Diagnosis
Prior to examination of the child, a detailed medical history has to be obtained by the doctor which will include the medical history of the child's family members. A physical examination will be performed to look for signs suggestive of leukaemia such as enlarged lymph nodes, liver or spleen. There may also be features of anaemia and thrombocytopenia (low blood platelet count). A neurological examination including examination of the eyes will also be performed and particularly for boys, the genitalia (testes) will be examined for the presence of swelling which is suggestive of leukaemic infiltrates.
Blood is usually taken from the child and sent for basic tests such as a full blood count to measure the number of white blood cells, red blood cells and platelets. It will also reveal the presence of blast cells.
A blood smear is done to look for the presence of leukaemic blasts and may also reveal abnormalities in the red blood cell and platelet population.
From the results of the physical examination and preliminary blood tests, further tests like those below may be needed:
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Bone marrow biopsy and aspiration
Bone marrow samples are obtained usually from the back of the hip bone to diagnose and further classify the specific type of leukaemia. Various tests will be performed on the bone marrow samples including that of genetic testing as different genetic subtypes would mean different risk groups and hence enable the doctor to better predict the outcome and adjust intensity of treatment accordingly.
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Lumbar puncture (spinal tap)
A sample of spinal fluid is removed from the lower back and examined for evidence of abnormal cells. This is to determine if the leukaemia has spread to the central nervous system (brain and spinal cord).
All the procedures will be done by our paediatricians specialising in oncology and children will receive anaesthesia or sedatives for any painful procedures.
Treatment
ALL, AML and chronic leukaemia are all treated with different chemotherapy drugs. The aim is to kill all the leukaemia cells in the body but this usually damages the neighbouring healthy cells. In recent years, new drugs that target specific parts of cancer cells have been developed. These drugs work differently from standard chemotherapy drugs and generally have different and less severe side effects.
In
9a Viva-University Children's Cancer Centre, we run several clinical trials for treatment of leukaemia, most notably the Malaysia-Singapore ALL study and more recently, Natural Killer Cell (Expanded) Singapore which is more cellular therapy based. Together with our scientists and the support of the clinical and research laboratory, we perform the necessary advanced tests, including analysing the genetic abnormalities in the leukaemia cells, to characterise the leukaemia cells and thus allow us to customise the therapy to suit the individual child. We are also able to modify immune cells to target leukaemia cells such as using expanded natural killer cells to attack cancer cells.
In the next year or 2, we also hope to be able to offer chimeric antigen receptor T-cell (CAR-T) cell therapy to our patients. As shown by the groups in Childrens' Hospital of Philadelphia, CAR-T cell therapy has improved the cure rates of relapsed refractory leukaemia.
We also have a 24-hour helpline that allows children to consult with a member of the oncology team and receive immediate medical attention should the need arise.
Chemotherapy
Chemotherapeutic drugs can be given orally (taken by mouth), intravenously (given through the blood vessel), intramuscularly (injection into muscle) and also intrathecally (injected into the cerebrospinal fluid through an opening in the spine). The drugs are usually given based on a protocol but adjustments will be made to each individual depending on his or her age, weight, risk factors and response to therapy.
During this period, close monitoring by a paediatrician specialising in oncology is crucial. As treatment progresses, the cancer treatment team will monitor the child closely for side effects, especially looking out for infections as the drugs given will impair the child's immune system and the ability to fight infections. As the bone marrow becomes suppressed, the red blood cells and platelets will decrease and the problems of fatigue, headaches and bleeding may ensue. To decrease the chance of leukaemia invading the central nervous system, children will receive intrathecal chemotherapy, which administers cancer-killing drugs into the cerebrospinal fluid around the brain and spinal cord. Radiation treatments to eradicate leukaemia in the brain may also be used for certain high-risk children.
Haematopoietic Stem Cell Transplant
In some instances, a stem cell transplant may be necessary in addition to chemotherapy, depending on the type of leukaemia a child has. The child will undergo 'conditioning' whereby chemotherapy drugs and sometimes radiotherapy is given to clear the bone marrow of its stem cells to allow a niche for new healthy stem cells to grow and make new healthy cells. These healthy new stem cells are collected from a healthy donor and will be injected into the child's blood.