The Role of the Practitioner in the Care of Children with Acute Leukemia

Abstract

The prognosis for a child with acute leukemia has improved dramatically over the past two decades. There are many factors that account for the improved survival rate including: better supportive care, especially for infectious and hematologic complications; sophisticated diagnostic techniques; and more effective multimodality treatment. The purpose of this article is to provide a guide for handling some of the more common questions and problems that may arise in the course of managing the care of a child with leukemia in practice. The classification of leukemia, previously based simply on the morphology of the bone marrow elements, is now determined by a complex array of morphologic, cytochemical, and immunologic characteristics. The determination of cell surface and cytoplasmic markers by immunologic assays now permits the subclassification of acute lymphocytic leukemia, the most common form of childhood leukemia, into T, B, null, and pre-B subtypes (Table 1). The T and B cell subtypes are associated with a poorer prognosis than the null and pre-B cell subtypes and treatment is tailored accordingly. Antileukemic therapy also has undergone change and refinement. The 1950s and 1960s brought many new cytotoxic drugs, first used singly and then in combinations. The end of this era was marked by the discovery of the value of prophylactic CNS treatment, using cranial irradiation and intrathecal methotrexate, in greatly reducing the incidence of meningeal leukemia.