childhood leukemia tab course20061113

8/13/2019 Childhood Leukemia TAB Course20061113

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First Published:

Childhood Leukemiaand Lymphoma


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Acknowledgement _________________________________________________________4Purpose and Object ives ____________________________________________________5Introduction ______________________________________________________________6Case Study-Li ly Rose ______________________________________________________7SECTION ONE: Leukemia Disease, Diagnosis, and Decisions _____________________7The Eight Warning Signs of Childhood Cancer (American Cancer Association 2005)__8

What is Leukemia? _______________________________________________________8Childhood Cancer Statistics _______________________________________________9What are the types of Childhood leukemia? __________________________________9Risk Factors for Childhood Leukemia ______________________________________10Signs and Symptoms of Chi ldhood Leukemia _______________________________10Diagnosing Leukemia in Children__________________________________________11

An in it ial diagnosis assessment for childhood leukemia may include: ___________12Prognosis and Recovery _________________________________________________12The following factors affect a childs prognosis for recovery. __________________13Treatment for Chi ldhood Leukemia. ________________________________________13Treatment modali ties ____________________________________________________13

Treatment _______________________________________________________________15Support ive Care ________________________________________________________15Surgery _______________________________________________________________15Chemotherapy__________________________________________________________15Radiation ______________________________________________________________16Bone Marrow Transplant, Stem Cell Transplant ______________________________16Bone Marrow Transplants may come from several sources:____________________17SECTION TWO: Childhood Lymphoma _____________________________________18Case Study ____________________________________________________________18What is Lymphoma?_____________________________________________________18Types of Lymphoma_____________________________________________________19Hodgkin Lymphoma _____________________________________________________19Non-Hodgkin Lymphoma (NHL) ___________________________________________19Risk Factors for Lymphoma ______________________________________________19What are the symptoms of Lymphoma? ____________________________________20


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Signs and Symptoms ____________________________________________________20Diagnosis______________________________________________________________20The Staging of the Disease _______________________________________________21Treatment for Lymphoma ________________________________________________21Section III: Managing Side Effects of Leukemia and Lymphoma Treatment _______21Side Effects of Leukemia Lymphoma Cancer Treatment in Children and Adolescents______________________________________________________________________22Pain Management for Children diagnosed with Leukemia and Lymphoma. _______23Commonly used analgesics for childrens and adolescents diagnosed with painrelated to Leukemia and Lymphoma. _______________________________________24Long Term Late effects of Leukemia and Treatment __________________________24Psychosocial and Emot ional Aspects of Childhood Leukemia __________________25Survival and Life after Cancer Treatment____________________________________26

Conclusion ______________________________________________________________27Reference _______________________________________________________________28Post Test ________________________________________________________________29


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Acknowledgement

Childhood Leukemia and Lymphoma by

Claudia H. Lupia RN, BS, OCN and

Charmaine Biega, RN, NC


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Purpose and Objectives

The purpose of this course is to provide information and statistics about childhood leukemiaand lymphoma. The course includes information on signs and symptoms of leukemia, howleukemia is diagnosed, childhood cancer statistics, current treatment patterns, long term side

effects, and the emotional and psychosocial issues surrounding a childhood cancerdiagnosis.

At the completion of this continuing education course the participant will be able to:

1. Define childhood leukemia and lymphoma.

2. Identify the eight warning signs of childhood cancer.

3. Identify signs and symptoms of childhood leukemia and lymphoma.

4. Describe how leukemia & lymphoma is diagnosed and staged.

5. Identify the current treatment for childhood leukemia & lymphoma.

6. Describe side effects associated with treatment.

7. Describe statistics for childhood leukemia and lymphoma.

8. Describe treatment for pain associated with childhood leukemia & lymphoma.

9. Identify stressors and psychosocial issues for the pediatric patient, family, and health

care professional and list positive coping strategies.

Disclaimer

RN.com strives to keep its content fair and unbiased.

The author(s), planning committee, and reviewers have no conflicts of interest inrelation to this course. There is no commercial support being used for this course.

There is no "off label" usage of drugs or products discussed in this course.

You may find that both generic and trade names are used in courses produced byRN.com. The use of trade names does not indicate any preference of one tradenamed agent or company over another. Trade names are provided to enhance

recognition of agents described in the course.

Note: All dosages given are for adults unless otherwise stated. The information onmedications contained in this course is not meant to be prescriptive or all-

encompassing.You are encouraged to consult with physicians and pharmacists about all

medication issues for your patients.


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Introduction

Children who are diagnosed with leukemia or lymphoma develop symptoms and side effectswhich are different than adults. The pediatric patient can become acutely ill quickly,presenting a medical challenge for the health care team. Diagnosis, treatment, and

intervention by a specialized pediatric hematology oncology center can help ensure a positiveoutcome for ill children and adolescents with cancer. Acute Lymphocytic Leukemia (ALL) isthe most common hematologic malignancy found in children. Acute lymphocytic leukemia istreatable and can be cured. Survival rates have increased dramatically in recent decadesdue to advances in research and chemotherapy treatment. (NCI 2005)

Lymphoma is a type of cancer which develops in the lymphatic system and is morecommonly diagnosed in adolescents and young adults. The two main types of lymphomasare Hodgkin Lymphoma and Non-Hodgkins Lymphoma. Pediatric patients and adolescentsdiagnosed with lymphoma respond well to treatment, particularly chemotherapy and/orradiation.


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Case Study-Lily Rose

A 2 year old white female, Lily, is rushed by her parents into the local Childrens HospitalEmergency Room. The toddler is acutely ill, chalky pale, listless, bruised and having difficultybreathing. The ER team responds immediately performing a comprehensive physical

assessment. The attending physician suspects leukemia. Lilys parents are tearful andanxious, the ER staff solemn and watchful. A preliminary diagnosis of childhood cancer isdifficult for the family and health care workers to consider. Will the little girl survive? Thisquestion is on everyones mind. The Emergency Room staffs works quickly with the pediatrichematologist oncologist to treat and diagnose the ill child. The patients preliminary bloodwork is consistent with Acute Lymphoblastic Leukemia, ALL. Lily will be admitted to thepediatric hematology oncology unit for observation and further assessment.

Sections I, II, and III, will present Lilys case study while describing Childhood Leukemia andtreatment.

SECTION ONE: Leukemia Disease, Diagnosis, and DecisionsLilys preliminary diagnosis of ALL is the most common cancer occurring in children,representing 30% of cancer diagnosis in children younger than 15 years and 25% of childrenunder age 20 years. (NCI 2005). ALL is treatable and can be cured. The survival rate hasincreased dramatically in recent decades (NCI 2005). A diagnosis of childhood cancer canprecipitate a crisis for the child, family, health care team, and the childs community. Thehealth care team must act rapidly to ensure a positive outcome. There is great cause forhope for this young girl. Today advances in treatment have improved the outlook for survivalfor children diagnosed with leukemia. A majority of children, 90% of pediatric patientsdiagnosed with ALL will be in remission 5 years after diagnosis (NCI 2005). Many of theseyoung children and adolescents will be cured. This course will discuss childhood leukemiaand lymphoma, childhood cancer statistics, life saving treatment, side effects of treatment,and the stressors and psychosocial issues surrounding a diagnosis.


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The Eight Warning Signs of Childhood Cancer (American CancerAssociation 2005)C - Continued unexplained weight lossH - Headaches with vomiting in the morningI - Increased swelling or persistent pain in bones or jointsL - Lump or mass in abdomen, neck or elsewhereD - Development of a whitish appearance in the pupil of the eyeR - Recurrent fevers not due to infectionE - Excessive bruising or bleedingN - Noticeable paleness or prolonged tiredness

Why do children get leukemia? The majority of cases of childhood leukemia and lymphomacan not be prevented. The cause of pediatric leukemia and etiology is unknown. Howeverthere are signs of childhood cancer the parents and health care workers should be aware of.Cancer and leukemia detected early may have a better chance of responding to treatment.The risk of leukemia cells spreading to the childs other organs is also decreased with earlydetection.

Lilys parents brought her to the Emergency room quickly within a week of symptomsand deteriorating health. Early detection of childhood leukemia may help her chancesto survive.

What is Leukemia?Leukemia is a cancer and disease of the bone marrow. Bone marrow is found in the bonesand makes blood cells. In leukemia the bone marrow makes large amounts of abnormalwhite cells. The abnormal white cells may crowd out red blood cells and platelets resulting inanemia and thrombocytopenia. Rarely leukemia can also originate in other blood cells.

Bone Marrow is the spongy material found in the bones, bone marrow producesblood cells?

White blood cells (WBCs) B and T cells - leukocytes, monocytes, andgranulocytes, neutrophils, the normal white cells fight infection, destroy bacteria andgerms, protect against microorganisms and viruses throughout the body.

Red Blood cells (RBCs) carry oxygen to the organs in the body.


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Platelets small blood cells which assist in blood clotting and prevent bleeding andbruising. Platelets form the plug to stop bleeding.

Thrombocytopenia- decreased platelets.

Neutropenia a- decreased number of neutrophils or absence of neutrophils

In leukemia abnormal white blood cells grow out of control. These out of control cells invade

the childs bone marrow crowding out the good cells needed for life. As the leukemia cellsincrease and multiply the patients normal cells decrease and are pushed out. The marrowfound inside the bones is then replaced by the dangerous abnormal cells. The type ofleukemia is identified by the type of cell affected. As the white cells multiply the child willbecome ill and exhibit signs of leukemia.

Childhood Cancer Statist icsIn the United States approximately 2,200 children a year will be diagnosed with ALL(American Cancer Association)#1 cause of death from disease in children ages 1-15. (The Leukemia & Lymphoma Society

2003)ALL is more common in white children than in Asians or blacks (ACS).

The five year survival rate for ALL is 80 % (ACS). The five year survival rate for AML is 40%(ACS). Children develop different types of cancer than adults. They also respond differentlyto treatment than adults.

Leukemia is more common in adults than children. People over 60 are most affected. Childhood leukemia accounts for 30 % of child hood cancers under age 15.

ALL peak incidence is the preschool years, ages 2-3 years old.

ALL is more common in boys.

AML (acute mylogenous is more common infants under one and in adolescents.

Caucasian children with ALL had a better 5 year survival rate than black children.

ALL 70% -75% of childhood leukemias.

AML 20% of childhood leukemias.

Rare child hood leukemias 5-10%.

What are the types of Childhood leukemia?There are many types of childhood leukemia. The most common is ALL which is fast growing.

Acute Lymphocytic (Lymphoblast ic) Leukemia (ALL) ALL is the most commonchildhood cancer and accounts for about 30 % of all cancer cases. Approximately 70% to75% of all childhood leukemias are ALL.

Acute Mylogeneous Leukemia(AML)Acute Non-Lymphocytic Leukemia (ANLL)


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AML and ANLL account for approximately 20% of Childhood Leukemia.

5 to10% of cases include the rare leukemias including:Chronic Lymphocytic Leukemia (CLL) and Chronic Mylogeneous Leukemia (CML) arerarely found in children. Chronic Leukemia is slow growing and a patient may live for severalyears after diagnosis.

The pediatric patients diagnosis of childhood leukemia will be classified by cell type. The celltype will help determine the prognosis for the child.Prognosis is a determination on how the child will respond to treatment and how long thepatient is expected to live. However each child is an individual and will respond differently toleukemia treatment. For this reason many hematologist are reluctant to give a parent a firmprognosis or expected timeline.

Risk Factors for Childhood Leukemia

In the majority of pediatric cancers and leukemia cases the cause is unknown. There is noway to prevent leukemia. However there are risk factors for leukemia in children.

1. Age.2. Inherited genetic conditions, including Down Syndrome, Fanconis Anemia, Ataxia

Telangectasis, Li Framai Syndrome.3. Children receiving medication to suppress the immune system.4. Children who have rare immune disorders.5. Children previously diagnosed with cancer or leukemia.6. Children who have received chemotherapy or radiation.7. Viruses two viruses have been linked to certain types of leukemia.

Two year old Lilys risk factor is her age. The incidence of childhood leukemiaincreases at age 2 through age 8 years. Her age also increases her chances forsurvival. However her cell type and chromosome analysis wil l also be impor tant togauge how she will respond.

Signs and Symptoms of Childhood LeukemiaChildren diagnosed with childhood leukemia may have multiple abnormal findings on physicalassessment and laboratory analysis. Leukemia starts in the bone marrow and spreads

through the blood. The leukemic cells can spread to the lymphphatic system, spleen, liver,central nervous system and throughout the body.

Lily exhibited signs and symptoms of anemia, lethargy, and fever. While fevers andchildhood illness can mimic childhood leukemia, Lilys overall appearance of profoundillness alerted her parents to a serious disorder.Which blood cells in Li lys bone marrow may have been affected?White blood cells?Red blood cells?


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Platelets?

Some children may present with no apparent symptoms of leukemia. The abnormal whiteblood cell count may be discovered on a routine blood screening. In these cases the diseaseis not advanced enough to cause symptoms.When leukemia is found early the child has a better chance for recovery. The parents and

health care professional should watch for the following abnormal signs in an ill child.

Fatigue, anemia The child or adolescent appears tired, lacking in energy. Thismay be due to anemia, a lack of red blood cells which carry oxygen.

Pallor, anemia The child is pale, chalky in color, skin has a white appearance, lipsand nail beds may look pale or blue.

Infection the child has an unusual infection which may be unresponsive totreatment. An example would be an unexplained rectal abscess. Neutropenia a lackof neutrophils, new white bloods cells with the ability to fight infection is common.

Bleeding, bruising, petechaie, abnormal decreased platelet count,thrombocytopenia (tiny red & purple pin pint dots & freckle like pattern). A patient

might present with a prolonged nose bleeds lasting longer than 15 minutes. Multiplelarge dark blue black bruises larger than the size of quarters are not uncommon inyoung children presenting with leukemia. As the platelet count falls and theyoungster becomes thrombocytopenic bruising emerges. At initial exam the healthcare professional may suspect child abuse.

Bone pain, joint pain the child may complain of pain in the long bones, parentsoften think this is just growing pains.

o Enlarged spleen on physical assessment the abdomen may be swollen.o Enlarged liver liver function studies can be abnormal; the childs color may

be jaundiced.o Enlarged thymus

o Lymph nodes - may be swollencareful physical assessment can revealabnormalities in the lymph nodes

Headache, seizures- persistent headaches in young children are a danger sign andcould indicate a brain tumor or leukemia cells spread to the central nervous system.Seizures require immediate medical assessment.

Vomiting- unexplained and persistent, lack of appetite, weight loss.

Rash - which does not go away or appears abnormal

Mouth sores

Fevers - Frequent fever without infection.

Diagnosing Leukemia in ChildrenLily was admitted to the Hematology Oncology Unit of a large teaching ChildrensHospital affil iated with a universi ty. There a multidisciplinary team will begin theprocess of finding out what kind of leukemia Lily has and which treatment offers thebest hope for survival. Lilys physicians and nurses perform a complete physicalassessment including medical and family history. Lily s parents are overwhelmed withmany questions about their daughters condition.

Lily was sobbing and struggling with the nurse as peripheral intravenous lines wereinserted and fluids are started for maintenance hydration. She was monitored closely


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for any deterioration in vital signs. Lilys laboratory results revealed an abnormallyhigh WBC (white blood cell count) of 60,000, a low hemoglobin of 5.0, and decreasedplatelet count of 5,000, (thrombocytopenia). A bone marrow and biopsy wasperformed with a spinal tap. The preliminary tests are consistent with ALL, leukemia.Red blood cells were ordered for her anemia and a platelet transfusion was given toincrease the platelet count and preventbleeding.

How can the staff help Lily cope with the many invasive procedures she willexperience?Play therapy? Child life specialist?Distraction? Toys, books, videos, music?

Al lowing her parents to stay wi th her?Lilys nurse does not approach her to give nursing care. The nurse enters the roomwith a book; she reads Lily the book about frogs. Lily calms down and enjoys beingread to. Later she allows the nurse to take her vital signs without fight ing and sheasks the nurse to read the book again! Lily s nurse takes the 5 minutes to read to Lilyand build trust .

An initial diagnosis assessment for childhood leukemia mayinclude: A complete in depth physical assessment.

A health history from the mother and pediatrician. Has the child lost weight? Is there alack of energy? Has there been bruising and prolonged bleeding? Was the childtaking medication? Is there a family history of cancer or bleeding? Does the childhave any additional health problems?

Laboratory analysis, including a CBC with differential, obtain slide for assessment,clotting labs, electrolytes, type and cross, liver function tests, blood sugar,chromosome analysis, blood gases.

Chest, X-ray, a CT scan, MRI, Bone scan may be indicated.

Bone marrow aspirate and bone marrow biopsy, spinal tap.

Chromosome studies.

Prognosis and RecoveryThe majority of parents want to know if their child can be cured. This is quickly followed byWhat is the prognosis? Some parents may find it too painful to utter the word cancer orleukemia while others speak freely and head to the internet to search for any informationavailable. The hematologist and comprehensive team will conference with the family anddiscuss prognosis and treatment.

Lilys diagnosis and cell type, ALL is low risk and her prognosis is favorable. Howeverthe treatment will be aggressive and the coming months may be difficult. Treatmentwill begin as soon as possib le, after all her staging tests have been completed. Lily issettled in her crib for the night and her parents are encouraged to spend the night inher room. The nurse rolls in 2 parents cots. Children and adolescents are comfortedby close physical proximity to their parents or significant caregivers. Every effortshould be made to keep the family close to the child and include the family into thechild s plan of care, both inpatient and outpatient. Family centered care is the goaland will help the child and family cope positively with the diagnosis.


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The following factors affect a childs prognosis for recovery.1. Age at diagnosis of leukemia. Ages one year to nine years respond well. Children

less than one year old and greater than ten years are higher risk.2. White Blood Cell count at diagnosis greater than > 50,000. The higher the WBC the

higher the risk. WBC greater than 100,000 is especially dangerous and raises the riskof relapse.

3. Gender affects prognosis. Girls have a better chance of recovery than boys.4. Race affects response. Black and Hispanic children have a lower cure rate than

Caucasians.5. Metastasis to other parts of the body. When leukemia cells have spread to the spleen,

liver, brain, testicles, and other organs there is a poorer outcome.6. Immunophenotype of the leukemia cell. B cells or T cells. T cells are higher risk.7. The number of chromosomes, types of chromosomes and the translocation of

chromosomes.8. Response to therapy. A primary indicator of a patients recovery is how well they

respond to treatment. Many children with a poor prognosis will surprise the medicalteam by responding well. Infrequently a child with a good prognosis may not respond

to treatment. While prognostic statistics are helpful a patients response and survivalis individual.

Lilys treatment for ALL will be determined by the Hematology Team in the morningwith her parents consent. Later in this learning module the case study will continuedescribing Lilys treatment, side effects to treatment and her response to cancertherapy.

Treatment for Childhood Leukemia.Childhood Leukemia is treated with a combination of therapies. This combination of drugs,radiation and surgery has helped cure many cases of cancer. Major advances in treatingchildhood cancers have taken place in the past 30 years. Many children diagnosed withleukemia will be cured.The goal of treatment includes the following:

Kill the leukemia/cancer cells.

Control the symptoms of disease in the child.

Achieve a remission of the disease and the symptoms.

Cure the disease.

Treatment modalitiesThe childs initial treatment for leukemia will depend on several different factors including:

What is the leukemia cell type and stage? What is the childs age?

What is the physical condition of the child? Each child should be evaluated as anindividual when choosing treatment. Physical conditions which could affect treatmentmodalities include, heart defect or heart failure, liver or organ failure, poor kidneyfunction, decreased pulmonary function, among others. These pediatric patients mayneed treatment modified to decrease further risk of side effects.

Is the child eligible for a clinical trial? Clinical trials are studies which evaluate whichtreatments effectively treat childhood leukemias and cancers. COG or the Childrens


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Cancer Study Group includes approximately 100 Childrens Hospitals and UniversityHospitals in the United States currently taking part in research clinical trials.

The parents understanding of the treatment, approval, and their written legal consent.Social, cultural, and economic factors need to be considered. An example mightinclude: the Amish population without access to health insurance and their individualbelief in herbal remedies, families of the Jehovah Witness faith who believe in

bloodless treatment, families from rural or Appalachian regions may experiencedifficulty arranging transportation for follow up treatment. The health care team shouldmake every effort include the familys beliefs and needs while providing effectivetreatment for the child.

The hospital and hematologist caring for the child. The hematologist is ultimatelyresponsible for writing the orders which determine the patients treatment.


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Rare leukemias which can be cured with a bone marrow transplant.

Children with rare leukemias, who have a perfect sibling bone marrow, match.

Stem cell aphaeresis donation for children receiving regimes which suppress theimmune system and need a bone marrow rescue or boost.

Bone Marrow Transplants may come from several sources: Autologous the patients own marrow. Allogeneic matched family (usually sibling) donor.

Matched Unrelated Donor (MUD transplant) usually from a bone marrow donor bank.

Stem Cell Transplant patients own marrow, or matched marrow.

Umbilical Cord Stem cell transplant patients own or matched donor.

The type of transplant deemed necessary will depend on the following:

Childs protocol (treatment plan).

The disease status and disease type, the relapse diagnosis. Relapsed leukemia canchange cell type.

The available bone marrow or donor. Does the child have a sibling? What if the childis adopted? May the patient donate his/her own marrow?

Can the child physically withstand a bone marrow transplant and pretreatment?

Lilys parents sit in a small conference room and consult with the Hematology team.The hematologist explains her disease and the treatment options. The mother cr ies asshe hears the possible side effects from treatment, hair loss, infection, infertility,secondary tumors. However the parents agree this is Lily s best chance at life and thefather signs the consent for treatment. They agree with the oncologistrecommendation for a clinical trial for ALL. This trial is showing much promise for acure for Lilys disease. Lily receives her first dose of intravenous chemotherapy that

afternoon. She is irritable and nauseated, crying and clinging to her mother. Multiplevisitors arrive, grandparents, aunt and uncles, cousins and neighbor bringing balloonsand toys. The many visitors excite Lily and tire her parents. The phone rings nonstop. Lilys father comments to the nurse, I wish I could tell her visitors to stay home.Could they bring in germs which could hurt her? She hasnt been able to take a nap. Iam not sure what to do? He looks overwhelmed and exhausted.

How can the nurse and team help the family gain control over the visitors andphone calls?

Will the visitors bring in germs?

Lilys parents talk with the nurse about options for controlling their hospitalenvironment. Together they come up with a workable plan, appointing one familymember (Lilys paternal grandparents GramDee and PaPa to be the contact personfor family and friends. Her grandparents let the relatives and friends know Lilysstatus and advise them on visitor restrictions. Adults without contagious illnessesmay visit at the parents request. Children are requested to stay home, away from thehospi tal. The phone ringer is turned off in the room. Lilys nurse medicates her withanti nausea medicine and the child and family get some much needed sleep. A sign is


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Prolonged chemical or environmental exposure to cancer causing agents.

Certain virus including HIV (Human Immunodeficiency Virus) and EBV (Epstein BarrVirus) found in Africa, HTLV (Human T Cell Lymphocytotropic Virus.

Helicobacter pylori bacterium is associated with stomach ulcers and lymphoma of thestomach wall.

What are the symptoms of Lymphoma?Jaycee presented with the most common early sign of Hodgkin lymphoma, a painlessswelling of the lymph nodes. He also reported a history of weight loss and nightsweats. Jaycee admitted to the medical student during a patient history that he hadfelt sick for several weeks. He felt he might have mono . Jaycee delayed seekingtreatment so he could continue to play football. The size of the lymph node in his neckcaused him to show the swollen area to his mother. Jaycees mother immediatelymade an appointment with their family doctor. As Jaycee awaits his lymph nodebiopsy in the morning he asks his mother, When can I play football? Can antibioticsget rid of the lump in my neck?How can the health care team help Jaycee cope with his diagnostic tests and

diagnosis?Would age appropriate educational materials dealing with lymphoma help?Let him talk to another teen patient with cancer?Tell him he can not play football?

Assess Jaycees perception of why he is in the hospital?

Signs and Symptoms The most common early sign of lymphoma is painless swelling or lump in the neck,

upper chest, groin, armpits, and abdomen

Fatigue the child exhibits unexplained tiredness

Fever Night sweats sweating occurs mainly at night

Weight loss loss of weight is rapid and unexplained

Loss of appetite the teen or child may lose his appetite

Itching- a feeling of skin itching, skin crawls

Spleen enlargement the abdomen and spleen may be enlarged

Rarely lymph node enlarged in other areas (intestine, bones, lung, and the skin)

Tumor masses may be present

Chest mass seen on Chest X-ray

DiagnosisJaycee is prepared for a biopsy of the cervical lymph node under general anesthesia inthe main operating room at Childrens Hospital. The anesthesiologist and surgeon areconcerned about the mass surrounding his heart. They will biopsy the neck node butnot the chest mass, they moni tor him closely. While under anesthesia thehematologist performs a bone marrow and biopsy and a spinal tap. A review of theslides from the biopsy reveals Reed-Steinberg cells consistent Hodgkin Lymphoma.Jaycee undergoes additional diagnostic imaging and is diagnosed with Stage IIIHodgkin Disease.


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Diagnosing lymphoma may include the following:

In depth physical exam the child/ teen may exhibit different symptoms than an adult.Feel for lymph node abnormality, any swelling.

Medical and family history.

Complete blood analysis blood count, blood chemistry.

Chest X-ray.

CAT scan or a CT Computerized Tomography Scan.

PET scan - Positron Emission Tomography Scan.

MRI Magnetic Resonance Imaging.

Imaging of the chest, pelvis, and abdomen to look for spread of the disease.

Gallium Scan to check the lymphatic system for disease.

Bone Marrow aspiration and biopsy to see if lymphoma has spread to the bonemarrow.

Spinal Tap disease spread into central nervous system.

Exploratory surgery staging surgery to look for extent of disease.

Lymph angiogram to check the lymph system for disease.

The Staging of the DiseaseStaging for lymphoma is based on the following factors.

How many abnormal lymph nodes are present

The location of the lymph nodes

Has the cancer spread outside the lymph nodes

Are the abnormal cells slow or fast growing, aggressive

What is the cell type

Is the abnormal cell orderly or poorly differentiated?

What is the cell grade

Treatment for Lymphoma Surgery

Chemotherapy common medications, Nitrogen mustard, Vincristine, Vinblastine,Dacarbazine, Procarbazine, Adriamycin, Bleomycin, Vi

Radiation

Immunotherapy

Bone Marrow Transplant

Stem Cell Transplant

Section III: Managing Side Effects of Leukemia and LymphomaTreatmentChildren receiving treatment can suffer side effects. The goal is to control and kill theleukemia and lymphoma cells. While suppressing the malignant cells, treatment may alsosuppress the childs immune system leading to life threatening complications. Side effectscan be treated and controlled leading to increased cure rates and decreased mortality rates.

Lily is 3 weeks post in itial chemotherapy and is experiencing neutropenia (a decreasedwhite blood cell count and low neutrophils) a fever of 103 degrees, mouth sores, oral


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pain, and mucusitis, decreased platelet counts, and a lack of appetite. Lily s mother isworried and states, She will not take her medicine or eat or drink. I think her mouthhurts. Will she get dehydrated?How can the staff support Li lys side effects?Lily is admitted to the Childrens Hospital, her support ive care includes:

1) Three broad spectrum intravenous antibiot ics,

2) Anti fungal mouth care and oral regime for mouth sores.3) Platelet transfus ions for a platelet count less than 50, 0000.4) Pain control, a mild narcot ic based pain medication is administered for oral pain.With her pain controlled Lily starts to take fluids and eat solids, she is able to takeher medicine. She is discharged three days later as her temperature returns tonormal and her white count increases. As mother wheels Lily out of the oncologyward in her strol ler she is smil ing, waving at the nurses and states, Bye-Bye, goinghome! Lily and her parents are build ing a trust ful relationship with the staff.

A fol low up bone marrow in the out pat ient cl in ic reveals Li ly s marrow to be f ree ofleukemia cells. She is responding to treatment.

These side effects can be mild or serious requiring hospitalization. Each child is an individualand will respond to the treatment uniquely. The health care worker needs to stay aware ofeach patients response. A baby may experience diarrhea and weight loss. A five year oldmay suffer from anemia and fevers. A teenager could be prone to depression. The majorityof patients receiving chemotherapy and other cancer treatments will experience more thanone side effect. These side effects can be treated effectively and the child supported duringtherapy. Prompt, proper support can increase the childs chances to recover from leukemiaor lymphoma.

Jaycee is receiving chemotherapy and radiation. He returns via ambulance to the emergencycomplaining of chest pain, rapid heart rate, and difficulty breathing. Jaycees parents aredistraught asking what is happening? As Jaycee is rolled into the trauma room he exclaims;Am I dying? Help me!How can the staff support Jaycee?The Emergency Room staff quickly performs a complete physical assessment. Afterdetermining Jaycees vital signs and oxygen saturations are normal the staff accompanieshim to the radiology department for a Chest X-ray and Chest Cat Scan. All of Jayceesimaging reports are normal and his lymphoma is shrinking in his chest. The doctors diagnosehim with anxiety and a panic attack. The hospital psychologist comes and talks to withJaycee. They set up follow up appointments to discuss the stressors affecting cancerpatients and effective coping strategies such as deep breathing, positive imagery, andmeditation. Jaycee states he feels better, the chest pain is gone.

Side Effects of Leukemia Lymphoma Cancer Treatment inChildren and Adolescents

Nausea and vomiting

Fatigue, tiredness, lethargy

Decreased appetite and weight loss

Skin rash

Mucositis and mouth sores


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Decreased white blood count

Fevers

Infection secondary to bone marrow immunosuppression

Infertility

Late term side effects

Cardiac toxicity

Pulmonary toxicity Anemia

Bleeding

Diarrhea

Depression

Dehydration and Electrolyte imbalance

Pain secondary to disease and treatment

Hair loss (alopecia)

Sleep disturbances

Anxiety

Extravasations of veins and subcutaneous skin burns from vesicant chemotherapy Neuropathy

Side effects of treatment can be treated effectively. Common treatments include anti nauseamedication, antibiotic therapy, antifungal therapy, nutritional support, pain medications, whitecell and red cell support, electrolyte and fluid replacement, supportive red blood celltransfusions, platelet transfusions.Health care workers need to train families and patients to recognize and report side effects.

Pain Management for Children diagnosed with Leukemia and

Lymphoma.Children and adolescents experience pain from abnormal cells and side effects fromtreatment. Children relate pain differently from adults. A young toddler may not be able tovoice pain. Crying and grimacing indicates pain in babies. A school age child may withdrawand exhibit a lack of appetite. A teen may exhibit acting out and anger when in pain. Facescharts and number charts are helpful in assessing pain in adolescents and Children.(Insert faces chart)

Pain Management Techniques

1) Distraction young children react well to distracting games and toys, videos, and TV whenin pain or during a painful procedure.2) Music soothing music and book tapes help children and teens cope with pain.3) Play Therapy board games, play activities, allow young patients an outlet from pain.4) Massage massage therapy can be comforting and help relieve cramps, aching joints,tired back, and pain secondary to treatment.5) Visualization teaching techniques which allow a child or adolescent to visualize positiveand calming scenes like a sunny beach can help relive pain.


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Pain Medication Analgesia

When pain is more severe and the child exhibits signs and symptoms of discomfortmedication can effectively control pain.

Commonly used analgesics for childrens and adolescents

diagnosed with pain related to Leukemia and Lymphoma.Local anesthetic topical via patches, creams and gels

Oral analgesics

No narcotic nonopioid analgesics

Acetaminophen

Ibuprofen

Ketorolac

Naprosyn

Refecoxib

Commonly used opiates narcotic pain medication

Codeine

Meperidine oxycodone

Methadone

Morphine

Hydromorphone

Fentanyl

Opiates may be administered orally, intravenously, via topical skin patches, implanted pumpsand reservoirs. The child needs to be frequently observed for pain response and respiratory

depression while on opioids.Pain control allows the young child to get on with the work of play and discovery and use herpositive resources to fight and recover from their disease. The adolescent with effective paincontrol will allow him to enjoy listening to music, watch TV and interact with peers. He willhave better prepared to cope with the rigors of chemotherapy or radiation if his pain iscontrolled.

Long Term Late effects of Leukemia and TreatmentChildren are surviving leukemia and lymphoma in great numbers. Many who do survive maysuffer late term side effects. These side effects can be effectively managed with appropriateintervention. Assessment in a pediatric long term follow up clinic can help detect late effects.

Late term side effects include

Learning Deficits

MRDD

Vision changes, blindness

Cognitive deficits

Hearing loss


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Secondary leukemias & cancers

Infertility

Depression

Anxiety Disorders

Social disorders

Organ damage

Cardiology complications Pulmonary dysfunction

Gastroenterology and liver disease

Chronic pain

Referral to the appropriate professional can help childhood survivors cope with long term sideeffects.

Psychosocial and Emotional Aspects of Childhood LeukemiaWhen a child is undergoing treatment for leukemia or lymphoma the child and family face

many stressors. The diagnosis and treatment can precipitates a crisis for the pediatricpatient, parents, siblings, extended family. The neighbors, school and community quicklyhears the news and want to offer help. The health care professional is a witness andparticipant in the care of the child and family. The child, family, and extended family needsupport and nurturing.

Each family and patient will experience individual stressors and coping mechanisms.Individual response should be respected. Children and families cope differently with adiagnosis of leukemia or lymphoma.Common feelings and stressors associated with a diagnosis of childhood leukemia orlymphoma on initial diagnosis.

Shock associated with diagnosis

Fear of cancer, diagnostic tests, hospital environment, treatment, chemotherapy,death

Helpless related to loss of control

Grief related to ill child, loss of health child

Anger why me syndrome, feels diagnosis is unfair, anger over being ill

Guilt did something cause cancer diagnosis; could parents have known sooner?

Confusion

Denial

Depression

Financial crisis Strain on marriage and family relationships

Role changes

Developmental delay

Children and families can be helped in negotiating the emotional aspects of diagnosis andtreatment by nurturing and support from relatives, friends, community, and health careworkers. Helpful interventions include:

Patient/ Parent support groups


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Sibling support groups

Teen support groups

I Can Cope classes

Counseling for child, parents or siblings

Spirituality and Church support

Financial support

Meditation Play Therapy

Education

Hematology Oncology Camps

Family Camps

Recreational outings

Extended family support

Community support

Disease related web sites and web support group

Make a Wish programs granting wishes

School bridge reentry programs, teacher tutoring assistance

Survival and Life after Cancer TreatmentPatients and families find life after cancer therapy hopeful yet frightening. The staff can helpthis transition by providing clear guidelines for follow up care and education. Individuals copedifferently in their reaction to survival as health improves and life returns to normal.

Lily has achieved remission. She has no signs or symptoms of leukemia. Treatment iscompleted. Lily s parents are happy, hopeful yet fearful. Will the leukemia come back?These parental feelings are normal. Lily will need frequent follow-up with theHematology team in the years ahead to watch for relapse. Lily has a 90% chance of

staying cancer free. Lily doesnt understand the details she is just happy, feels welland calls out to the staff as she leaves Heme-Clinc, No sticks today! Bye-Bye! Good-bye Lily!Jaycee is graduating from high school and going to college in the fall. Jaycee isdisease free. The lymphoma is in complete remission. He does not like to talk abouthis treatment. However he volunteers as a camp counselor at Oncology Camp andwants to help other children diagnosed with cancer. His parents are relieved andcautiously optimist ic. Jaycee will follow-up yearly with the Long Term Follow-upTeam. He has a good chance of maintaining his remission and be cured of lymphoma. See you next year he calls out to the staff.


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Conclusion

The outlook for children and adolescents diagnosed with childhood leukemia and lymphomahas never looked brighter. Modern medical advances in cancer research, treatment and longterm follow up has improved survival rates dramatically. With appropriate diagnosis and care

from the healthcare provider the majority of pediatric patients presenting with leukemia and/orlymphoma will achieve long term remissions.


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Reference

Eden OB, Harrison G, and Richards S, et al.: Long-term follow-up of the United KingdomMedical Research Council protocols for childhood acute lymphoblastic leukemia, 1980-1997. edical Research Council Childhood Leukemia working Party. leukemia 14 (12):

2307-20, 2000.

Gayon PS, Trigg ME, Heerema NA, et al.: Childrens Cancer Group trials in Childhoodacute lymphoblastic leukemia: 1983-1995. Leukemaia 14 (12): 2223-33, 2000.

Harms, DO, Janka-Schaub GE: co-operative study group for childhood acutelymphoblastic leukemia (COALL): long term follow-up trials 82, 85, 89, and 92. Leukemia14 (12): 2234-9, 2000.

Lones MA, Perkins SL, Sposto R, et al.: Non-Hodgkins lymphoma arising in bone inchildren and adolescents is associated with an excellent outcome: a Childrens CancerGroup report. J Clin Oncol 20 (9): 2293-301, 2002.

McNeil DE, Cote TR, Clegg L, et al.: SEER update of incidence and trends in Pediatricmalignancies: acute lymphoblastic leukemia. Med Pediatric Oncology 39 (6): 554-7;discussion 552-3, 2002.

Maloney KW, Schuster JJ, Murphy S, et al.: Long-term results of treatment studies forchildhood lymphoblastic leukemia: Pediatric Oncology Group studies from 1986-1994.Leukemia 14 (12): 2276-85, 2000.

Pinkerton CR: The continuing challenge of treatment for non- Hodgkins lymphomas inchildren. r J Haematology 107 (2): 220-34, 1999.

Pui CH, Campana D, Evans WE: Childhood acute lymphoblastic leukemia current status

and future perspectives. Lancet Oncology 2 (10): 597-607, 2001.

Pui CH, Sandlund JT, pei D, et al.: Improved outcome for children with acutelymphoblastic leukemia: results of Total Therapy Study X111B at St Jude Childrenresearch Hospital. Blood 104 (9): 2690-6, 2004.

Ries LA, Kosary CL, Hankey BF, et al., eds.: SEER Cancer Statistics Review, 1973-1996.Bethesda, Md: National Cancer Institute, 1999.

Sandlund JT, Downing JR, Crist WM: Non-Hodgkins lymphoma in childhood. N Engl JMed 334 (19): 1238-48, 1996.

Smith MA, Ries LA, Gurney JG, et al., eds.: Leukemia. Cancer incidence and survivalamong children and adolescents: U.S. SEER Program 1975-1995. Bethesda, Md:National Cancer Institute, 1999. NIH Pub. No. 99-4649., pp 17-34.

Taylor AM, Metcalfe JA, Thick J, et al.: Leukemia and lymphoma in ataxia telangiectasia.Blood 87 (2): 423-38, 1996

Xie Y, Davies SM, Xiang Y, et al.: Trends in leukemia incidence and survival in TheUnited States (1973-1998). Cancer 97 (9): 2229-35, 2003


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Post Test

1. Childhood leukemia is a disease originating from the:

A. Liver.

B. Spleen.C. Bone marrow.D. Lymphatic system.

2. One of the eight warning sign of childhood cancer is:

A. Weight gain.B. Virus with high fever.C. Nausea and vomiting.D. Persistent pain in bones and joints.

3. One sign of childhood leukemia is:

A. Night sweats.B. A painless lump.C. Petechia and bruising.D. Clubbing of fingers and toes.

4. An adolescent presenting with lymphoma may describe:

A. Mouth sores.B. A bone mass.C. Rapid weight loss.D. Increased appetite.

5. Leukemia and Lymphoma staging includes the following factors:

A. Serial blood counts.B. Cell characteristics type and location.C. Blood counts and bone marrow aspiration.D. Radiology imaging, MRI, CAT scan, Gallium Scan.

6. The current treatment for ALL includes:

A. Surgery.B. Total body radiation.

C. A low carbohydrate diet.D. Combination chemotherapy.

7. Side effects associated with treatment for lymphoma include:

A. Oliguria.B. Increased appetite.C. Excessive hair growth.D. Bone marrow suppression.


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8. The most common type of child hood leukemia is:

A. Eosinophil Leukemia.B. Acute Lymphocytic Leukemia.C. Acute Mylogeneous Leukemia.D. Chronic Lymphocytic leukemia.

9. An appropriate pain medication for an adolescent with lymphoma experiencing pain frommild mucousitis:

A. Aspirin.B. Fentanyl patch.C. Acetaminophen.D. Meperidine (Demerol).

10. Helpful interventions for families and children diagnosed with childhood cancer includeallowing the ill child to make all decisions and choices regarding care if he has nausea,vomiting and pain.

A. TrueB. False

11. The five year survival rate for AML is:

A. 10%B. 40%C. 70%D. 90%

12. Chronic Mylogeneous Leukemia is:

A. Common in infants.B. A slow growing leukemia.C. Rarely diagnosed in children.D. Common in preschool children.

13. A child diagnosed with leukemia:

A. May present with no apparent symptoms.B. Always presents with profound symptoms.C. Usually has a ruddy or red blotchy complexion.D. May have an increased number of red blood cells.

14. Family centered care:

A. Is not considered a factor for well being.B. Is always an option and up to the child to decide.C. Is discouraged; care should be left to the professionals.D. Is always the goal and will help the child and family to cope.


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15. Children with newly diagnosed leukemia:

A. Do not often require blood transfusions to treat anemia.B. Will likely not require supportive therapy before treatment.C. Are not usually suffering from dehydration, sepsis or infection.D. May require supportive therapy before during, and after therapy.

16. Bone marrow transplants used for childhood leukemia may:

A. Come from several sources.B. Come from a matching relative only.C. Are never used for childhood leukemia.D. Only come from the patients own marrow.

17. Lymphoma develops:

A. In the blood.B. Outside of organs.C. In the bone marrow.

D. In the lymphatic system.

18. Risk factors for developing lymphoma include:

A. Ethnicity.B. History of diabetes.C. History of receiving blood transfusions.D. Patients that have received on organ transplant and are receiving immune

suppressant medication.

19. The most common early sign of lymphoma is:

A. Bruising.B. Sudden rapid weight gain.C. Unexplained hyperactivity.D. Painless swelling or lump in the neck, upper chest, groin, armpits and abdomen.

20. The most common lymphoma diagnosed in children and adolescents is:

A. Burkitts Lymphoma.B. Hodgkins Lymphoma.C. Neoplastic Lymphoma.D. Non Hodgkins Lymphoma.

21. Treatment for Non Hodgkins Lymphoma commonly includes:

A. Cisplatin.B. Radiation.C. Aromitase Inhibitors.D. Experimental herbal medications.


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22. Side effects of leukemia and lymphoma treatment:

A. Are difficult to treat.B. Can be treated effectively.C. Are always treated with antibiotics.D. Are primarily related to pain medications.

23. A school aged child experiencing pain will often:

A. Become angry and act out.B. Talk to their parents about it.C. Cling to caregivers and over-eat.D. Withdraw and exhibit a lack of appetite.

24. Long term late effects of leukemia and treatment included:

A. Obesity.B. Diabetes.C. There are no long term effects.

D. Organ damage and chronic pain.

End of Test


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Childhood Leukemia and Lymphoma

I have no vested interests in this course or topic.

Signature:

childhood leukemia tab course20061113

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