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Oncology

Leukaemia (Paediatric Overview)

Malignancy of blood-forming cells (bone marrow), leading to overproduction of abnormal white blood cells (blasts) and suppression of normal blood cell production. Acute Lymphoblastic Leukaemia (ALL) is the most common childhood cancer globally.

Also known as: Blood Cancer (Child)

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Referral and warning signs

When to refer

Immediate urgent referral to specialized Paediatric Oncology centre for ALL suspected cases.

Red flags

  • Unexplained pallor, bruising, or bleeding
  • Persistent or recurrent fevers/infections
  • Bone pain, limp
  • Lymphadenopathy or hepatosplenomegaly
  • Presence of blasts on peripheral blood film

Signs and symptoms

  • Symptoms related to Bone Marrow Failure: Anaemia (Pallor, fatigue, lethargy, irritability, shortness of breath), Thrombocytopenia (Easy bruising, petechiae, purpura, epistaxis - nosebleeds, gum bleeding), Neutropenia (Recurrent or persistent infections, fever).
  • Symptoms related to Leukaemic Infiltration: Bone pain or joint pain (often causing limp or refusal to walk), Lymphadenopathy (swollen lymph nodes), Hepatosplenomegaly (enlarged liver and spleen), Less common (Testicular enlargement, CNS involvement - headache, vomiting, cranial nerve palsies, mediastinal mass - T-ALL - cough, dyspnoea, SVC obstruction).

Risk factors

  • Genetic predisposition (e.g., Down syndrome, Fanconi anaemia, Li-Fraumeni syndrome).
  • Exposure to high-dose radiation.
  • Previous chemotherapy.
  • Most cases have no known cause.

Diagnosis

Clinical assessment

Suspect in child with unexplained pallor, bruising/bleeding, persistent fever/infections, bone pain, lymphadenopathy, or hepatosplenomegaly.

Investigations

  • Complete Blood Count (CBC) with Differential: Key initial test. May show anaemia, thrombocytopenia, and variable WBC count (low, normal, or very high) often with presence of abnormal blast cells on peripheral smear.
  • Peripheral Blood Film Examination: Morphological assessment of blood cells, identification of blast cells.
  • Bone Marrow Aspiration and Biopsy: Essential for diagnosis and classification. Shows increased blasts (>20-25% for acute leukaemia), determines lineage (lymphoid - ALL vs myeloid - AML), cytogenetics, immunophenotyping, molecular studies (risk stratification).
  • Lumbar Puncture with CSF analysis: Assess for CNS involvement.
  • Chest X-ray: Assess for mediastinal mass (T-ALL).
  • Biochemistry: LDH, Uric acid, Renal/Liver function (baseline, assess for tumour lysis risk).

Diagnostic criteria

Diagnosis confirmed by bone marrow examination showing excess blast cells, with further classification based on morphology, immunophenotyping, cytogenetics, and molecular studies.

Management

Non-pharmacological management

  • Urgent referral to specialized Paediatric Oncology centre (UCI/RRH).
  • Supportive care: Blood product transfusions (RBCs, platelets), management of infections (antibiotics, antifungals), management of tumour lysis syndrome (hydration, allopurinol/rasburicase), nutritional support, psychosocial support.

Pharmacological treatment

  • Multi-agent Chemotherapy: Mainstay of treatment. Specific protocols depend on leukaemia type (ALL vs AML) and risk group stratification.
  • - Induction phase: Aim to achieve remission.
  • - Consolidation/Intensification phase: Eliminate residual disease.
  • - Maintenance phase (for ALL): Prolonged low-dose chemo to prevent relapse.
  • Central Nervous System (CNS) Prophylaxis/Treatment: Intrathecal chemotherapy +/- cranial radiation (less common now) is crucial.
  • Targeted therapies and Stem Cell Transplantation may be used for specific subtypes or relapsed/refractory disease (highly specialized).

Monitoring

Monitor blood counts frequently during chemotherapy (myelosuppression). Monitor for infections, bleeding, tumour lysis syndrome. Monitor treatment response via bone marrow exams. Long-term follow-up for relapse and late effects of treatment.

Complications

  • Infections (due to neutropenia)
  • Bleeding (due to thrombocytopenia)
  • Anaemia
  • Tumour Lysis Syndrome
  • CNS Leukaemia
  • Treatment-related toxicity (short-term and long-term - cardiotoxicity, infertility, secondary malignancies, neurocognitive effects)
  • Relapse

Prevention

  • Generally not preventable.

Patient education

  • (To parents/guardians) Explain leukaemia as cancer of the blood/bone marrow.
  • Need for urgent referral and specialized treatment (chemotherapy).
  • Explain treatment phases and expected duration.
  • Discuss common side effects of chemotherapy and supportive care needed.
  • Importance of infection precautions.
  • Need for regular follow-up and monitoring.
  • Prognosis (generally good for standard-risk childhood ALL with appropriate therapy).
  • Psychosocial support resources.

Uganda-specific notes

ALL is the most common form. Diagnosis and treatment require referral to UCI/specialized centres. Supportive care (blood products, antibiotics) is critical. Treatment protocols adapted to local context may be used.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 12, Section 12.3.1

  • Uganda Cancer Institute Treatment Guidelines / Paediatric Oncology Protocols

    (Specific protocols)

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