Chapter 33: Acute Lymphocytic Leukemia (ALL) (Children)

Question 1

Acute Lymphocytic Leukemia (ALL)

Answer 1

most common type of cancer in children

• a type of blood and bone marrow cancer which mainly affects the white blood cells
• peak between 2 to 5 years of age
• during infancy, boys are more likely to develop
• the leukemic cells are usually acquired versus inherited
• increased risk among children with certain genetic disorders such as Down Syndrome

Question 2

Signs and Symptoms

Answer 2

• fever (in 50% of cases)
• fatigue and lethargy
• have anemia and therefore are pale
• anorexia
• bone or joint pain may be present
• parents may notice a limp or the child may refuse to walk

Question 3

Less Common Symptoms

Answer 3

• headache, vomiting, difficulty in breathing, and low urine output
• bleeding under the skin, in the mouth, or sometimes in the eyes may be present
• petechiae can also be noted
• abdominal distention caused by an enlarged spleen
• enlarged lymph nodes
• hepatomegaly

Question 4

Diagnosis

Answer 4

-CBC and other blood tests to evaluate the WBC count, platelets, and liver and kidney function
-bone marrow aspirate is required to make the diagnosis of ALL
>a finding of more than 25% abnormal lymphoblast cells in the bone marrow is diagnostic
-other samples in the bone marrow are sent for further testing and show chromosomal changes and better identify the specifics of the leukemia
-the child’s WBC count and age at diagnosis are important prognosis signs in ALL

Question 5

Best Prognosis is Associated with?

Answer 5

-a WBC less than 5000/mm3 and an age 2 to 9 years

Question 6

Worst Prognosis is Associated with?

Answer 6

• an initial WBC count of 50,000/mm3 and an age older than 10
• infants younger than 1 year of age at time of diagnosis

Question 7

Lumbar Puncture (LP)

Answer 7

“spinal tap”
is the introduction of a needle into the subarachnoid space of the lumbar spinal cord; the needle is inserted with a stylet into the interspace between the third and fourth lumbar vertebrae under strict sterile technique
-test is usually done to remove a sample of cerebrospinal fluid (CSF) to test for infection
>for cancer patients, this procedure is used to introduce chemotherapeutic agents into the CSF space; this is known as giving chemotherapy intrathecally (through the theca of the spinal cord into the subarachnoid space)
-b/c some medications cannot cross the blood-brain barrier easily, physicians have obtained better results by introducing chemotherapeutic agents into the CSF space to kill cancer cells so they cannot “hide” behind the blood-brain barrier

Question 8

Nursing Care

Answer 8

without effective therapy and nursing care, ALL is fatal
-leukemia is treated with chemotherapy and includes three phases: remission-induction, consolidation, and maintenance
-in the remission-induction phase, the tumor burden is reduced to an undetectable level; 95% of children with ALL achieve remission during induction, which usually lasts 4 weeks
>once remission is achieved, most children relapse within a few months if treatment is stopped

Question 9

Remission

Answer 9

the partial or complete disappearance of signs and symptoms of the disease

• does not mean “cancer free”
• there could still be cancer cells that are undetectable in the body; treatment will continue

Question 10

Induction

Answer 10

chemotherapy given to achieve remission

Question 11

Consolidation

Answer 11

chemotherapy given after the induction to control microscopic disease

Question 12

Maintenance

Answer 12

chemotherapy given on a long-term basis to maintain remission

Question 13

Complementary Care: Visualization and Distraction

Answer 13

the child may experience anticipatory anxiety before a procedure; visualization and distraction can be helpful

• Visualization: be creative; have child imagine a trip to his/her favorite place; have the child close their eyes while the nurse plays tour guide; ask questions about their favorite place and encourage the child to be apart of the the story/trip
• Distraction: depending on child’s developmental level; blowing bubbles, performing a magical light show, or simply reading a story

Question 14

Medical Care

Answer 14

-Chemotherapy agents used for remission-induction: vincristine (Oncovorin), L-asparaginase (Elspar), and prednisone (Deltasone) or dexamethasone (Decadron)
>children who have worse prognosis are also given a anthracycline drug (chemotherapy drug that is known to affect and damage the heat, such as doxorubicin (Adriamycin))
-children with ALL also receive CNS prophylaxis; the prophylactic chemotherapy agent is injected intrathecally into the CSF during an LP
-once child is stable, the chemotherapy can be given in an outpatient setting

Question 15

The goal of the second phase (consolidation)

Answer 15

is to destroy any residual leukemic cells

• this phase starts immediately after remission and is achieved and lasts about 6 months
• chemotherapy in this phase is frequently administered in high doses
• children not usually hospitalized for this stage unless a complication arises
• this phase may also require radiation

Question 16

What is the goal of the third phase? (maintenance)

Answer 16

controls the leukemia

-can last for 2 to 3 years after diagnosis

Question 17

Bone Marrow Transplant

Answer 17

is the treatment option for children who have a second remission after relapse
-involves giving the child high doses of chemotherapy and/or radiation to eradicate disease or cancer and then rescuing the patient with a source of stem cells that allows for recovery of healthy bone marrow
>two types of transplants: autologous and allogenic
-autologous= the patient’s own peripheral blood or bone marrow is given back
-allogenic= can be from matched sibling, a relative, or an unrelated donor accessed through the National Marrow Donor Program

Question 18

Biological Therapy

Answer 18

consists of high doses of hormones or other proteins that are normally made by the human body

• pharmaceutical companies can make these substances
• made to prevent or treat damage to other systems of the body that may be caused by other leukemia treatments

Question 19

Education/Discharge

Answer 19

• made aware of the importance of these children avoiding falls and “being careful” during play
• monitor for signs of red dots called petechiae that are described as small (1 to 2 mm), red or purple spots on the body caused by broken capillaries that do not blanch or fade when pressed by the finger
• with a low WBC count, tell parents to keep the child away from people who are ill and avoid crowded places, such as shopping malls

Question 20

Chemotherapy Agents Used for Remission-Induction

Answer 20

• vincristine (Oncovorin)
• L-asparaginase (Elspar)
• prednisone (Deltasone)
• dexamethasone (Decadron)

Question 21

Doxorubicin (Adriamycin)

Answer 21

• anthracycline drug (chemotherapy drug that is known to affect and damage the heart)
• for children who have a worse prognosis