Childhood Leukemia
and Lymphoma
Presented by:
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This course has been awarded (3) contact hours.
This course expires on November 27, 2006.
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First Published:
Acknowledgement _________________________________________________________4
Purpose and Objectives ____________________________________________________5
Introduction ______________________________________________________________6
Case Study-Lily Rose ______________________________________________________7
SECTION ONE: Leukemia Disease, Diagnosis, and Decisions _____________________7
The Eight Warning Signs of Childhood Cancer (American Cancer Association 2005)__8
What is Leukemia? _______________________________________________________8
Childhood Cancer Statistics _______________________________________________9
What are the types of Childhood leukemia? __________________________________9
Risk Factors for Childhood Leukemia ______________________________________10
Signs and Symptoms of Childhood Leukemia _______________________________10
Diagnosing Leukemia in Children__________________________________________11
An initial diagnosis assessment for childhood leukemia may include: ___________12
Prognosis and Recovery _________________________________________________12
The following factors affect a child’s prognosis for recovery. __________________13
Treatment for Childhood Leukemia. ________________________________________13
Treatment modalities ____________________________________________________13
Treatment _______________________________________________________________15
Supportive Care ________________________________________________________15
Surgery _______________________________________________________________15
Chemotherapy__________________________________________________________15
Radiation ______________________________________________________________16
Bone Marrow Transplant, Stem Cell Transplant ______________________________16
Bone Marrow Transplants may come from several sources:____________________17
SECTION TWO: Childhood Lymphoma _____________________________________18
Case Study ____________________________________________________________18
What is Lymphoma?_____________________________________________________18
Types of Lymphoma _____________________________________________________19
Hodgkin Lymphoma _____________________________________________________19
Non-Hodgkin Lymphoma (NHL) ___________________________________________19
Risk Factors for Lymphoma ______________________________________________19
What are the symptoms of Lymphoma? ____________________________________20
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Signs and Symptoms ____________________________________________________20
Diagnosis______________________________________________________________20
The Staging of the Disease _______________________________________________21
Treatment for Lymphoma ________________________________________________21
Section III: Managing Side Effects of Leukemia and Lymphoma Treatment _______21
Side Effects of Leukemia Lymphoma Cancer Treatment in Children and Adolescents
______________________________________________________________________22
Pain Management for Children diagnosed with Leukemia and Lymphoma. _______23
Commonly used analgesics for children’s and adolescents diagnosed with pain
related to Leukemia and Lymphoma. _______________________________________24
Long Term Late effects of Leukemia and Treatment __________________________24
Psychosocial and Emotional Aspects of Childhood Leukemia __________________25
Survival and Life after Cancer Treatment____________________________________26
Conclusion ______________________________________________________________27
Reference _______________________________________________________________28
Post 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 leukemia
and lymphoma. The course includes information on signs and symptoms of leukemia, how
leukemia is diagnosed, childhood cancer statistics, current treatment patterns, long term side
effects, and the emotional and psychosocial issues surrounding a childhood cancer
diagnosis.
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 in
relation 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 by
RN.com. The use of trade names does not indicate any preference of one trade
named 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 on
medications contained in this course is not meant to be prescriptive or allencompassing.
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 effects
which 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 positive
outcome for ill children and adolescents with cancer. Acute Lymphocytic Leukemia (ALL) is
the most common hematologic malignancy found in children. Acute lymphocytic leukemia is
treatable and can be cured. Survival rates have increased dramatically in recent decades
due to advances in research and chemotherapy treatment. (NCI 2005)
Lymphoma is a type of cancer which develops in the lymphatic system and is more
commonly diagnosed in adolescents and young adults. The two main types of lymphomas
are Hodgkin Lymphoma and Non-Hodgkin’s Lymphoma. Pediatric patients and adolescents
diagnosed with lymphoma respond well to treatment, particularly chemotherapy and/or
radiation.
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Case Study-Lily Rose
A 2 year old white female, Lily, is rushed by her parents into the local Children’s Hospital
Emergency Room. The toddler is acutely ill, chalky pale, listless, bruised and having difficulty
breathing. The ER team responds immediately performing a comprehensive physical
assessment. The attending physician suspects leukemia. Lily’s parents are tearful and
anxious, the ER staff solemn and watchful. A preliminary diagnosis of childhood cancer is
difficult for the family and health care workers to consider. Will the little girl survive? This
question is on everyone’s mind. The Emergency Room staffs works quickly with the pediatric
hematologist oncologist to treat and diagnose the ill child. The patient’s preliminary blood
work is consistent with Acute Lymphoblastic Leukemia, ALL. Lily will be admitted to the
pediatric hematology oncology unit for observation and further assessment.
Sections I, II, and III, will present Lily’s case study while describing Childhood Leukemia and
treatment.
SECTION ONE: Leukemia Disease, Diagnosis, and Decisions
Lily’s 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 children
under age 20 years. (NCI 2005). ALL is treatable and can be cured. The survival rate has
increased dramatically in recent decades (NCI 2005). A diagnosis of childhood cancer can
precipitate a crisis for the child, family, health care team, and the child’s community. The
health care team must act rapidly to ensure a positive outcome. There is great cause for
hope for this young girl. Today advances in treatment have improved the outlook for survival
for children diagnosed with leukemia. A majority of children, 90% of pediatric patients
diagnosed with ALL will be in remission 5 years after diagnosis (NCI 2005). Many of these
young children and adolescents will be cured. This course will discuss childhood leukemia
and 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 Cancer
Association 2005)
C - Continued unexplained weight loss
H - Headaches with vomiting in the morning
I - Increased swelling or persistent pain in bones or joints
L - Lump or mass in abdomen, neck or elsewhere
D - Development of a whitish appearance in the pupil of the eye
R - Recurrent fevers not due to infection
E - Excessive bruising or bleeding
N - Noticeable paleness or prolonged tiredness
Why do children get leukemia? The majority of cases of childhood leukemia and lymphoma
can not be prevented. The cause of pediatric leukemia and etiology is unknown. However
there 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 child’s other organs is also decreased with early
detection.
Lily’s parents brought her to the Emergency room quickly within a week of symptoms
and deteriorating health. Early detection of childhood leukemia may help her chances
to survive.
What is Leukemia?
Leukemia is a cancer and disease of the bone marrow. Bone marrow is found in the bones
and makes blood cells. In leukemia the bone marrow makes large amounts of abnormal
white cells. The abnormal white cells may crowd out red blood cells and platelets resulting in
anemia and thrombocytopenia. Rarely leukemia can also originate in other blood cells.
•
Bone Marrow – is the spongy material found in the bones, bone marrow produces
blood cells?
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White blood cells (WBC’s) – B and T cells - leukocytes, monocytes, and
•
granulocytes, neutrophils, the normal white cells fight infection, destroy bacteria and
germs, protect against microorganisms and viruses throughout the body.
Red Blood cells (RBC’s) – carry oxygen to the organs in the body.
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Platelets – small blood cells which assist in blood clotting and prevent bleeding and
bruising. 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 child’s bone marrow crowding out the good cells needed for life. As the leukemia cells
increase and multiply the patients normal cells decrease and are pushed out. The marrow
found inside the bones is then replaced by the dangerous abnormal cells. The type of
leukemia is identified by the type of cell affected. As the white cells multiply the child will
become ill and exhibit signs of leukemia.
Childhood Cancer Statistics
In 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 differently
to 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 leukemia’s.
• AML 20% of childhood leukemia’s.
• Rare child hood leukemia’s 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 (Lymphoblastic) Leukemia (ALL) – ALL is the most common
childhood cancer and accounts for about 30 % of all cancer cases. Approximately 70% to
75% of all childhood leukemia’s 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 leukemia’s including:
Chronic Lymphocytic Leukemia (CLL) and Chronic Mylogeneous Leukemia (CML) are
rarely found in children. Chronic Leukemia is slow growing and a patient may live for several
years after diagnosis.
The pediatric patient’s diagnosis of childhood leukemia will be classified by cell type. The cell
type will help determine the prognosis for the child.
Prognosis is a determination on how the child will respond to treatment and how long the
patient is expected to live. However each child is an individual and will respond differently to
leukemia treatment. For this reason many hematologist are reluctant to give a parent a firm
prognosis or expected timeline.
Risk Factors for Childhood Leukemia
In the majority of pediatric cancers and leukemia cases the cause is unknown. There is no
way 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 Lily’s risk factor is her age. The incidence of childhood leukemia
increases at age 2 through age 8 years. Her age also increases her chances for
survival. However her cell type and chromosome analysis will also be important to
gauge how she will respond.
Signs and Symptoms of Childhood Leukemia
Children diagnosed with childhood leukemia may have multiple abnormal findings on physical
assessment 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 and
childhood illness can mimic childhood leukemia, Lily’s overall appearance of profound
illness alerted her parents to a serious disorder.
Which blood cells in Lily’s 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 white
blood cell count may be discovered on a routine blood screening. In these cases the disease
is 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.
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•
•
•
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Fatigue, anemia –The child or adolescent appears “tired”, lacking in energy. This
may 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, lips
and nail beds may look pale or blue.
Infection – the child has an unusual infection which may be unresponsive to
treatment. An example would be an unexplained rectal abscess. Neutropenia a lack
of 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. Multiple
large dark blue black bruises larger than the size of quarters are not uncommon in
young children presenting with leukemia. As the platelet count falls and the
youngster becomes thrombocytopenic bruising emerges. At initial exam the health
care professional may suspect child abuse.
Bone pain, joint pain –the child may complain of pain in the long bones, parents
often 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 child’s color may
be jaundiced.
o Enlarged thymus
o Lymph nodes - may be swollen–careful physical assessment can reveal
abnormalities in the lymph nodes
Headache, seizures - persistent headaches in young children are a danger sign and
could 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 Children
Lily was admitted to the Hematology Oncology Unit of a large teaching Children’s
Hospital affiliated with a university. There a multidisciplinary team will begin the
process of finding out what kind of leukemia Lily has and which treatment offers the
best hope for survival. Lily’s physicians and nurses perform a complete physical
assessment including medical and family history. Lily’s parents are overwhelmed with
many questions about their daughter’s condition.
Lily was sobbing and struggling with the nurse as peripheral intravenous lines were
inserted and fluids are started for maintenance hydration. She was monitored closely
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for any deterioration in vital signs. Lily’s laboratory results revealed an abnormally
high WBC (white blood cell count) of 60,000, a low hemoglobin of 5.0, and decreased
platelet count of 5,000, (thrombocytopenia). A bone marrow and biopsy was
performed 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 to
increase the platelet count and prevent bleeding.
How can the staff help Lily cope with the many invasive procedures she will
experience?
Play therapy? Child life specialist?
Distraction? Toys, books, videos, music?
Allowing her parents to stay with her?
Lily’s nurse does not approach her to give nursing care. The nurse enters the room
with a book; she reads Lily the book about frogs. Lily calms down and enjoys being
read to. Later she allows the nurse to take her vital signs without fighting and she
asks the nurse to read the book again! Lily’s nurse takes the 5 minutes to read to Lily
and build trust.
An initial diagnosis assessment for childhood leukemia may
include:
•
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•
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A complete in depth physical assessment.
A health history from the mother and pediatrician. Has the child lost weight? Is there a
lack of energy? Has there been bruising and prolonged bleeding? Was the child
taking medication? Is there a family history of cancer or bleeding? Does the child
have 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 Recovery
The majority of parents want to know if their child can be cured. This is quickly followed by
“What is the prognosis?” Some parents may find it too painful to utter the word cancer or
leukemia while others speak freely and head to the internet to search for any information
available. The hematologist and comprehensive team will conference with the family and
discuss prognosis and treatment.
Lily’s diagnosis and cell type, ALL is low risk and her prognosis is favorable. However
the treatment will be aggressive and the coming months may be difficult. Treatment
will begin as soon as possible, after all her staging tests have been completed. Lily is
settled in her crib for the night and her parents are encouraged to spend the night in
her room. The nurse rolls in 2 parents cots. Children and adolescents are comforted
by close physical proximity to their parents or significant caregivers. Every effort
should be made to keep the family close to the child and include the family into the
child’s plan of care, both inpatient and outpatient. Family centered care is the goal
and will help the child and family cope positively with the diagnosis.
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The following factors affect a child’s 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 risk
of 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 patient’s recovery is how well they
respond to treatment. Many children with a poor prognosis will surprise the medical
team by responding well. Infrequently a child with a good prognosis may not respond
to treatment. While prognostic statistics are helpful a patient’s response and survival
is individual.
Lily’s treatment for ALL will be determined by the Hematology Team in the morning
with her parents consent. Later in this learning module the case study will continue
describing Lily’s treatment, side effects to treatment and her response to cancer
therapy.
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 treating
childhood cancers have taken place in the past 30 years. Many children diagnosed with
leukemia 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 modalities
The child’s initial treatment for leukemia will depend on several different factors including:
• What is the leukemia cell type and stage?
• What is the child’s age?
• What is the physical condition of the child? Each child should be evaluated as an
individual when choosing treatment. Physical conditions which could affect treatment
modalities include, heart defect or heart failure, liver or organ failure, poor kidney
function, decreased pulmonary function, among others. These pediatric patients may
need treatment modified to decrease further risk of side effects.
• Is the child eligible for a clinical trial? Clinical trials are studies which evaluate which
treatment’s effectively treat childhood leukemia’s and cancers. COG or the Children’s
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•
•
Cancer Study Group includes approximately 100 Children’s Hospitals and University
Hospitals 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 might
include: the Amish population without access to health insurance and their individual
belief in herbal remedies, families of the Jehovah Witness faith who believe in
bloodless treatment, families from rural or Appalachian regions may experience
difficulty arranging transportation for follow up treatment. The health care team should
make every effort include the family’s beliefs and needs while providing effective
treatment for the child.
The hospital and hematologist caring for the child. The hematologist is ultimately
responsible for writing the orders which determine the patient’s treatment.
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Treatment
Supportive Care
Supportive care is an important part of treatment for childhood leukemia. The ill child newly
diagnosed with leukemia may be dehydrated, suffering from sepsis, infection, or experiencing
organ shut down secondary to the disease. Supportive care may be needed before during
and after therapy.
• Antibiotics to prevent or treat infection caused by immune suppression.
• Hydration and electrolyte replacement to treat the dehydrated child. Vomiting and
nausea, poor appetite, treatment, and disease predispose the child to a poor oral
intake and dangerous electrolyte imbalances.
• Red blood cell transfusions to treat anemia.
• Platelet transfusions to treat thrombocytopenia (decreased platelet count) and control
bleeding.
• Granulocyte stimulating agents to increase low white blood cell and decreased
granulocyte counts.
• Red blood cell stimulating agents to increase the red blood cell count and prevent
anemia.
• Allopurinol – a medication to help decrease uric acid in the body and prevent tumor
lysis syndrome. Tumor lysis occurs when killed tumor cells flood into the blood stream
and organs causing life threatening conditions.
• Nutritional Support for the child unable to maintain sufficient calorie intake.
Surgery
Surgery is rarely used to treat childhood leukemia as there is seldom a solid tumor to remove.
The child may need surgery to:
• Insert a central venous line to administer medication and hydration.
• Obtain a bone marrow biopsy under anesthesia.
• Treat side effects caused by treatment. An example would be a large abscess
needing incision and draining.
Chemotherapy
Chemotherapy is the back bone of treatment for children diagnosed with leukemia. The
strides in research, clinical trials, and new medication regimes are responsible for the high
cure rates for children. Chemotherapy is medication which kills or controls leukemia or
cancer cells. There oare currently dozens of medications used to treat childhood leukemia.
These medications may be administered by the following routes:
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Intravenously via central lines or peripherally venous access (veins).
Orally, by mouth.
Intramuscular injection (into the muscle).
Subcutaneous injections (into the subcutaneous tissue).
Intra hepatic (into the liver).
Intra cranial (into the brain via reservoir).
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•
•
Intrathecially (into the spinal fluid).
Intra organ (chemotherapy administered directly into organs).
Common medications used to treat childhood leukemia include combinations of the following
drugs. Different classifications of medications are used to kill leukemia cells at different
stages of their cell cycle and to deprive the abnormal cells of the material it needs to multiply
and spread through the child’s body. Chemotherapy is timed at different days and weeks to
maximize leukemia cell kill. The majority of protocols for treating childhood leukemia include;
Induction treatment –inducing control of disease
Consolidation/ Intensification treatment – intensifying treatment to eradicate the leukemia and
achieve remission
Maintenance Therapy – to maintain control over the leukemia, maintain remission, maintain a
cure
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Vincristine –a plant alkaloid
Daunomycin, Adriamycin –an antibiotic
L-asparagines
Ara-C
Methotrexate 6-mercaptopurinol
Prednisone
Cytoxan –an alkalizing agent
Allopurinol –decrease uric acid
Radiation
Radiation is the administering of rays used to kill cancer cells. Radiation may be used for:
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Children who present with leukemia cells in their brain or spinal fluid.
Children who suffer from a CNS (Central Nervous System) relapse.
Patient with metastasis/ spread to other organs
Children being prepared for a Bone Marrow or Stem cell transplant.
Bone Marrow Transplant, Stem Cell Transplant
Bone Marrow and Stem Cell transplants may be used to treat childhood leukemia. In a
transplant a patient receives an intravenous transfusion of bone marrow or stem cells,
replacing the patients own marrow.
The treatment objective is to cure or control leukemia. The child receives chemotherapy
and/or radiation to kill all the bone marrow cells prior to infusing the new marrow and cells.
The goal is for the new healthy marrow to be accepted by the patient and the patient’s body
will not make leukemia cells.
Indications for a transplant include:
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Relapse –the leukemia returns, remission is not sustained.
Children whose disease is unresponsive to chemotherapy or conventional treatment,
the child has not achieved remission.
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•
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Rare leukemia’s which can be cured with a bone marrow transplant.
Children with rare leukemia’s, who have a perfect sibling bone marrow, match.
Stem cell aphaeresis donation for children receiving regimes which suppress the
immune system and need a bone marrow rescue or boost.
Bone Marrow Transplants may come from several sources:
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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:
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Child’s protocol (treatment plan).
The disease status and disease type, the relapse diagnosis. Relapsed leukemia can
change cell type.
The available bone marrow or donor. Does the child have a sibling? What if the child
is adopted? May the patient donate his/her own marrow?
Can the child physically withstand a bone marrow transplant and pretreatment?
Lily’s parent’s sit in a small conference room and consult with the Hematology team.
The hematologist explains her disease and the treatment options. The mother cries as
she hears the possible side effects from treatment, hair loss, infection, infertility,
secondary tumors. However the parent’s agree this is Lily’s best chance at life and the
father signs the consent for treatment.
They agree with the oncologist
recommendation for a clinical trial for ALL. This trial is showing much promise for a
cure for Lily’s disease. Lily receives her first dose of intravenous chemotherapy that
afternoon. She is irritable and nauseated, crying and clinging to her mother. Multiple
visitors arrive, grandparents, aunt and uncles, cousins and neighbor bringing balloons
and toys. The many visitors excite Lily and tire her parents. The phone rings non
stop. Lily’s 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 hasn’t been able to take a nap. I
am not sure what to do?” He looks overwhelmed and exhausted.
•
•
How can the nurse and team help the family gain control over the visitors and
phone calls?
Will the visitors bring in germs?
Lily’s parents talk with the nurse about options for controlling their hospital
environment. Together they come up with a workable plan, appointing one family
member (Lily’s paternal grandparents “GramDee” and “PaPa” to be the contact person
for family and friends. Her grandparents let the relatives and friends know Lily’s
status and advise them on visitor restrictions. Adults without contagious illnesses
may visit at the parent’s request. Children are requested to stay home, away from the
hospital. The phone ringer is turned off in the room. Lily’s nurse medicates her with
anti nausea medicine and the child and family get some much needed sleep. A sign is
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attached to the hospital room door directing visitors to the nurse’s station before
entering.
Lily has begun her life saving therapy. She is now a survivor and begins her long road to
recovery. Her side effects of treatment will be discussed later in the module.
SECTION TWO: Childhood Lymphoma
Case Study
Jaycee, a 15 year old high school foot ball player is brought to his family doctor for a
lemon size painless “lump on his neck”. Jaycee and his mother describe the lump as
appearing quickly “in the last 2 weeks”. The nurse practioner takes a careful medical
and family history. Jaycee describes a weight loss of 15 pounds, night sweats, and
feeling “tired” for the past month. He has a cough and inspiratory wheeze. He claims
he did not want to bother his parents and he hoped to finish the foot ball season and
participate in the state playoff games. He is sent to the local Children’s Hospital
Emergency Room where a chest X-Ray and CAT scan reveal a large mediastinal mass
surrounding his heart. A lymphoma is suspected.
Jaycee is admitted to the oncology unit. A biopsy of the enlarged cervical lymph nodes
is planned. The coach and sixteen of Jaycee’s fellow football team members arrive on
the Hematology Oncology Unit crowding into his room to offer their support. Jaycee
assures them he is fine and will be back playing football next week.
His parents retreat to the visitor waiting room exhausted and tearful, overwhelmed and
confused over the doctor’s explanations. The Hematology staff starts to orient the
patient and family to the unit. They watch Jaycee carefully for signs of cardiac and
respiratory distress. The hematologist is concerned about the large chest mass.
Jaycee is put on cardiac monitoring. The staff waits quietly, they have seen this
presentation before, and they will see it again.
How can the staff help Jaycee’s parents and Jaycee during the initial diagnosis stage?
Educational information?
Coffee?
Finding out how the parents feel they can best be supported?
Jaycee’s case study will be presented throughout Section II and III.
What is Lymphoma?
Lymphoma is a type of cancer which develops in the lymphatic system. Abnormal
lymphocytes grow multiply and form tumor masses. Lymphomas generally start in the lymph
nodes or in organs. Lymphomas can spread to the bone marrow and throughout the body.
The lymphatic system is present throughout the body. This large system is part of the
immune system and helps the body fight against infection. Elements of the immune system
include:
• Lymph nodes.
• Intestinal lymph nodes.
• Lymphatic vessels.
• Tonsils and adenoids.
• Spleen.
• Bone Marrow.
18
•
•
•
•
•
•
Skin.
T lymphocytes.
B lymphocytes.
Natural killer (NK) cells.
Plasma cells.
Lymphokines.
The parts of the lymph system combine to fight disease and infection. When normal cells
within the lymph system mutate to malignant cells they multiply into a dangerous lymphoma
with a high risk of spreading throughout the body.
Types of Lymphoma
There are several different types of lymphoma. The two main types of lymphoma are:
• Hodgkin Lymphoma.
• Non- Hodgkin Lymphoma.
Hodgkin Lymphoma
In children and teens, Hodgkin Lymphoma is more common in adolescents and young adults.
Hodgkin Lymphoma is characterized by the presence of a type of malignant cells identified as
Reed-Steinberg cells. The cause of Hodgkin Lymphoma is unknown. The incidence of
Hodgkin Lymphoma increases with age. Hodgkin Disease responds well to treatment and a
cure is possible.
Non-Hodgkin Lymphoma (NHL)
Non-Hodgkin Lymphoma includes all lymphomas except Hodgkin Lymphoma. These are a
large diverse group of malignant cell clusters originating from the immune system cells.
These cells in the lymph system are less differentiated. The chance of recovery is good if the
cancer is not wide spread. NHL is most often found in adults and less common in children
and adolescents. NHL is classified as slowly progressing or aggressive rapidly progressing.
Risk Factors for Lymphoma
Jaycee’s risk factor for lymphoma is his age and his gender. He is a male and a 15
year old adolescent. The incidence of lymphoma is more prevalent in adolescents and
in males.
The incidence of lymphoma has risen over the past three decades. The principle cause is
unknown.
The majority of lymphomas occur without a known cause, the etiology is unknown. However
some risk factors have been identified in rare cases.
• Children/ adolescents with a disease of the immune system.
• Children/ adolescents on medication which suppresses the immune system.
• Patient’s who have received an organ transplant and are receiving immune
suppressant medication.
• Age –Lymphoma rates rise with age, adults (NHL most prevalent in persons greater
than 60), lymphoma is uncommon under the age of five.
• Gender – the disease is more prevalent in males.
19
•
•
•
Prolonged chemical or environmental exposure to cancer causing agents.
Certain virus including HIV (Human Immunodeficiency Virus) and EBV (Epstein Barr
Virus) found in Africa, HTLV (Human T Cell Lymphocytotropic Virus.
Helicobacter pylori bacterium is associated with stomach ulcers and lymphoma of the
stomach wall.
What are the symptoms of Lymphoma?
Jaycee presented with the most common early sign of Hodgkin lymphoma, a painless
swelling of the lymph nodes. He also reported a history of weight loss and night
sweats. Jaycee admitted to the medical student during a patient history that he had
felt “sick” for several weeks. He felt he might have “mono”. Jaycee delayed seeking
treatment so he could continue to play football. The size of the lymph node in his neck
caused him to show the swollen area to his mother. Jaycee’s mother immediately
made an appointment with their family doctor. As Jaycee awaits his lymph node
biopsy in the morning he asks his mother, “When can I play football? Can antibiotics
get 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 Jaycee’s 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
Diagnosis
Jaycee is prepared for a biopsy of the cervical lymph node under general anesthesia in
the main operating room at Children’s Hospital. The anesthesiologist and surgeon are
concerned about the mass surrounding his heart. They will biopsy the neck node but
not the chest mass, they monitor him closely.
While under anesthesia the
hematologist performs a bone marrow and biopsy and a spinal tap. A review of the
slides from the biopsy reveals Reed-Steinberg cells consistent Hodgkin Lymphoma.
Jaycee undergoes additional diagnostic imaging and is diagnosed with Stage III
Hodgkin Disease.
20
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 bone
marrow.
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 Disease
Staging 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 Lymphoma
Treatment
Children receiving treatment can suffer side effects. The goal is to control and kill the
leukemia and lymphoma cells. While suppressing the malignant cells, treatment may also
suppress the child’s immune system leading to life threatening complications. Side effects
can be treated and controlled leading to increased cure rates and decreased mortality rates.
Lily is 3 weeks post initial chemotherapy and is experiencing neutropenia (a decreased
white blood cell count and low neutrophils) a fever of 103 degrees, mouth sores, oral
21
pain, and mucusitis, decreased platelet counts, and a lack of appetite. Lily’s mother is
worried and states, “She will not take her medicine or eat or drink. I think her mouth
hurts. Will she get dehydrated?”
How can the staff support Lily’s side effects?
Lily is admitted to the Children’s Hospital, her supportive care includes:
1) Three broad spectrum intravenous antibiotics,
2) Anti fungal mouth care and oral regime for mouth sores.
3) Platelet transfusions for a platelet count less than 50, 0000.
4) Pain control, a mild narcotic based pain medication is administered for oral pain.
With her pain controlled Lily starts to take fluids and eat solids, she is able to take
her medicine. She is discharged three days later as her temperature returns to
normal and her white count increases. As mother wheels Lily out of the oncology
ward in her stroller she is smiling, waving at the nurses and states, “Bye-Bye, going
home!” Lily and her parents are building a trustful relationship with the staff.
A follow up bone marrow in the out patient clinic reveals Lily’s marrow to be free of
leukemia cells. She is responding to treatment.
These side effects can be mild or serious requiring hospitalization. Each child is an individual
and will respond to the treatment uniquely. The health care worker needs to stay aware of
each patient’s response. A baby may experience diarrhea and weight loss. A five year old
may suffer from anemia and fevers. A teenager could be prone to depression. The majority
of patients receiving chemotherapy and other cancer treatments will experience more than
one side effect. These side effects can be treated effectively and the child supported during
therapy. Prompt, proper support can increase the child’s chances to recover from leukemia
or lymphoma.
Jaycee is receiving chemotherapy and radiation. He returns via ambulance to the emergency
complaining of chest pain, rapid heart rate, and difficulty breathing. Jaycee’s parents are
distraught 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. After
determining Jaycee’s vital signs and oxygen saturations are normal the staff accompanies
him to the radiology department for a Chest X-ray and Chest Cat Scan. All of Jaycee’s
imaging reports are normal and his lymphoma is shrinking in his chest. The doctors diagnose
him with anxiety and a panic attack. The hospital psychologist comes and talks to with
Jaycee. They set up follow up appointments to discuss the stressors affecting cancer
patients and effective coping strategies such as deep breathing, positive imagery, and
meditation. Jaycee states he feels better, the chest pain is gone.
Side Effects of Leukemia Lymphoma Cancer Treatment in
Children and Adolescents
•
•
•
•
•
Nausea and vomiting
Fatigue, tiredness, lethargy
Decreased appetite and weight loss
Skin rash
Mucositis and mouth sores
22
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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 nausea
medication, antibiotic therapy, antifungal therapy, nutritional support, pain medications, white
cell and red cell support, electrolyte and fluid replacement, supportive red blood cell
transfusions, 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 from
treatment. Children relate pain differently from adults. A young toddler may not be able to
voice pain. Crying and grimacing indicates pain in babies. A school age child may withdraw
and exhibit a lack of appetite. A teen may exhibit acting out and anger when in pain. Faces
charts 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 when
in 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 positive
and calming scenes like a sunny beach can help relive pain.
23
Pain Medication –Analgesia
When pain is more severe and the child exhibits signs and symptoms of discomfort
medication can effectively control pain.
Commonly used analgesics for children’s 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 pumps
and 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 her
positive resources to fight and recover from their disease. The adolescent with effective pain
control will allow him to enjoy listening to music, watch TV and interact with peers. He will
have better prepared to cope with the rigors of chemotherapy or radiation if his pain is
controlled.
Long Term Late effects of Leukemia and Treatment
Children are surviving leukemia and lymphoma in great numbers. Many who do survive may
suffer late term side effects. These side effects can be effectively managed with appropriate
intervention. 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
24
•
•
•
•
•
•
•
•
•
•
Secondary leukemia’s & 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 side
effects.
Psychosocial and Emotional Aspects of Childhood Leukemia
When 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 pediatric
patient, parents, siblings, extended family. The neighbors, school and community quickly
hears the news and want to offer help. The health care professional is a witness and
participant in the care of the child and family. The child, family, and extended family need
support and nurturing.
Each family and patient will experience individual stressors and coping mechanisms.
Individual response should be respected. Children and families cope differently with a
diagnosis of leukemia or lymphoma.
Common feelings and stressors associated with a diagnosis of childhood leukemia or
lymphoma 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 and
treatment by nurturing and support from relatives, friends, community, and health care
workers. Helpful interventions include:
• Patient/ Parent support groups
25
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
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 Treatment
Patients and families find life after cancer therapy hopeful yet frightening. The staff can help
this transition by providing clear guidelines for follow up care and education. Individuals cope
differently 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 is
completed. 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 the
Hematology team in the years ahead to watch for relapse. Lily has a 90% chance of
staying cancer free. Lily doesn’t understand the details she is just happy, feels well
and calls out to the staff as she leaves Heme-Clinc, “No sticks today! Bye-Bye!” Goodbye Lily!
Jaycee is graduating from high school and going to college in the fall. Jaycee is
disease free. The lymphoma is in complete remission. He does not like to talk about
his treatment. However he volunteers as a camp counselor at Oncology Camp and
wants to help other children diagnosed with cancer. His parents are relieved and
cautiously optimistic. Jaycee will follow-up yearly with the Long Term Follow-up
Team. He has a good chance of maintaining his remission and be cured of lymphoma.
“See you next year” he calls out to the staff.
26
Conclusion
The outlook for children and adolescents diagnosed with childhood leukemia and lymphoma
has never looked brighter. Modern medical advances in cancer research, treatment and long
term 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/or
lymphoma will achieve long term remissions.
27
Reference
Eden OB, Harrison G, and Richards S, et al.: Long-term follow-up of the United Kingdom
Medical Research Council protocols for childhood acute lymphoblastic leukemia, 19801997. edical Research Council Childhood Leukemia working Party. leukemia 14 (12):
2307-20, 2000.
Gayon PS, Trigg ME, Heerema NA, et al.: Children’s Cancer Group trials in Childhood
acute lymphoblastic leukemia: 1983-1995. Leukemaia 14 (12): 2223-33, 2000.
Harms, DO, Janka-Schaub GE: co-operative study group for childhood acute
lymphoblastic leukemia (COALL): long term follow-up trials 82, 85, 89, and 92. Leukemia
14 (12): 2234-9, 2000.
Lones MA, Perkins SL, Sposto R, et al.: Non-Hodgkin’s lymphoma arising in bone in
children and adolescents is associated with an excellent outcome: a Children’s Cancer
Group report. J Clin Oncol 20 (9): 2293-301, 2002.
McNeil DE, Cote TR, Clegg L, et al.: SEER update of incidence and trends in Pediatric
malignancies: 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 for
childhood lymphoblastic leukemia: Pediatric Oncology Group studies from 1986-1994.
Leukemia 14 (12): 2276-85, 2000.
Pinkerton CR: The continuing challenge of treatment for non- Hodgkin’s lymphomas in
children. 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 acute
lymphoblastic leukemia: results of Total Therapy Study X111B at St Jude Children
research 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-Hodgkin’s lymphoma in childhood. N Engl J
Med 334 (19): 1238-48, 1996.
Smith MA, Ries LA, Gurney JG, et al., eds.: Leukemia. Cancer incidence and survival
among 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 The
United States (1973-1998). Cancer 97 (9): 2229-35, 2003
28
Post Test
1. Childhood leukemia is a disease originating from the:
A.
B.
C.
D.
Liver.
Spleen.
Bone marrow.
Lymphatic system.
2. One of the eight warning sign of childhood cancer is:
A.
B.
C.
D.
Weight gain.
Virus with high fever.
Nausea and vomiting.
Persistent pain in bones and joints.
3. One sign of childhood leukemia is:
A.
B.
C.
D.
Night sweats.
A painless lump.
Petechia and bruising.
Clubbing of fingers and toes.
4. An adolescent presenting with lymphoma may describe:
A.
B.
C.
D.
Mouth sores.
A bone mass.
Rapid weight loss.
Increased appetite.
5. Leukemia and Lymphoma staging includes the following factors:
A.
B.
C.
D.
Serial blood counts.
Cell characteristics type and location.
Blood counts and bone marrow aspiration.
Radiology imaging, MRI, CAT scan, Gallium Scan.
6. The current treatment for ALL includes:
A.
B.
C.
D.
Surgery.
Total body radiation.
A low carbohydrate diet.
Combination chemotherapy.
7. Side effects associated with treatment for lymphoma include:
A.
B.
C.
D.
Oliguria.
Increased appetite.
Excessive hair growth.
Bone marrow suppression.
29
8. The most common type of child hood leukemia is:
A.
B.
C.
D.
Eosinophil Leukemia.
Acute Lymphocytic Leukemia.
Acute Mylogeneous Leukemia.
Chronic Lymphocytic leukemia.
9. An appropriate pain medication for an adolescent with lymphoma experiencing pain from
mild mucousitis:
A.
B.
C.
D.
Aspirin.
Fentanyl patch.
Acetaminophen.
Meperidine (Demerol).
10. Helpful interventions for families and children diagnosed with childhood cancer include
allowing the ill child to make all decisions and choices regarding care if he has nausea,
vomiting and pain.
A. True
B. False
11. The five year survival rate for AML is:
A.
B.
C.
D.
10%
40%
70%
90%
12. Chronic Mylogeneous Leukemia is:
A.
B.
C.
D.
Common in infants.
A slow growing leukemia.
Rarely diagnosed in children.
Common in preschool children.
13. A child diagnosed with leukemia:
A.
B.
C.
D.
May present with no apparent symptoms.
Always presents with profound symptoms.
Usually has a ruddy or red blotchy complexion.
May have an increased number of red blood cells.
14. Family centered care:
A.
B.
C.
D.
Is not considered a factor for well being.
Is always an option and up to the child to decide.
Is discouraged; care should be left to the professionals.
Is always the goal and will help the child and family to cope.
30
15. Children with newly diagnosed leukemia:
A.
B.
C.
D.
Do not often require blood transfusions to treat anemia.
Will likely not require supportive therapy before treatment.
Are not usually suffering from dehydration, sepsis or infection.
May require supportive therapy before during, and after therapy.
16. Bone marrow transplants used for childhood leukemia may:
A.
B.
C.
D.
Come from several sources.
Come from a matching relative only.
Are never used for childhood leukemia.
Only come from the patient’s own marrow.
17. Lymphoma develops:
A.
B.
C.
D.
In the blood.
Outside of organs.
In the bone marrow.
In the lymphatic system.
18. Risk factors for developing lymphoma include:
A.
B.
C.
D.
Ethnicity.
History of diabetes.
History of receiving blood transfusions.
Patients that have received on organ transplant and are receiving immune
suppressant medication.
19. The most common early sign of lymphoma is:
A.
B.
C.
D.
Bruising.
Sudden rapid weight gain.
Unexplained hyperactivity.
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.
B.
C.
D.
Burkitts Lymphoma.
Hodgkin’s Lymphoma.
Neoplastic Lymphoma.
Non Hodgkin’s Lymphoma.
21. Treatment for Non Hodgkin’s Lymphoma commonly includes:
A.
B.
C.
D.
Cisplatin.
Radiation.
Aromitase Inhibitors.
Experimental herbal medications.
31
22. Side effects of leukemia and lymphoma treatment:
A.
B.
C.
D.
Are difficult to treat.
Can be treated effectively.
Are always treated with antibiotics.
Are primarily related to pain medications.
23. A school aged child experiencing pain will often:
A.
B.
C.
D.
Become angry and act out.
Talk to their parents about it.
Cling to caregivers and over-eat.
Withdraw and exhibit a lack of appetite.
24. Long term late effects of leukemia and treatment included:
A.
B.
C.
D.
Obesity.
Diabetes.
There are no long term effects.
Organ damage and chronic pain.
End of Test
32
Childhood Leukemia and Lymphoma
I have no vested interests in this course or topic.
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I have the following vested interests in this course or topic:
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