Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
6.4 Acute Promyelocytic Leukemia
HL is an uncommon presenting feature in APL although pediatric patients have an increased incidence of microgranular APL M3v with concomitant HL Rovelli et al. 1992 ; Guglielmi et al. 1998 ; de Botton et al. 2004 . HL can more commonly be seen as part of APL differentia- tion syndrome previously called retinoic acid syndrome after commencement of either all- trans retinoic acid ATRA or arsenic trioxide ATO therapy Vahdat et al. 1994 ; Camacho et al. 2000 ; Levy et al. 2008 ; Zhang et al. 2008 ; Sanz et al. 2009 ; Zhou et al. 2010 . In some studies, increasing leukocytosis WBC 10 × 10 9 L was a risk factor for the develop- ment of the clinical fi ndings of APL differentia- tion syndrome such as unexplained fever, weight gain, respiratory distress, pulmonary infi ltrates, pleural effusions or pericarditis Frankel et al. 1992 ; Vahdat et al. 1994 ; Camacho et al. 2000 . HL either at diagnosis or after initiation of dif- ferentiating therapy is a risk factor for early death, especially from ICH secondary to dis- seminated intravascular coagulation DIC Rovelli et al. 1992 ; Roberts et al. 2000 ; Zhang et al. 2008 ; Zhou et al. 2010 . Due to the risk of early death from DIC and hemorrhage, especially in those with the highest WBC counts, it is vital to initiate supportive care and induction therapy with ATRA andor ATO emergently Sanz et al. 2005 , 2009 ; Tallman and Altman 2009 . In lieu of random- ized data, expert guidelines recommend treat- ment of coagulopathy with fresh frozen plasma, fi brinogen fi brinogen concentrate or cryopre- cipitate, and platelet transfusion to maintain fi brinogen 150 mgdL and platelets 50 × 10 9 L at the minimum in those with HL, with frequent i.e., every 6–8 h monitoring and correction Sanz et al. 2005 , 2009 ; Tallman and Altman 2009 . Studies on the complementary use of antifi brinolytics such as tranexamic acid have not shown benefi t Sanz et al. 2009 . Diagnostic lumbar puncture and placement of a central venous catheter should be avoided until the coagulopathy has resolved Sanz et al. 2005 , 2009 ; Tallman and Altman 2009 . Initiation of treatment with a differentiating agent should start prior to genetic confi rmation of diagnosis in those cases with suffi cient clinical suspicion Sanz et al. 2005 , 2009 ; Tallman and Altman 2009 . The clinician should be cognizant of the risk for HL development and concomitant DIC after initiation of either ATRA or ATO. In the pediatric North American INT0129 APL trial, hydroxyurea was initiated at a dose of 1 gm 2 and ATRA held if the WBC rose to 30 × 10 9 L during ATRA therapy until the WBC count was 10 × 10 9 L Gregory et al. 2009 . In a Chinese study of 19 children with APL who received single-agent ATO, all developed an increase in WBC count with induction ATO with 5 having WBC 100 × 10 9 L Zhou et al. 2010 . The two children with the highest WBC counts, 178 × 10 9 L and 252 × 10 9 L after ATO initiation, both died from ICH. Zhou et al. 2010 initiated hydroxyurea for all WBC 20 × 10 9 L while also decreasing the ATO dose or even holding it in patients with severe leukocytosis. The benefi t of holding ATO therapy with HL is unclear Levy et al. 2008 ; Sanz et al. 2009 . Oral corticoste- roids, which are utilized as treatment for APL differentiation syndrome, have also been sug- gested as a prophylactic agent with WBC 5–50 × 10 9 L or with the initiation of induction therapy in all patients to prevent the development of subsequent HL as well as severe pulmonary or CNS symptoms Wiley and Firkin 1995 ; Sanz et al. 2005 , 2009 ; Tallman and Altman 2009 Randomized data are lacking. The use of leuka- pheresis in APL with HL is controversial and dis- cussed in Sect. 6.7 .6.5 Chronic Myelogenous
Leukemia HL is reported to be more common in pediatric patients with CML as compared to adults Rowe and Lichtman 1984 ; Millot et al. 2005 . Even with the high WBC counts at presentation, preva- lence of leukostasis secondary to pediatric CML is thought to be uncommon although it was seen frequently in the small review by Rowe and Lichtman 1984 . Symptoms of leukostasis in CML patients can include neurologic complaints such as papilledema, cranial nerve defects, and tinnitus, respiratory complaints, and priapism Rowe and Lichtman 1984 . Priapism has been noted in pediatric ALL and CML Castagnetti et al. 2008 ; Vaitkevičienė et al. 2013 . Management of HL in CML prior to the initiation of tyrosine kinase inhibitor therapy can be accomplished with hydroxyurea Schwartz and Canellos 1975 . Management of pediatric patients with signs and symptoms of leukostasis lacks an evidence basis in the literature although sources recommend utilization of chemotherapy in addition to leukapheresis Rowe and Lichtman 1984 ; Castagnetti et al. 2008 . For low-fl ow ischemic priapism in particular, adult guide- lines recommend chemotherapy, leukapheresis, and urologic therapy with therapeutic aspiration and intracavernous sympathomimetics if aspira- tion alone is not successful Montague et al. 2003 ; Rogers et al. 2012 . Castagnetti et al. 2008 suggest patients can be managed without invasive urologic procedures utilizing chemo- therapy and leukapheresis alone; however, their small cohort required a long period of time to recover from priapism and half did not receive leukapheresis. In addition they recommend the use of anticoagulation with low-molecular- weight heparin especially with concomitant thrombocytosis although signifi cant evidence on utility is lacking. On long-term follow-up, none of their patient cohort had developed clinical evi- dence of erectile dysfunction.6.6 Management of Tumor
Lysis Syndrome The general management of tumor lysis syn- drome TLS is discussed in Chap. 3 . Patients with HL are at increased risk of both laboratory and clinical TLS, especially those with ALL. Truong et al. 2007 showed that WBC 20 × 10 9 L was an independent risk factor for the development of TLS in pediatric ALL. Montesinos et al. 2008 similarly reported that WBC 25 × 10 9 L was an independent risk factor for TLS in adult AML patients, but it is unclear if TLS is a signifi cant issue in pediatric AML even with HL Inaba et al. 2008 ; Sung et al. 2012 . Prevention through the utilization of hyperhydra- tion, urine alkalinization, and allopurinol are all proven methods to reduce the risk of metabolic complications in pediatric patients with HL and ALL Maurer et al. 1988 ; Lascari 1991 . Maurer et al. 1988 showed no benefi t in preventing metabolic derangement through the use of low- dose prednisone prior to initiation of induction chemotherapy in pediatric ALL patients with WBC 200 × 10 9 L. The most recent expert TLS guidelines list both ALL and AML with concomitant HL as high-risk for the development of TLS and recom- mend prophylactic use of rasburicase in addition to aggressive hydration to prevent hyperuricemia Cairo et al. 2010 . These recommendations con- curred with the Italian consensus guidelines for ALL, although in the Italian opinion TLS was rare in AML even with HL and therefore should not be considered high-risk Tosi et al. 2008 . Cairo et al. 2010 recommend one dose of rasburicase at a dose of 0.1–0.2 mgkg prior to the initiation of therapy, while Tosi et al. 2008 recommend con- tinuing daily therapy at a dose of 0.2 mgkgday for 3–5 days. Additionally, the concomitant use of allopurinol due to the very rarely reported pre- cipitation of uric acid precursor xanthine andParts
» Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Introduction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» History and Physical Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Defi ning the Risk for Serious
» Initial Laboratory Evaluation Diagnostic Evaluation
» Chest Radiography CXR A supine CXR may identify pleural effusions,
» Computed Tomography CT Radiographic Imaging
» Magnetic Resonance Imaging MRI
» Positron Emission Tomography PET
» Aspergillus Galactomannan GMN Biomarkers for Invasive
» 1,3-β- Biomarkers for Invasive
» Polymerase Chain Reaction PCR
» Viral Studies Diagnostic Evaluation
» Invasive Procedures: Diagnostic Evaluation
» Adult FN Guidelines Empiric Management
» Monotherapy Versus Combination Therapy
» Which Monotherapy to Choose A Cochrane review of antipseudomonal beta-
» Alterations in Initial Empiric FN Antibiotic Management
» Outpatient Management of FN Although there remains a lack of one uniform
» Choice of Empiric Antifungal Therapy
» Duration of Antimicrobial Empiric Management
» Endovascular Sources Empiric Management
» Adjunctive Treatment Empiric Management
» Emergence of Resistant Empiric Management
» Red Blood Cell Administration
» Granulocyte Transfusion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hemolytic Transfusion Risks of Blood Product
» Infection and Sepsis Risks of Blood Product
» Allergic Reactions Risks of Blood Product
» Febrile Nonhemolytic Risks of Blood Product
» Transfusion-Related Acute Risks of Blood Product
» Transfusion-Associated Risks of Blood Product
» Iron Overload Risks of Blood Product
» Laboratory Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» General Management Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Alkalinization Urinary alkalinization has been a long-standing
» Allopurinol Allopurinol inhibits xanthine oxidase, an enzyme
» Rasburicase Rasburicase, recombinant urate oxidase, converts
» Renal Interventions Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pathophysiology Superior Vena Cava
» History and Physical Exam SVCSSMS should be suspected in a patient
» Imaging Studies The diagnosis of SVCSSMS is often made on
» Other Studies Tissue is required to make a defi nitive diagnosis
» Treatment Superior Vena Cava
» History and Physical Exam Small pericardial effusions are frequently asymp-
» Imaging and Other Studies The presence of a pericardial effusion can be
» History and Physical Exam Many patients with small pleural effusions are
» Imaging Studies When a pleural effusion is suspected, a chest
» History and Physical Exam Patients with pheochromocytoma typically have
» Laboratory Studies The diagnosis of pheochromocytoma is best made
» Imaging Studies Clinical Presentation
» Pulmonary Leukostasis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Presentation Spinal Cord Compression
» Differential Diagnosis Spinal Cord Compression
» Imaging MRI of the spine can help narrow the differential
» Surgery Surgery in spinal cord compression can be uti-
» Radiation Therapy The advantages of external beam radiation ther-
» Outcomes Spinal Cord Compression
» Presentation Altered Mental Status
» Initial Management Altered Mental Status
» Metabolic The metabolic causes of AMS or seizure in pedi-
» Chemotherapy-Associated Neurotoxicity Differential Diagnosis
» Posterior Reversible Encephalopathy Syndrome
» Outcomes Altered Mental Status
» Initial Management Increased Intracranial
» Soft Tissue A large meta-analysis of published data suggests
» Cerebrospinal Fluid Hydrocephalus is an excess of CSF within the
» Hemorrhage and Thrombosis Differential Diagnosis
» Idiopathic Intracranial Hypertension Differential Diagnosis
» Presentation of Stroke Cerebrovascular Disease
» Differential Diagnosis Cerebrovascular Disease
» Etiology of Stroke in Pediatric
» Ischemic Stroke After an ischemic stroke is diagnosed, the patient
» Hemorrhagic Stroke Hematomas can expand over several hours from
» Acute Lymphoblastic Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Myelogenous Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Acute Promyelocytic Leukemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Chronic Myelogenous Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Tumor Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Leukapheresis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Hyperhydration Other Treatment Modalities
» Hydroxyurea Other Treatment Modalities
» Cranial Irradiation Other Treatment Modalities
» Pseudohyperkalemia Hyperleukocytosis has been noted to cause pseudo-
» Pseudohypoxemia Due to the rapid consumption of oxygen by leu-
» Pseudohypoglycemia Consumption of glucose by excess leukocytes
» Pseudothrombocytosis Leukemic blast lysis can lead to cell fragmenta-
» Transfusion Practice with Other Supportive Care
» Anesthetic Procedures Other Supportive Care
» Neutropenic Enterocolitis Gastrointestinal Infection
» Perirectal Abscess Gastrointestinal Infection
» Gastrointestinal Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Pancreatitis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Bowel Obstruction Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Abdominal Compartment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» ALL Risk Factors Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Other Malignancies Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Central Venous Catheters Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diagnosis Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nociceptive Pain Types of Pain
» Neuropathic Pain Types of Pain
» World Health Organization Pharmacologic Treatment
» Intermittent Opioid Use Pharmacologic Treatment
» Long-Acting Opioids Pharmacologic Treatment
» Breakthrough Dosing Pharmacologic Treatment
» Opioid Rotation Pharmacologic Treatment
» Patient-Controlled Analgesia Pharmacologic Treatment
» Constipation Side Effects of Opioids
» Nausea and Vomiting Nausea and vomiting are rare opioid side effects
» Pruritus Pruritus is a common side effect of opioid use
» Sedation Side Effects of Opioids
» Confusion and Agitation Renal and hepatic function should be checked
» Respiratory Depression When dosed appropriately, opioids rarely result
» Myoclonus Patients receiving very high doses of opioids for
» Urinary Retention Urinary retention can be caused by any opioid but
» Calcium Channel Blockers Neuropathic Pain
» Serotonin and Norepinephrine Neuropathic Pain
» Tricyclic Antidepressants Neuropathic Pain
» Interventional Techniques Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vincristine-Related Peripheral Oncology-Specifi c Pain
» Osteonecrosis Oncology-Specifi c Pain
» Post-lumbar Puncture Oncology-Specifi c Pain
» Mucositis Pain Oncology-Specifi c Pain
» Pathophysiology of Emesis Chemotherapy-Induced
» Principles of Emesis Control in the Cancer Patient
» Emetogenicity of Chemotherapy Chemotherapy-Induced
» Dopamine Receptor Antagonists Classes of Antiemetics
» Corticosteroids Classes of Antiemetics
» Cannabinoids The plant Cannabis contains more than 60 differ-
» Other Antiemetic Agents Antihistamines
» Alternative Therapies Ginger Classes of Antiemetics
» Management of CINV Management of CINV Table
» Special Considerations Anticipatory Nausea and Vomiting
» Radiation-Induced Nausea Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Initiation The initiation stage occurs immediately following
» Primary Damage Response Pathophysiology of Oral Mucositis
» Signal Amplifi cation Pathophysiology of Oral Mucositis
» Ulceration Ulceration is the phase with the most clinical sig-
» Healing Pathophysiology of Oral Mucositis
» Clinical Course of Oral Mucositis
» Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Palifermin Prevention and Treatment
» Low-Level Laser Therapy Prevention and Treatment
» Glutamine Prevention and Treatment
» Cryotherapy Prevention and Treatment
» Oral Care Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Infections Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Nutrition Assessment Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Dietary Counseling Nutrition Intervention
» Appetite Stimulants Nutrition Intervention
» Enteral Tube Feeding Nutrition Intervention
» Parenteral Nutrition Nutrition Intervention
» Nutrition and Survivorship Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Management of Neutropenia Hematologic Toxicity
» Management of Thrombocytopenia Hematologic Toxicity
» Management of Anemia Hematologic Toxicity
» Somnolence Syndrome Central Nervous System
» Lhermitte’s Sign Central Nervous System
» Skin Complications Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Oral Mucositis Head and Neck
» Ear Complications Head and Neck
» Laryngeal Complications Head and Neck
» Dysphagia and Esophagitis Gastrointestinal
» Nausea, Vomiting and Anorexia
» Pneumonitis Major Organ Infl ammation
» Pericarditis Major Organ Infl ammation
» Hepatitis Major Organ Infl ammation
» Nephropathy Major Organ Infl ammation
» Cystitis Major Organ Infl ammation
» Risk Stratifi cation Prevention of Bacterial
» Adult Data Antimicrobial Approaches
» Pediatric Data Data regarding the utility of bacterial prophylaxis
» Risks of Prophylaxis Prevention of Bacterial
» Guidelines and Current Usage of Antibacterial Prophylaxis
» Protocols for Line Placement and Care
» Antibiotic and Ethanol Locks
» Chlorhexidine Cleansing Chlorhexidine gluconate CHG is a bactericidal
» Future Directions Prevention of Bacterial
» Risk Stratifi cation Prevention of Fungal
» Approaches to Antifungal Prophylaxis
» Guideline Recommendations for Antifungal Prophylaxis
» Limitations of Current Options for Antifungal Prophylaxis
» Risks of Prophylaxis Prevention of Fungal
» Biomarkers Prevention of Fungal
» Future Directions Prevention of Fungal
» Risk Stratifi cation Prevention of Pneumocystis
» Approaches to PCP Prophylaxis
» Summary of the Recommendations
» Future Directions Prevention of Pneumocystis
» Postexposure Chemoprophylaxis Prevention of Viral Infections
» Suppressive Therapy Prevention of Viral Infections
» Future Directions Prevention of Viral Infections
» Hand Hygiene Infection Control Practices
» Mandatory Vaccination Infection Control Practices
» Hospital Isolation Practices Infection Control Practices
» Visitor Screening Policies Infection Control Practices
» Work Restriction Infection Control Practices
» Cytomegalovirus CMV Status of Transfused Blood
» Treatment of Myelosuppression with
» Prevention of Febrile Neutropenia, Delay
» Treatment of Febrile Neutropenia
» Treatment of Myelosuppression Clinical Usage of Myeloid Growth Factors
» Comparison of Granulocyte Colony-Stimulating Factor
» Optimal Dosing Adult guidelines recommend dosing of 5 mcgkg
» Route of Administration Optimal Administration of Colony-Stimulating Factors
» Optimal Timing Optimal Administration of Colony-Stimulating Factors
» Erythropoietin Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Interleukin-11 Platelet Growth Factors
» Thrombopoietin Receptor Agonists Platelet Growth Factors
» Immune Status Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Status During Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immune Recovery After Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Immunization Practice Prior Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Diphtheria, Tetanus, and Acellular Pertussis
» Pneumococcal Conjugate Vaccine Recommendations
» Hemophilus Infl uenzae Type b
» Inactivated Infl uenza Vaccine Although in a Cochrane review Goossen et al.
» 2009 H1N1 Pandemic Vaccine Seven studies have reported on effi cacy of the
» Live Attenuated Infl uenza Vaccine
» Meningococcal Conjugate Vaccine Recommendations
» Varicella Zoster Virus Recommendations
» Recommendations Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Treatment of Hypogammaglobulinemia Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Vaccination of Household Contacts
» Peripherally Inserted Central Catheter
» External Tunneled Central Venous Catheter
» Implanted Port Types of Central Venous
» Catheter Insertion Supportive Care in Pediatric Oncology irantextbook.ir 93df
» Exit Site Infection Infection
» Prevention of Infection Infection
» Drug Precipitate or Lipid Residue Occlusion Thrombotic Occlusion
» Evaluation of Catheter- Related Thrombosis
» Treatment of Catheter- Related Thrombosis
» Special Considerations During Anticoagulation Therapy
» Contraindications of Anticoagulant Therapy
» Skin Antisepsis Catheter Maintenance
» Central Venous Catheter Dressings
» Hub Care Catheter Maintenance
» Central Venous Catheter Flushing and Locking
» Chlorhexidine Bathing Chlorhexidine has been shown to be effective in
» Antiseptic Needleless Connectors and Antiseptic
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