Uterine Myoma Uterine Fibroids, Leiomyomas, Myomas, Fibromyomas
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Transcript Uterine Myoma Uterine Fibroids, Leiomyomas, Myomas, Fibromyomas
Acute Lymphoblastic
Leukemia
I2 黃 柏
瑋
Malignancy remains the major cause of
death to disease between the age of 1 and
15 years
The precise cause of childhood cancer is
unknow
Leukemia, Neuroblastoma, Wilms tumor ,
retinoblastoma and tumor of liver
Introduction
Leukemia – the most common malignancy in
childhood.
Acute leukemia– 97%
Acute lymphoblastic leukemia– 75%
Acute myeloblastic leukemia– 20%
Chronic leukemia– 3%
Chronic myelogenous leukemia (Ph positive)
Juvenile myelomonocytic leukemia ( JMML)
Introduction to pediatric neoplastic
disease and tumor
Leukemia and a more pronounced rise
in central nervous system tumor
Boy > girl
Leukemia
The most common childhood cancer ( 1/3
of pediatric malignancies ).
Acute lymphoblastic leukemia (ALL)
represents about 75 % (peak incidence at
age 4 years).
Acute myeloid leukemia (AML) accounts for
about 20 % of leukemia (stable from birth
through age 10)
Others : CML
Acute Lymphoblastic Leukemia
Childhood acute lymphoblastic
leukemia (also called acute lymphocytic
leukemia or ALL).
is a disease in which too many
underdeveloped infection-fighting white
blood cells, called lymphocytes, are
found in a child's blood and bone
marrow.
Acute Lymphoblastic Leukemia
These abnormal cells reproduce very
quickly and do not function as healthy
white blood cells to help fight infection.
the most common form of leukemia
the most common kind of childhood
cancer.
Acute Lymphoblastic Leukemia
In the United States, about 3,000
children each year are found to have
ALL
Peak incidence occurs from 3 to 5
years of age.
Acute Lymphoblastic Leukemia
the most common symptoms of
leukemia:fever, anemia, bleeding
and/or bruising ,persistant
weakness or tiredness, achiness in the
bones or joints, recurrent infections ,
difficulty breathing (dyspnea) or
swollen lymph nodes.
Clinical manifestations
Protean
Bone marrow failure & Organ infiltration
Common symptoms
Fever ( 60%)
Malaise ( 50%)
Pallor ( 40%)
Etiology
Unknown ( usually)
Hereditary
Down’s syndrome
Leukemia in siblings
Chemicals
Chronic benzene exposure
Alkylating agents
Ionizing radiation
Predisposing hematological disease ( MPD, AA)
Viruses ( HTLV-1)
Diagnostic criteria
ALL is often difficult to diagnose.
The early signs may be similar to the
flu or other common diseases.
Diagnostic criteria
bone marrow aspiration and biopsy
complete blood count (CBC)
additional blood tests
computerized tomography scan
magnetic resonanec imaging (MRI)
x-ray
ultrasound
lymph node biopsy
spinal tap/lumbar puncture
Diagnostic criteria
Peripheral blood:
anemia,thrombocytopenia, variable white
cell count with or without blasts.
Bone marrow: hyper-or hypo-cellularity
with excess of blasts (blasts>30% of
nucleated cells).
Diagnostic criteria
Cytochemistry study and surface
marker study confirm the lymphoid
origin .
Diagnostic criteria
blood tests to count the number of each of
the different kinds of blood cells..
If the results of the blood tests are not
normal, a doctor may do a bone marrow
biopsy .
The chance of recovery (prognosis) depends
on how the leukemia cells look under a
microscope.
V-25 Leukemic cells in acute lymphoblastic leukemia
characterized by round or convoluted nuclei, high
nuclear/cytoplasmic ratio and absence of cytoplasmic graulnes.
Differential diagnosis
AML.
MDS.
Non-Hodgkin‘s lymphoma with bone
marrow involvement or with leukemic
change.
CLL.
Differential diagnosis
Viral infection with lymphocytosis
CML with acute blastic crisis.
Acute lymphoblastic leukemia
Laboratory examinations
Full blood count
Coagulation screening – esp AML M3.
Biochemical screening
Chest radiography
Bone marrow aspiration
Immunophenotyping
Cytogenetics & molecular studies
Lumbar puncture ( CNS involvement)
Complications
Cerebral hemorrhage, pul. hemorrhage
or other vital organ hemorrhage.
Infection(sepsis or septic shock ) ,
pulmonary edema.
Tumor lysis syndrome.
Complications
Infiltration syndrome(CNS, GI tract or
gonads).
Coagulopathy before or after
chemotherapy.
Anemia.
Risk Grouping of TPOG
(ALL)
Standard Risk
High Risk– CNS leukemia, cranial nerve
palsy, testicular leukemia, pre-B ALL
t(1;19) or E2A-PBX1 fusion
Very High Risk
WBC > 100000/mm3
T – cell
< 1y/o
Lymphoblastic lymphoma with bone marrow
lymphoblasts > 25%
t(9;22) or BCR-ABL fusion
t(4;11) or MLL-AF4 fusion
Other MLL gene rearrangement
Hypodiploidy ( chr 44 or less)
Poor Prognosis (I)
Acute lymphoblastic leukemia
Relapse
Bone marrow– the most common site,
blast cell increase
CNS– IICP ( vomiting, headache,
papilledema, lethargy)
Convulsion
Behavior disturbance
Testis– painless swelling
Survival rates
75 % to 80% of children with ALL
survive at least 5 years from diagnosis
with current treatments that incorporate
systemic therapy (e.g., combination
chemotherapy) and specific central
nervous system (CNS) preventive
therapy (i.e., intrathecal chemotherapy
with or without cranial irradiation).
Recurrent
The most important extramedullary sites of
relapse are the CNS and the testes.
Treatment
Chemotherapy – reach to remission (blast<5%)
CNS prophylaxis
Intrathecal C/T
Cranial irradiation
Bone marrow transplantation
Management and treatment
Hydration, prevention of hyperuricemia
and tumor lysis syndrome.
Antibiotics, may need the 3rd
generation of cephalosporin or other
strong antibiotics, even antifungal
agents.
Management and treatment
Chemotherapy(include remission
induction, consolidation & maintenance.
CNS prophylaxis with chemotherapeutic
agents(methotrexate 10~15mg,
intrathecal injection).
Management and treatment
Blood transfusion(component therapy)
Nutritional support
Bone marrow transplantation
Growth factor
Treatment
The primary treatment for ALL is
chemotherapy.
Radiation therapy may be used in
certain cases
Bone marrow transplantation is being
studied in clinical trials.
Treatment : Chemotherapy
uses drugs to kill cancer cells
drugs may be taken by mouth, or may
be put into the body by a needle in a
vein or muscle.
All chemotherapy is stopped after two
to three years of treatment .
Treatment : Chemotherapy
Prednisone:
Used in induction and reinduction
therapy and also given as intermittent
pulses during continuation therapy.
toxicity :
fluid retention, increased appetite,
transient diabetes, acne, striae,
personality changes, peptic ulcer,
immunosuppression, osteoporosis,
growth retardation; caution in diabetes,
fungal infections, and osteonecrosis
Vincristine:
toxicity :
Peripheral neuropathy manifested by
constipation, ileus, ptosis, vocal cord
paralysis, jaw pain, abdominal pain,
loss of deep tendon reflexes; reduce
dosage with severe peripheral
neuropathy; bone marrow depression;
local ulceration with extravasation,
SIADH
Asparaginase
local rash, hives, anaphylaxis; bone marrow
depression, hyperglycemia, hepatotoxicity,
and bleeding may occur.
Daunorubicin
Myelosuppression and thrombocytopenia;
may cause cardiac arrhythmias immediately
following administration and cardiomyopathy
after long-term use; nausea, vomiting,
stomatitis, and alopecia; extravasation may
occur, resulting in severe tissue necrosis;
caution with impaired hepatic, renal, or
biliary function.
Methotrexate (Folex PFS)
Hematologic, renal, GI, pulmonary, and
neurologic systems; discontinue if
significant drop in blood counts;
aspirin, NSAIDs, or low-dose steroids
may be administered concomitantly
with MTX (possibility of increased
toxicity with NSAIDs, including
salicylates, has not been tested)
Radiation Therapy
uses x-rays or other high-energy rays
to kill cancer cells and shrink tumors.
Treatmet for VHR
Induction:(10 weeks)
Prednisolone,Vincristine,Idarubicin,
Asparaginase,cyclophosphamine,cytarabine,
6-MP,TIT.
Consolidation:(8 weeks)
6-MP,MTX,TIT
Reinduction:(7 weeks)
Dexamethasone, ,Vincristine,Idarubicin,
Asparaginase,cyclophosphamine,cytarabine,
6-MP,TIT.
Bone Marrow Transplantation
Hematopoietic stem cell transplantation
is an option for very high-risk cases
(e.g., Philadelphia chromosomepositive ALL) or those who develop an
early relapse in the bone marrow.
Bone Marrow Transplantation
a newer type of treatment.
high doses of chemotherapy with or without
radiation therapy are given to destroy all of
the bone marrow in the body.
Healthy marrow is then taken from another
person (a donor).
autologous bone marrow transplant, is being
studied in clinical trials.
Treatment
Induction : 4 weeks
Hyhration.
Allopurinol
Vincristine iv qw & Prednisolone po qd
L- asparaginase
Mediastinum or spine tumor : R/T
Treatment
CNS prophylaxis
Intrathecal ingestion : methotrexate
Intrathecal ingestion : methotrexate ,
Ara-C, hydrocortisone
High risk:Intrathecal ingestion C/T&R/T
THANKS !