
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17. 17
• Epidemiology of ALL
 peak incidence in 2 to 6 years
 more in boys
 median age in adults-35years.
• Etiology
 environmental and genetic factors
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18. 18
Factors predisposing ALL
GENETIC ENVRONMENTAL
Down’s Syndrome Ionising radiation
Fanconi, diamond blackfan Drugs
Ataxia telengiectasia Alkylating agents
Turner’s Syndrome Nitrosourea
Klinefelter Syndrome Benzene exposure
Blooms syndrome Advanced maternal age
Paternal smoking
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19. 19
Classifications of ALL
• FAB CLASSIFICATION
• WHO CLASSIFICATION
• Cyto-genetic CLASSIFICATION
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20. 20
ALLpresentation
 Anemia
 Bleeding and bruising
 Bone and joint pain
 Fever
 Weight loss
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21. CLINICAL FEATURES
Due to infiltration of marrow
• SYMPTOMS
Due to decreased production
of normal marrow elements
21
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22. Symptoms
Symptoms
Fatigue
Bone or joint pain
Fever
Weight loss
Abnormal masses
Purpura
Hemorrhage
Infection
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23. 23
Physical Signs
Physical Signs
Splenomegaly
Lymphadenopathy
Hepatomegaly
Sternal tenderness
Purpura
Fundus changes
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24. 24
Diagnosis
• Confirmative tests
• Supportive tests
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25. 25
Investigation (confirmative)
• CBC
• Bone marrow aspiration/biopsy
• Cyto genetics.
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26. Investigations
CBC-Anemia, thrombocytopenia, leucopenia or
leucocytosis.
Peripheral smear study-circulating blast can be
seen.
26
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27. 27
Investigation (supportive)
• LDH,Serum uric acid
• Coagulation profile
• LFT, RFT
• Chest x-ray,
• CT scan of chest & brain
• Blood culture
• Baseline Echo,ECG
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28. Confirmatory
Bone marrow aspiration/biopsy
28
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29. Bone marrow biopsy
gross specimen Marrow showing blasts
29
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30. Bone marrow changes
Normal marrow
Entire marrow replaced
by blast
30
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31. Marrow showing blasts
31
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32. 32
Criteria for diagnosis
• Bone marrow or peripheral smear showing
Aleast 30% blast (FAB)
Atleast 20%blast (WHO)
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33. Differential diagnosis
• ITP
• Aplastic Anaemia
• Juvenile Rheumatoid Arthritis
• Infectious mononucleosis
• Metastatic solid tumours

34. 34
Treatment
• Pre Chemotherapy supportive care
• Chemotherapy
Preinduction
 Remission induction-phase 1 & 2 Reinduction
 CNS preventive therapy
 Consolidation (or intensification),
 Continuation (or Maintenance therapy)
• Allogenic stem cell transplantation
• Newer drugs
• Supportive care
• Treatment of relapse
• Effects of treatment
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35. 35
Supportive care
• Treat metabolic complications
hyperuricemia - hydration, rasburicase
hyperphosphatemia - po4 binders
hypocalcemia - Ca supplements
• Hyperleuckocytosis –leukopharesis
Infection control-broad spectrum
antibiotics
• Hematologic support
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36. 36
Preinduction
• Prednisolone 1mg/kg p.o for 5 days
• Recheck blast after 5 days, if blast
count dropped - good response.
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37. INDUCTION PHASE
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38. 38
Induction phase 1
Cycle chemotherapy Dose and schedule
Induction Prednisolon or 1mg/kg p.o days 1-28 days
vincristine 1.5mg/m2 i.v weekly once
x 4 weeks
doxorubicin 30mg/m2 i.v weekly once
x 4 weeks
L-Asparginase 1,00,000 u/m2(total dose) in
divided doses of 10,000 u
daily for 10 days
CNS Proph. Methotrexate 12mg IT days 1,8,15,22
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39. CNS prophylaxis
• Given the concern of long-term neurotoxicity
and risk of brain tumors following standard
cranial irradiation, experts recommend lower
dose irradiation combined with intrathecal
administration of methotrexate.
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40. CNSProphylaxis
 CNS involvement at diagnosis <5%
– Without prophylaxis, over 80% of patients in CR
will relapse in the CNS
– With prophylaxis, less than 5% have CNS relapse
 Intrathecal chemotherapy is now the
mainstay
– Sample intermediate risk regimen: IT MTX
alone or “triple therapy”: IT cytarabine Day 1 of
CR followed by MTX/hydrocortisone/cytarabine
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41. 41
Reassess
• After 4 weeks of phase 1 induction
assess marrow for remission.
• If there is remission taper prednisolone and
after 1 week, start phase 2 induction,
• If there is no remission give 2 more weekly
doses of vincristine and doxo and then assess,
if still no remission go for alternate regimen.
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42. 42
Induction phase 2
Inductio
n2
Drugs Dose and
schedule
Cyclophosphamide
Cytosine
arabinoside
650mg/m2 i.v days 1
and 15
75mg/m2 i.v x 4 days a
weeks for 4 week
Methotrexate 12mg/m2 IT days
1,8,15,22
Cranial radiation 200 cGy x 9days
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43. Consolidation (2weeks)
Consol
dation
Drugs Dose and schedule
cyclophosp
hamide
750/m2 .i.v on days 1
and 15
Cytosine
arabinoside
75mg/m2 doses
days 1-4 and 15-18
4/28/2014 41
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44. Maintenance phase
duration- upto 2 years
maintena
nce
drug Dose and schedule
1st
month
methotrexate 12.5mg i.t on day 1
vincristine 1.4mg/m2 .v day 1
prednisolone 1mg/kg p.o daily day 1-7
6 mercaptopurine 60mg/m2 p.o. daily for
next 3 weeks
methotrexate 15mg/m2 p.o. once a
week for 3 weeks.
2nd
month
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6 MCP and
T.Methotxerate for
4 weeks. 42
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45. 45
Follow up
• If the patient completes chemotherapy for 2
years without relapse-stop chemo and follow
up.
• No relapse within 5 years -can be declared as
cured.
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46. 46
Allogenic stem cell transpantation
• Usually done in second remission.
• Can be done in first remission in high risk
patients
 WBC>25000,
 philadelphia chromosome positive,
poor initial response to remission
induction.
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47. 47
Newer drugs
Monoclonal antibodies
rituximab(CD20),epratuzumab(CD22)
alemtuzumab(CD52),gemtuzumab(CD33)
Antimetabolites
clofarabine,nelarabine
Tyrosine kinase inhibitor imatinib,
nilotinib, dasatinib,
Vornistat, sirolimus,everolimus,oblimersen.
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48. SUPPORTIVE CARE
• use of packed red cells
• When high fever and possible septicemia
occur in the presence of neutropenia,
antibiotic therapy should be started.
(NEUTROPENIA REGIME)
• Platelet transfusions should be
administered to patients with overt bleeding
or when the platelet count is below
10,000/mm3.

49. Nursing management
Assessment
- General condition, activity, alertness
- Pain, fever
- Bleeding
- Intake of child
- Side effects of chemotherapy
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50. Nursing diagnosis
1.Acute Pain related to physical agents, e.g.,
enlarged organs/lymph nodes, bone marrow
packed with leukemic cells.
2.Risk for Deficient Fluid Volume related to
decrease fluid intake and increase loss.
3.Imbalanced nutrition: less than body
requirement related to cachexia.
4.Risk for Infection related to inadequate
secondary defense.
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51. Nursing diagnosis
4. Activity Intolerance related to generalized
weakness and increased metabolic rate from
massive production of leukocytes.
5. Deficient Knowledge related to lack of
information.
6. Anxiety related to unfamiliar disease condition.
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52. Course of treatment
• The average duration of treatment in ALL is
24- 30 months, with no advantage of extending
treatment beyond 3 years.
• The outcome of ALL remains poor in infants,
even with intense therapy including stem cell
transplant.
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53. Late Effects of Treatment
- cranial irradiation: cognitive and intellectual
impairment and development of CNS neoplasms.
- There is a risk of secondary AML after intensive
use of epipodophyllotoxins (etoposide,
teniposide).
- Endocrine dysfunction leads to short stature,
obesity, precocious puberty, osteoporosis, thyroid
dysfunction and growth hormone deficiency.
- Patients with prior therapy with an anthracycline
are at risk of cardiac toxicity.
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54. Prognostic factors in ALL
Determinants Favourable Unfavorable
WBC Counts <10,000 >2,00,000
Age 2-10 years <1yr,>10yr
Gender female male
Ethnicity white black
Node,liver,splenomegaly absent massive
Testicular enlargement absent present
CNS involvement absent Csf blast and pleocytosis
FAB Type L1 L2
Cytogenetics T(12;21)(TEL-AML1)
Trsomies 4,10,17
t(9;22)(bcr-abl)
t(4;11)(MLL-AF4)
Ploidy hyperdipoidy hypodiploidy
T
4/2
i8
m
/20
e
14
to remission <14days >28days 48
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55. Acute Myeloid Leukemia
- It happens when the body makes too many
immature white blood cells. These cells,
called myeloid blasts, can't mature into normal
white blood cells.
- Because AML develops and gets worse
quickly, prompt treatment is very important.
- Of kids who have leukemia, 20% have AML.
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56. Clinical features
•swollen gums
•infections (like bronchitis or tonsillitis) that keep
coming back
•night sweats
•belly pain (caused by the build-up of cells in
organs like the kidneys, liver, and spleen)
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57. Management
- Chemotherapy: The treatment goal is remission,
which is when tests don't find any cancer cells in the
body.
- Then, maintenance chemotherapy is used to keep
the child in remission and prevent the cancer from
coming back. The child will get maintenance chemo
for 2 to 3 years.
- Stem cell transplant
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58. Chronic Myeloid Leukemia
- It constitute 3% of leukemias in childhood.
- It is characterized by myeloid hyperplasia of
the bone marrow, extra medullary
hematopoiesis, elevation of white blood cell
count.
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59. Chronic Myeloid Leukemia
Adult CML: The condition is clinically and
hematologically comparable to the adult form of
chronic myelogenous leukemia and occurs in
children above the age of 4 years.
Juvenile CML: This form presents in infancy and
early childhood, usually below the age of 4 years,
and has a more rapid course.
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60. Clinical features
chronic phase
- fatigue,
- malaise,
- weight loss,
- excessive sweating,
- abdominal fullness, and
- bleeding due to platelet dysfunction
- splenomegaly is usually massive.
- Symptoms of leukocytosis such as headache,
dizziness and visual disturbances.
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61. Treatment
Aim:
To control increasing white cell counts.
- First and second-generation oral tyrosine
kinase inhibitors (TKI) are the treatment of
choice.
- imatinib therapy.
- The starting dose of imatinib is 340 mg/ m2/
day.
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62. Treatment
- Bone marrow cytogenetics: 6 monthly until a
complete cytogenetic response is obtained.
- Allogeneic stem cell transplantation is
recommended for patients who do not respond
to TIU.
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63. Chronic Lymphocytic Leukemia
- Chronic lymphocytic leukemia (CLL) is a type
of cancer of the blood and bone marrow.
- Chronic lymphocytic leukemia most commonly
affects older adults.
- There are treatments to help control the disease.
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64. Facilities in Nepal
- Bipanna Nagarik Kosh was started after the
Janandolan of 2062 BS.
- Cardiovascular diseases, Cancer, Renal failure,
Alzheimer's disease, Parkinson's disease, Head
and Spinal injury, Sickle Cell Anaemia and
Stroke are covered under this program.

65. Facilities in Nepal
Those eligible to claim services under the Bipanna
Nagarik Kosh will receive the following:
1.Each patient will be provided NRs. 1,00,000/- as
health care expense including medicines required
for disease management
2.For patients with renal impairment (मृगौला रोगीको
उपचार सम्बन्धमा)
3.Free hemodialysis and peritoneal dialysis for 1
year

66. Facilities in Nepal
1.NRs. 2,00,000/- as kidney transplant expense
2.NRs. 1,00,000/- in one or more instalments as
medicine expense for post-transplant management
3.NRs. 1,00,000 to purchase medicine post kidney
transplant is provided as cash grant. All other
subsidies are provided directly through hospitals
in Nepal.
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67. Facilities in Nepal in listed hospital
for Cancer
1.National academy of health sciences, Bir
hospital, Kathmandu
2.Tribhuwan University, Teaching Hospital,
Kathmandu
3.Patan Academy of Health Science, Patan
4.B.P. Koirala Institute of Health Science, Dharan
5.Maternity Hospital, Kathmandu
6.Civil Service Hospital, Kathmandu
7.Kanti Children hospital, Kathmandu

68. Facilities in Nepal in listed hospital
for Cancer
1.B.P. Koirala Memorial Cancer Hospital,
Bharatpur
2.Chitwan Medical College Teaching Hospital,
Chitwan
3.Bhaktapur Cancer Hospital, Bhaktapur
4.Cancer Care Nepal, Lalitpur
5.Nepal Cancer Hospital & research centre
6.Kathmandu Cancer Center, Tathali, Bhaktapur
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69. REFERENCES
• Ghai O, Paul V, Bagga A. Essential Pediatrics. 7th ed. CBS
Publisher & Distributers; 2008.
• Before you continue to Google Search [Internet]. Google.com.
2021 [cited 20 April 2021]. Available from:
https://www.google.com/search?q=fab+classification+of+leuke
mia&oq=FAB+classifica&aqs=chrome.0.0l2j69i57j0l7.12372j0j
15&sourceid=chrome&ie=UTF-8
• Blinatumomab Effective for Children with Relapsed Leukemia
[Internet]. National Cancer Institute. 2021 [cited 20 April 2021].
Available from: https://www.cancer.gov/news-events/cancer-
currents-blog/2021/blinatumomab-relapsed-b-cell-leukemia-
children-young-adults
• S et al. Leukemia [Internet]. WebMD. 2021 [cited 20 April
2021]. Available from:
https://www.webmd.com/cancer/lymphoma/understanding-
leukemia-basics
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70. 4/28/2014 49
THANK
YOU
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71. Reinduction
Re
induction
Drug Dose and schedule
Vincristine 1.5 mg/m2 i.v weekly one
dose on day 1 and 8
Doxorubicin 30mg/m2 i.v. weekly one
dose on day 1 and 8
4/28/2014
Prednisolone 1mg/kg p.o daily for 14
days
40
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