04.02 Leukemia

Hey guys, in this lesson we are going to be talking about the diagnosis Leukemia. You’ve probably come across this diagnosis in your adult course, but the focus of this lesson is going to be it’s presentation in childhood.

Leukemia is a broad term that refers to cancer of the bone marrow- and there are 4 different types. The leukemia lesson in the Hematology/Oncology course covers all 4 of these, but we are going to focus on ALL or Acute Lymphocytic Leukemia and AML, Acute Myelogenous Leukemia.

We are going to start by looking at the pathology of leukemia - I’m sure this will be a review for you but if you understand what’s going on with the cells it’s so much easier to remember both your assessment findings and diagnostic information.

So, like I said, Leukemia is a cancer of the bone marrow. The bone marrow is producing excessive amounts of white blood cells that are abnormal and underdeveloped. Let’s pause here for second and look at the picture to the right. When someone has leukemia- the myeloid and lymphoid cells you see here can’t differentiate and become what they are supposed to be so they stay immature and they start to build up. These immature cells are called blasts. As they build up you end up with bone marrow and blood that has tons of ineffective, immature cells not the healthy cells we need.

If the cells that are broken are Lymphoid cells you get Acute Lymphocytic Leukemia and ALL accounts for 80% of childhood cancers. If the cells that are broken are myeloid cells you get Acute Myelogenous Leukemia. AML is less common but is associated with poorer outcomes than ALL.

So the peak onset for leukemia is usually ages 2-5 yrs. What does all of that look like for the patient? Well, unfortunately, the clinical picture associated with leukemia is pretty non-specific. The story of diagnosis tends to be that a parent brings a child in to be seen with the history of the kid being tired, having a decreased appetite and having had a couple of back to back infections with fevers that just don’t seem to want to go away. So, it’s pretty vague- but those back to back infections are always a red flag! Then, when you add in symptoms like bruising and bone pain you’ve definitely got a clinical picture that’s concerning.

So when we see a child present with these symptoms and suspect leukemia, what tests should we expect done for diagnosis?

The first test that will be done is a CBC w/Differential. Remember, a Complete Blood Count w/Differential, gives us a lot more information about the WBCs. There are a lot of different types of WBCs and the differential tells how many of each type of cell there are.

For the patient with leukemia the initial CBC will show either an increase or decrease in WBC, a decrease in RBC and decreased platelets - which we are expecting based on the clinical presentation we just talked about.
If the CBC is abnormal the next step is to get a bone marrow biopsy. Looking at the biopsy will tell us what percent of the bone marrow is full of those immature blast cells and it can tell us if the leukemia is ALL or AML.

The next test to expect is a lumbar puncture - this will tell us if the leukemia has spread into the central nervous system.

All of these tests together provide the diagnosis and guide the treatment plan.

Treatment for leukemia occurs in 3 phases: Induction, Consolidation and Maintenance. Induction is an intense 4-6 weeks and the goal is to get blast cells to <5%. This is called remission. Consolidation is another 6 months or so and the goal is to get rid of the rest of those cancer cells and prevent it from coming back. The last phase is Maintenance and it can last 2-3 years. The goal here is to keep the patient in remission and prevent a relapse. This phase can last 2-3 years.

During these phases, treatment is primarily a combination of chemotherapy and steroids. Radiation is given to those at high risk for it spreading to the brain, but is avoided if possible and Bone Marrow Transplant is used in patients at high risk for relapse or those who have already relapsed.

The lesson on Peds Oncology Basics will fill you in on how these different treatments work.

Nursing care for a child with leukemia is all about managing side effects and complications of treatment. Refer back to the Peds Oncology Basics lesson for more comprehensive information about general nursing care- most of what you are doing is focused on dealing with the fact that their bone marrow is suppressed. So, putting the child on neutropenic precautions, giving lots of antibiotics, and administering blood and platelet transfusions. Other interventions are working to support the child’s nutritional status so preventing and treating nausea with meds like ondansetron, providing oral care and managing enteral feeding if their weight drops too much.

Your priority nursing concepts for a pediatric patient with leukemia are cellular regulation, infection control and comfort.

Okay guys- we’ve talked about a lot, let’s recap the most important things for you to take away from this lesson. Leukemia is a cancer of the bone marrow. The bone marrow produces an excessive amount of immature WBCs called blast cells. These take up space in the bone marrow and blood stream and there isn’t enough room for other important cells like RBCs and platelets. Symptoms at diagnosis reflect these cellular changes so you have patients who are getting frequent infections, are tired, have a lot of bruises and bone pain. Treatment for leukemia is primarily chemotherapy and steroids so we need to be on the lookout for side effects like bone marrow suppression, ulcers along the gi tract and hair loss. Nursing care for these patients is all about managing those side effects and preventing complications. The most common complications are infection, anemia, bleeding and weight loss from poor nutrition.

That’s it for our lesson on Leukemia in Pediatric Patients. Make sure you check out all the resources attached to this lesson. Now, go out and be your best self today. Happy Nursing!