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COMPLICATIONS OF

CHILDHOOD LEUKEMIA

ALL is the most common malignancy in


children
+ 25 % of all childhood cancer
Complication due to :
Leukemia
Therapy

HYPERLEUKOCYTOSIS
WBC > 100.000/mm3 9-13% (ALL)
5-22% (ANLL)
Blood viscosity
blast cells aggregate & thrombi
Plasma trapped between blast cells poor perfusion &
anaerobic metab.
Death by CNS hemorrhage or thrombosis, pulmonary
leukostasis
metabolic derangement (tumor lysis)

Signs and Symptoms

Have no particular signs & symptoms


Doesnt differ from the usual presenting of leukemia
Blurred vision, confusion, headache, stupor
papilledema, tachypnoe, dyspnoe, oliguria,
bleeding

Tumor Lysis Syndrome

Degradation of blast cell

RENAL FAILURE
Potassium
Hyperuricemia
Nucleic Acid
Hyperkalemia
Phosphate
Hyperphosphatemia

Solubilities of phosphate & uric acid LOW in acid solution

Precipitate
Hyperleukocytosis

in renal tubules

RENAL FAILURE
Hyperkalemia

Poor tissue oxygenisation

Lactic acidosis

Clinical features
Symptoms of malignancy abdominal pain/fullness
backpain
Symptoms of renal insufficiency changes in the
amount of urine
Symptoms of Hyperkalemia & hypocalcemia
vomiting, cramps, spams, tetany, seizure

TREATMENT
1. Hydration

3000 ml/m2/24 hours (5% Dx 0.25% NS)


2. Alkalinization
3. Allopurinol
4. Chemotherapy
5. Monitoring

NaHCO3 50-100 mEq/L (titrate to maintain


urine pH = 7.0 - 7.5)
10 mg/kg/day or 300 mg/m2/day
Delayed until stabilization of metabolic
status
Electrolytes, BUN, creatinin, uric acid, Ca,
phosphate, renal out-put

OUTCOME OF Pediatric ALL with


HYPERLEUKOCYTOSIS (1994-1999)
DR Cipto Mangunkusumo Hospital, Jakarta

Year

No Pts.

Hyperleukocytosis

Remission

Relapse

1994

27

1995

38

1996

25

1997

32

1998

51

12

1999

58

15

11

Total

231

47(20.5% )

35(74.5% )

16(45% )

OUTCOME of Pediatric ALL with


HYPERLEUKOCYTOSIS (1997-2001)
Kariadi General Hospital, Semarang
Years

No.Patients

Hyperleukocytosis Outcome

1997

Death

1998

1999

Death

2000

Death

2001

Death

CNS LEUKEMIA

Hematogenous spread
Direct extension

At diagnosis
Relapse

Diagnosis :
> 5 WBC/ul with blast cell in CSF

Signs and Symptoms

Headache, nausea, vomiting, lethargy


irritability, papilledema
central nerve involvement

Treatment
INDUCTION
CONSOLIDATION
MAINTENANCE
Methotrexate IT
Craniospinal irradiation
Methoterxate IT
MTX IT alone
induces CNS remission > 90%
but relapse occurs within 3-4 months
CNS relapse < 10%
Other regimen :

High dose Methotrexate

High dose Cytarabine


CNS relapse remains a significant cause of treatment failure

Hematopoietic Dysfunction
Anemia
Leukopenia
Thrombocytopenia

ANEMIA :

Therapy

- Replacement by leukemic cells


- Chronic disease
- Uncontrolled bleeding
- Myelosupressive effect of chemo
: Transfusion
EPO

THROMBOCYTOPENIA : - Extensive marrow infiltration


- Attributable to chemotherapy
and radiation
-DIC
Bleeding caused by decrease of coagulation protein
production

Underlying disease/leukemia
Chemotherapy
Immunocomprimised patient

At significant risk for serious INFECTION


RISK FACTORS : - Neutropenia
- Impaired host defense

Febrile Children with Acute Leukemia


1. Nongranulocytopenia : - History & physical examination
Antibiotic therapy should be aimed
toward positive findings
2. Granulocytopenia : - History & physical examination
- Blood culture
- Urinalysis & culture
- Chest X Ray
Empirical antibiotic is indicated

Toxic Effects of Chemotherapy


ANTHRACYCLIN
Cardiomyopathy & heart failure
ASPARGINASE
CYTARABINE

Hypertensitivity reaction
Coagulopathies
Acute cerebelar syndrome

METHOTREXATE
Nephrotoxic & hepatotoxic (high dose)
CYCLOPHOSPHAMID
E

Cystitis hemorrhagica

VINCRISTIN

Peripheral sensory & motor neuropathy

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