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Acute lymphocytic leukemia (ALL) is a fast-growing cancer in which the body produces a large
number of immature white blood cells (lymphocytes). These cells are found in the blood, bone
marrow, lymph nodes, spleen, and other organs.

ALL makes up 80% of childhood acute leukemias & the most common malignancy in chldren. Most
cases occur in children ages 3 ± 7.In acute leukemia, cancerous cells take over normal parts of the
bone marrow, often causing low blood counts .
Most cases of ALL have no obvious cause. However,some conditions like chromosome
anomaly,radiation exposure ,past treatment with chemotherapy drugs,Toxins such as benzene,
Down syndrome or other genetic disorders, or who have a brother or sister with leukemia are at
increased risk for ALL..
Thre common symptoms include bone and joint pain or tenderness,easy bruising and bleeding ,
tiredness, fever, anorexia, pallor, lymphadenopathy, hepatosplenomegaly. A peripheral smear of such
a patient usually hints the prescence of abnormal lymphocytes. The bone marrow stud is the
confirmatory test. . Apart from marrow involvement it can also present with testicular or CNS
involvement, which can be diagnosed by testicular biopsy or lumbar puncture. Tests like
immunophenotyping,chromosomal studyand cytogentic study can subclassify as well as
prognostically assess the disease Leukemias with certain types of chromosome changes have a poor
outlook, while those with other types of genes can have a very good outlook. This may determine
what kind of therapy is used to treat the ALL.
©  
The goal of treatment is to get the blood counts and the bone marrow back to normal . If there is
<5% blast in marrow,ALL is said to be in remission. Several protocols are available for treatment of
leukemia. One of the successful protocol is MCP 841 .
It consist of 3 phases ±
1. Induction of remission (4 to 5 weeks)
2. Consolidation & intensification ()
3. Maintanence cycle(1.5 to 2.5 yrs)
The treatment takes nearly 3 yrs to complete, many times it gets prolonged due to various factors like
marrow suppression (drug toxicity), infections, relapse, poor compliance etc...
With modern intensive protocols in developed countries, approximately 70% to 80 % of ALL are now
long term survivors. c

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©he treatment of ALL is one of the true success stories n medical oncology. Before advent of
chemotherapy in 1960s, ALL was a fatal disease. With modern intensive protocols in developed
countries, approximately 70% to 80 % of ALL are now long term survivors; however ©

 NO©
©
N CA OF DLOP
NG CON©
 where 80% of ALL reside. According to cancer registry
data approximately 8000 new cases of ALL are diagnosed each year in
ndia, unfortunately only 25%
receive appropriate treatment. tudies from
ndia have shown that 40% to 60% of patients treated n
paediatric oncology centre on an affordable protocol with manageable toxicity with manageable
toxicity can be cured.

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©here are several reasons for this poor results including poverty, lack of awareness, lack of access to
medical facility, lack of adequate trained personnel and oncology units and many NN factors.

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dentifying the prognostic factors, common clinical features, events during treatment &treatment
outcome of ALL cases treated with MCP 841 protocol in a referral centre.



 

All cases admitted in
C Kottayam with a diagnosis of ALL and tretd with MCP 841 protocol was
included in study. Cases were diagnosed on basis of history , clinical features like fever, fatigue,
bone & joint pain, abnormal mass, weight loss , hemorrhage, recurrent infections ,
lymphadenopathy, hepatosplenomegaly, testicular swellings etc.. & lab investigations like peripheral
smear, bone marrow studies & immunophenotping.

All case treated bY MCP 841 protocol in a time period of january 2009 till january 2012 was included.
©hose not treated or previously treated with other regimens, and cases who were lost to follow up
were not included.

A detailed proforma covering all major clinical, prognostic & treatment events was prepared. Details
were collected from the case records,interview of patients and followed up closely.


 

cases of ALL treated by MCP 841 protocol from
C kottayam in a time period of January 2009 till
January 2011.


  

30 patients

©

Clinical history, examination findings, case records, lab investigations like complete blood counts,
peripheral smear, bone marrow studies & immunophenotyping.





observational study

   

 1. Cases of ALL
2. Cases treated by MCP 841 protocol
3. admitted in
C kottayam in a time period of January 2009 till January 2011

   


1. ALL cases treated with regimens other than MCP 841

2. Cases lost to follow up




dentifying the

prognostic factors,

common clinical features,

events during treatment,

treatment outcome





3 years


  

©he study will conform to the guidelinesof declaration of elsinki 1964 revised on 1975. ©he study
will be subjected to ethical review board of the study centre




 

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Appearance

Pallor/ icterus/ cyanosis/ clubbing/ edema

Lymphadenopathy

P

BP






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Built

fever,

air

ye- bitot spot/ hemorrhage/ telengiectasia/ corneal haziness/ fundus-

ar discharge

Oral mucositis/gum bleed/ gingivitis or mucositis/ thrush/ glossitis or atrophy/ cheilitis/ stomatitis/
hygiene/ caries/ leucoplakia

Any facial dysmorphism

tenderness over the sternum and other bones

Abdominal distention/ ascitis/ scars

©esticular swelling/ hypogonadism

petechiae or purpura/ ecchymosis/ rash/ hyperpigmentation of knuckles or

fingers/telengiectasia/ulcers/infection/ vitiligo/ koilonychia/ onycholysis/white nails

limbs-any dysmorphism

arthritis/ arthralgia

 

height

weight

head circumference

MAC(1-6yr)




 



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© ʹ abdominal distention/ hepatomegaly/ splenomegaly/ ascitis/ any mass-

CN- higher mental functions-

Any cranial nerve palsy-

Fundus examination

Wasting/ weakness/ hypertonia/hypotonia/ D© brisk or absent/ sensory involvement/

meningismus/ incoordination

KLL & P
N

GN
©O
ONAY- testicular swelling/ edema/ rickets

MCLOKL©AL- jt pain /swelling/ rom /deformity

P
A©OY Y©M ʹtenderness/ respiratory distress/ tachypnoea

auscultation

C- any abnormality of pulse-

JP elevation/ Any abnormal heart sounds-




 


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1. Age less than 1year & more than 10 year

2. CN or ©esticular presentation
3. WBC count at presentation >50000/cumm
4. ©-cell lineage, pre-pre B ALL
5. P LADLP
A positive ALL
6. Male
7. esponse to treatment <4 weeks
8. ypo diploid (MLL-ALL / 11q23/ Ph+)
9. FAB 2/3
10. Mediastnal enlargement
11. isceromegaly +++
12. LD high

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1. Age between 1yr to 10yr

2. No CN or testicular disease at presentation
3. WBC count at presentation<50000
4. CALLA + ALL
5. Female
6. esponse to treatment >4 weeks
7. Pre- B ALL
8. yperdiploid
9. FAB 1




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DC

Platelet



Blast atypical lymphocytes

Peripheral smear

BC

WBC

PLA©L©

MP
ON

Bone marrow aspirate

Bone marrow biopsy

mmunophenotyping
Chromosomal study

taining

cytogenetic study

chest X ray

lumbar puncture

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Any isolated neutropenic episodes no lowest ANC phase

? Febrile /afebrile-
i) any proven infection
ii) Antimicrobial given
? interruption of therapy & no of days
? GMCF & no of days
? ANC value at reastart of therapy

nfections with out neutropenia

? Diagnosis
? ©reatment given
? response

Pancytopenia

? No of episode phase
? Febrile events
? Any treatment interruption
Anemia

? Phase
? b
? cause
? ©ransfusion
?
? esponse

©hrombocytopenia

? alue
? Cause
? ©ransfusion
? esponse

nappropriate dose intensification

? Drug
? eason

nterruption of therapy

? phase
? eason
? No of days

Drug toxicity

? Drug
? ©reatment given
? esponse

Peripheral smear on day 10 of intensification

Bone marrow

1) 2nd week of induction 1-

2) nd of induction phase-

3) Any other time-

-reason-

elapse

? No Phase
? Confirmed by

? Action taken

Drug toxicity




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