Problem list: -Weakness, lethargy -pain in abdomen and shoulder -painless lumps on back of neck -ecchymoses over mid-thorax

-spleenomegaly -hepatomegaly -nontender lymph nodes -15y.o, boy Painless nodes imply a malignancy. Often fixed to surrounding tissue Hodgkins lymphoma (lymphocyte predominant common in <35y.o. males). More common in adults. First peak 15-34y.o., second peak >50y.o. Common site is neck region. Burkitts lymphoma adolescents or young adults. EBV relationship. Acute lymphoblastic leukemia occurs in children. Most common leukemia and cancer in children newborn to 14y.o. Fatigue, bleeding, bone pain, lymphadenopathy. Acute Myeloblastic leukemia common in ages 15-39. DIC is common. Mainly a disease of adults (20% of childhood leukemias). Fatigue due to anemia, bleeding due to thrombocytopenia Acute myeloid mainly adults Chronic lymphocytic Usually greater than 60y.o., more common in males (1.8:1) Chronic Myeloid rare in children Hodgkins lymphoma - First peak 15-34y.o Lymphoblastic leukemia most common childhood tumor Myelodisplastic syndrome most common in elderly patients Multiple Myeloma common in adults (40-50) Thrombocytopenia and anemia (RBC down, hemoblogin low, hematocrit low) Blood smear shows irregularly shaped RBC of varying sizes and tons of abnormal Lymphoblasts show condensed nuclear chromatin, small nucleoli and scant cytoplasm. Increased number of lymphoblasts. Some smudge cells due to fragility of lymphoblasts

Acute lymphoblastic leukemia - Normocytic anemia with thrombocytopenia, over 20% lymphoblasts in peripheral blood. Normal hematopoietic precursors are markedly decreased in marrow Bone marrow biopsy hypercellular bone marrow totally replaced by lymphoblasts Children with lymphoblasts exhibiting hyperdiploidy (54 to 58 chromosomes) have the best
prognosis, particularly if associated with the combined trisomies of chromosomes 4, 10, or

17 [45,46]. Such patients usually do well and require less toxic therapies. In contrast, extreme hyperdiploidy (59 to 84 chromosomes) or hypodiploidy (fewer than 45 chromosomes) is associated with poor outcome Approximately 70 to 80 percent of cases of childhood ALL are of B-precursor lineage (ie, precursor B-cell leukemia or early pre-B cell ALL). B-precursor leukemia typically is CD10+, CD19+, and sometimes CD20+. Leukemic lymphoblasts with the L3 morphology (described above) usually have markers for mature-B-cell ALL (CDs 10 19,20,22,25, and surface immunoglobulin [sIg]). Cases of T-cell ALL (ie, precursor T lymphoblastic leukemia), which comprise 15 to 17 percent of all cases of ALL, are positive for CDs 2, 3, 4, 5, 7, and 8

t(9:22) Because of its association with poor outcome, patients with this abnormality are
assigned to higher intensity treatment. L1 morphology At the time of diagnosis, patients with ALL commonly require transfusion support, treatment of suspected or proven infections with broad-spectrum antibiotics, and, for patients with a high tumor burden, correction of any metabolic imbalances such as hyperuricemia. A rare patient may require leukapheresis or exchange transfusion to control extreme leukocytosis. Rasburicase is approved for use by the U.S. Food and Drug Administration (FDA) (and European [1] counterparts) for the prevention and treatment of tumor lysis syndrome (TLS) in patients receiving chemotherapy for hematologic cancers such as leukemias and lymphomas. In a study of 328 children with ALL, the following four factors were identified as independent predictors of tumor lysis syndrome on multivariate analysis [23]: Age >10 years Splenomegaly Mediastinal mass Initial white blood cell count >20,000/microL

Absence of all four of these risk factors indicated a low risk for development of tumor lysis syndrome, with a negative predictive value of 98 percent and a sensitivity of 96 percent. CNS PREVENTIVE THERAPY Leukemic involvement of the central nervous system (CNS) at the time of diagnosis is an uncommon finding, occurring in fewer than 5 percent of patients [45]. However, before the use of preventive CNS therapy, up to 80 percent of children with ALL who were in complete bone marrow remission relapsed with "leukemic meningitis" [46]. The routine use of preventive CNS therapy is a major therapeutic advance in the treatment of childhood ALL. CNS treatment usually begins during the induction phase and continues throughout the remainder of the treatment regimen.