Disease and Treatment

Overview of the Role of Certain Blood Cells:

Blood cell development; drawing shows the steps a blood stem cell goes through to become a red blood cell, platelet, or white blood cell. A myeloid stem cell becomes a red blood cell, a platelet, or a myeloblast, which then becomes a granulocyte (the types of granulocytes are eosinophils, basophils, and neutrophils). A lymphoid stem cell becomes a lymphoblast and then becomes a B-lymphocyte, T-lymphocyte, or natural killer cell.

  • Red Blood Cells
    • Carry oxygen to tissues and organs throughout the body1
  • White Blood Cells
    • Fight infection and disease1
    • Types:
      • B Lymphocytes- make antibodies that help fight infection1
      • T Lymphocytes- help to make antibodies to fight infection1
      • Natural Killer Cells- attack viruses and cancer cells1
  • Platelets
    • Help form blood clots to prevent bleeding1

Leukemia (ALL) 

What is it? 

In a healthy child, the bone marrow produces blood stem cells that eventually become mature blood cells. Leukemia, in general, is when the bone marrow begins producing too many immature blood cells. Acute Lymphocytic Leukemia involves the production of too many immature lymphocytes or white blood cells1. These immature white blood cells do not function properly, taking up space for the production of healthy blood cells, including red blood cells, platelets, etc. After diagnosis and determining the number of immature white blood cells produced, the leukemia is categorized as Standard/Low Risk, High Risk, or Very High Risk and a treatment plan is determined1.

Anatomy of the bone; drawing shows spongy bone, red marrow, and yellow marrow. A cross section of the bone shows compact bone and blood vessels in the bone marrow. Also shown are red blood cells, white blood cells, platelets, and a blood stem cell.

What does this look like?

  • Due to the increase of immature lymphocytes, the child’s immune system may not function properly. The child may have issues getting over a cold or virus or may be more susceptible to acquiring an infection with unexplained fevers1. With the continual production of immature cells, the amount of red blood cells can decrease causing faulty oxygen delivery which can manifest as chronic exhaustion or weakness1. In addition, a decrease in platelets may also occur, leading to an increase in bleeding and bruising1.

Who does this typically affect?

  • ALL is the most common type of childhood cancer2.
  • Approximately 3 of 4 children and teenagers who are diagnosed with leukemia are diagnosed with ALL3.
  • It is most common in children younger than 5, with most cases occurring between the ages of 2 and 4.
  • It is less common in girls than boys2.
  • Children with Down syndrome have a 20 fold increased risk of developing ALL4.

What does the typical treatment look like? 

  • Three Phases of Treatment: (Typically 2-3 years)1
  1. Remission Induction1
    1. Goal: To kill all leukemia cells in the blood and bone marrow
    2. Length: Approximately 1 month and requires lengthy hospitalization
  2. Consolidation/Intensification1
    • . Goal: To kill any remaining leukemia cells to prevent a relapse once the patient is in remission, or showing no signs or symptoms
  1. Length: Several months, possible hospitalization
  1. Maintenance1
    • . Goal: To kill any remaining leukemia cells and prevent relapse with lower doses and not as intense of therapy
  1. Length: Several months, but only coming in once every 4-8 weeks
  • Types of Treatment used in the Three Phases:
    • Chemotherapy
      • Goal: To kill cancer cells, but can also kill other healthy cells such as hair, cells in the gut, etc.
      • Can be given by different routes such as by mouth, through the vein, injected into the spine, etc.1
    • Radiation Therapy
      • Goal: To kill cancer cells or stop them from growing using high energy X-rays
      • May be used in combination with chemotherapy1
    • Chemotherapy with Stem-Cell Transplant
      • Goals: To eradicate the child’s bone marrow cells with chemotherapy and radiation and introduce healthy stem cells from a donor with the hope of further growth and restoration of healthy bone marrow.
    • Targeted Therapy
      • Goal: To attack cancer cells with other drugs without harming healthy cells
        • Much research is being done to increase the number of drugs in this category.1

What does it look like for the child when he/she comes back to school?

  • Physical5:
    • Child may still be on oral chemotherapy and other medications that could change their appearance (ex: losing hair, gaining water weight, etc.)
    • Growth development delays
    • Generalized weakness that may require the child to take frequent breaks or naps throughout the day
    • Muscle and joint pain
  • Psychological5:
    • Child may be worried about their absence from school
    • Child may feel socially isolated, especially after prolonged hospitalizations

Depending on the treatment, cognitive changes may be apparent such as impaired attention, decreased information processing speed, impaired memory, etc.

Hodgkin Lymphoma 

What is it? 

Image retrieved from https://doi.org/10.1016/j.soncn.2013.08.005

  • Hodgkin Lymphoma is a type of cancer that develops in the body’s lymph system7. The lymph system is a part of the immune system that helps to protect the body from infections or diseases. It includes lymph vessels, lymph nodes, the spleen, the thymus, the bone marrow, and tonsils. Lymphoma is typically diagnosed by observing cell change of the lymph tissue in lymph nodes7. There are two types: Classic Hodgkin Lymphoma and the more rare Nodular Lymphocyte-Predominant Hodgkin Lymphoma7.

What does this look like?

  • Typical symptoms of Hodgkin Lymphoma are painless, swollen lymph nodes, unexplained fever, night sweats, exhaustion, and unexplained weight loss7. Areas of the body that typically exhibit swollen lymph nodes are the collarbone, neck, chest, underarm, or groin7. The process of diagnosis may include blood draws, CT scans, PET scans, biopsies, etc7.

Who does this typically affect?

  • Occurs most often in adolescents 15-19 years of age7
  • Risk factors include7:
    • Epstein-Barr virus diagnosis
    • Personal history of mononucleosis
    • HIV diagnosis
    • Having an autoimmune disease
    • Family history of Hodgkin Lymphoma
    • Recent organ transplant

What does typical treatment look like? 

  • After diagnosis of Hodgkin Lymphoma, the cancer is categorized as either Stage I, Stage II, Stage III, or Stage IV. The stage is determined by whether or not the cancer has spread as well as by how many lymph nodes or organs have been affected. Once the cancer has been staged, it can then be categorized as Low-Risk, Intermediate-Risk, or High-Risk and a treatment plan can be created7.
  • Six Types of Treatment Used:
    • Chemotherapy
      • Goal: To kill cancer cells and stop them from dividing but can kill other healthy cells such as hair, cells in the gut, etc.
      • Can be given by different routes such as by mouth, through the vein, injected into the spine, etc7.
    • Radiation Therapy
      • Goal: To use high energy X-rays to kill cancer cells or stop them from growing
      • There are several types and are able to target specifically where a tumor may be growing7
    • Targeted Therapy
      • Goal: To use other drugs to attack cancer cells without harming healthy cells. Much research is being done to increase drugs in this category7.
    • Immunotherapy
      • Goal: To stimulate the body’s natural defenses or use an outside medication to boost the body’s ability to fight and kill cancer cells7
    • Surgery
      • Goal: To remove a tumor or lymph nodes containing dividing cancer cells7
    • High-dose Chemotherapy with Stem Cell Transplant
      • Treatment that includes eradicating the child’s bone marrow cells with chemotherapy and radiation. After, the patient receives healthy stem cells with the goal of growing and restoring healthy cells in the patient’s bone marrow7.

What does it look like for the child when they come back to school?

  • Physical5:
    • Child may still be on oral chemotherapy and other medications that could change their appearance (ex: losing hair, gaining water weight, etc.)
    • Growth development delays
    • Generalized weakness and fatigue and may need naps or breaks throughout the day
    • Muscle and joint pain
  • Psychological5:
    • May feel socially isolated, especially after lengthy hospitalization
    • May exhibit signs of anxiety and depression in adolescents1,8 

Depending on the treatment, cognitive changes may be apparent such as impaired attention, decreased information processing speed, impaired memory, etc.

Non-Hodgkin Lymphoma 

What is it? 

  • Lymphomas are a type of blood cancer that start in the lymphatic system, a component of the immune system. When a type of white blood cell called a lymphocyte becomes malignant and eventually crowds out healthy lymphocytes, a tumor develops. This type of tumor enlarges the lymph nodes and may spread to other sites of the immune system or other organs.
  • The two major types of lymphoma are Hodgkin lymphoma and non-Hodgkin lymphoma (NHL).
  • NHL is a type of blood cancer that arises from DNA damage in a lymphocyte parent cell. Unrepaired DNA damage can cause malignant transformation that results in uncontrolled growth and a subsequent tumor mass.
  • NHL typically begins in the lymph nodes or other lymphatic tissues in the stomach, intestines, or skin.
  • Physicians use a physical examination, imaging tests such as computed tomography (CT) scans or Magnetic Resonance Imaging (MRI), tissue biopsies, and blood tests to evaluate the severity of the patient’s NHL and to determine the appropriate treatment plan.
  • NHL can be described using a combination of stages and categories.
    • There are a total of 4 stages:
    • In NHL, the classification of Stage IV doesn’t have the same implications as in other cancer types. More than 80% of indolent types of NHL are given the Stage IV diagnosis and a stage IV diagnosis may be highly curable.

    • Within each of the 4 stages, there are different categories:
      • Category A: No fevers, excessive sweating, or weight loss
      • Category B: Fevers, excessive sweating, and weight loss
      • Category X: Large masses of malignant lymphocytes are present
      • Category E: The tumor has spread to other organs or tissues beyond the lymphatic tissues and lymph nodes

Who does this typically affect?

  • NHL is the fifth most common diagnosis of pediatric cancer in children under 15 years of age.
  • In the developed world, NHL accounts for approximately 7% of childhood cancers.
  • Risk Factors:
    • The prevalence of NHL is between 50 fold to 100 fold higher among people with HIV/AIDS.
    • There is a higher incidence in farming communities due to some ingredients in herbicides and pesticides that may be linked to lymphoma.
    • Another risk factor is having an autoimmune disease, such as Sjögren’s syndrome, lupus, or rheumatoid arthritis.

What does the typical treatment look like? 

  • Chemotherapy and radiation therapy are the main forms of NHL treatment, and some NHL subtypes are also treated using stem cell transplantation. Other forms of drugs have been emerging in the treatment of NHL, including DNA-damaging drugs, antitumor antibiotics, and immunotherapy. In most treatment plans, a combination of different therapies is used to treat patients.
  • Chemotherapy
    • Can be given by different routes such as by mouth, through the vein, injected into the spine, etc.
    • Goal: To kill cancer cells and stop them from dividing but can kill other healthy cells such as hair, cells in the gut, etc.
  • Radiation Therapy
    • There are several types of radiation therapy that are able to target specifically where a tumor may be growing
    • Goal: To use high energy X-rays to kill cancer cells or stop them from growing
  • Childhood and adolescent cancer survivors require close follow-up since cancer therapy side effects may persist or develop months or years after treatment.

What does it look like for the child when he/she comes back to school?

  • The side effects of NHL treatment are diverse and dependent on the individual patient’s susceptibility. Therapies can cause fatigue, fever, cough, lung or cardiac function impairment, and allergies. The child may have rashes and experience hair loss or nerve function impairment such as tingling sensations.
  • Many NHL survivors do not develop long-term effects of treatment, however, treatment-related fatigue may be a long-term effect of NHL treatment that persists for months or years after treatment ends.9,10,11

Brain and Spinal Cord Tumors

What is it? 

  • There are many types of brain tumors, with each type having a different treatment and outlook. In children, many brain and spinal cord tumors differ from those in adults in terms of origin, treatment, and prognosis. Most brain tumors in children start in the lower parts of the brain, such as the cerebellum or brain stem.
  • Brain and spinal cord tumors are classified by the grade of the tumor. Grade I or II (lower grade) tumors typically grow slowly and are less likely to infiltrate into nearby tissues. Grade III or IV (higher grade) tumors need more intensive treatment because they typically grow more quickly and are more likely to infiltrate into nearby tissues.
  • The most common types of brain and spinal cord tumors in children:
  • Gliomas
    • Approximately half of all childhood brain and spinal cord tumors are gliomas.
    • Gliomas are a group of tumors that start in the glial cells, which are the supportive cells in the central nervous system (the brain and the spinal cord). Glial cells are the most abundant in the central nervous system and surround neurons, providing support and insulation.
    • Gliomas include astrocytomas, oligodendrogliomas, ependymomas, brain stem gliomas, and optic gliomas.
  • Astrocytomas
    • Tumors that start in astrocytes, a type of glial cell that supports and nourishes nerve cells
    • Some astrocytomas are spread out throughout the brain and sometimes spread along the cerebrospinal fluid pathways, making them difficult to remove by surgery
    • Tumors that are classified as low grade (grade I or II) astrocytomas or non-infiltrating astrocytomas:
      • Pilocytic astrocytomas
        • A grade I tumor that typically occurs in the cerebellum but also it is also found to start in the optic nerve, hypothalamus, brain stem, and other areas. This tumor accounts for almost 1 out of 5 childhood brain tumors.
      • Subependymal giant cell astrocytomas (SEGAs)
        • A grade I tumor that occurs in the ventricles of the brain
        • Grows slowly and rarely infiltrates into nearby tissues
      • Diffuse astrocytomas
        • A grade II tumor that can infiltrate into nearby tissues, making them hard to remove by surgery
        • Over time, this tumor becomes more aggressive and increases its growth rate
      • Pleomorphic xanthoastrocytomas (PXAs)
        • Most can be cured using surgery along
        • A grade II tumor
      • Optic gliomas
        • Low grade tumors (grade I or II)
        • Start in the optic nerves and typically grow slowly; may cause vision loss
      • Tumors that are classified as high grade (grade III or IV) astrocytomas:
        • Glioblastomas are grade IV and the type of astrocytoma that grows the quickest
        • Anaplastic astrocytomas are a grade III tumor.12,13 

Who does this typically affect?

  • Brain and spinal cord tumors are the second most common cancers in children, accounting for about 1 out of 4 childhood cancers.
  • One environmental risk factor is exposure to radiation, which usually comes from treating other environmental conditions. However, other than radiation exposure, there are very few risk factors that have been found for brain and spinal cord tumors as there is no clear cause for the majority of these tumors.12,14

What does the typical treatment look like? 

  • The principle treatments for brain and spinal cord tumors are surgery, radiation therapy, chemotherapy, targeted therapy, and drug treatments.
  • Surgery:
    • Usually, a neurosurgeon first removes or destroys as much of the tumor as possible without impairing normal brain or nerve function
    • For the slow-growing brain tumors (low-grade astrocytomas, dysembryoplastic neuroepithelial tumors, ependymomas, craniopharyngiomas, gangliogliomas, and meningiomas), surgery can help control the tumor. However, with tumors that grow into nearby brain tissue, these cannot be cured by surgery alone. These tumors are typically treated with a combination of surgery,  radiation, and chemotherapy.
    • Surgery can relieve the headaches, nausea, vomiting, and blurred vision that is caused by increased pressure within the skull of patients with brain tumors.
    • In some cases, surgery may not be an option especially when the tumor has spread to a part of the brain that can’t be removed such as the brain stem or if the tumor is deep within the brain tissue.15
  • Radiation Therapy:
    • Using high energy X-rays to kill cancer cells or stop them from growing
    • Ways radiation therapy can be used:
      • To kill remaining tumor cells post-surgery
      • As the primary treatment in cases where surgery is not ideal
      • To prevent/relieve symptoms the patient experiences from the tumor
    • Physicians called radiation oncologists deliver radiation to the tumor while limiting the exposure to radiation by the surrounding brain areas.
    • After radiation therapy, patients may become irritable and tired. Several weeks after the therapy, some patients may experience drowsiness or other nervous system symptoms, called the radiation somnolence syndrome or early-delayed radiation effect. After a few weeks, all symptoms should pass.16
  • Chemotherapy:
    • Chemotherapy involves using anti-cancer drugs that are taken orally or given into a vein (IV). These drugs travel through the bloodstream and reach almost all parts of the body.
    • Some anti-cancer drugs are unable to reach the tumor cells in the brain, so they are given into the cerebrospinal fluid, the fluid that surrounds the brain and spinal cord. This requires a minor operation where a thin tube called a ventricular access catheter is inserted through a small hole in the skull.
    • Chemotherapy is used for medulloblastomas, a type of brain tumor which responds well to the treatment, as well as for quickly growing brain tumors.17
  • Targeted Therapy Drugs:
    • New research in cancer therapy has led to the development of newer drugs that function differently from standard chemotherapy drugs. Currently, targeted therapy drugs are helpful in treating some types of brain and spinal cord tumors but overall, they do not play a large role in treatment.18
  • Drugs to Mitigate Symptoms from the Tumor or Treatment Side Effects:
    • Children are often given drugs to help relieve symptoms caused by the tumor itself or the side effects from treatments.
    • These drugs include:
      • Corticosteroids
        • Used to reduce the swelling caused by brain tumors
        • Given a few days before and after surgery or radiation therapy
        • These relieve headaches, nausea, and vomiting
      • Anti-seizure drugs (anticonvulsants)
        • Used to lower the possibility of seizures
      • Hormones
        • Pituitary hormones or other hormones may be given to the child if the pituitary gland, which controls the body’s hormone levels, has been damaged by the tumor and/or by different treatments.19

What does it look like for the child when he/she comes back to school?

  • Once childhood tumors are successfully treated, follow-up visits and tests are needed to determine how successful the treatment was and whether the tumor was completely removed and to watch for tumor growth or recurrence. Some patients such as those who get radiation therapy are at a higher risk of another tumor development and may need follow-up tests for many years after treatment.
  • Late and long-term effects of treatment
    • Some effects of treatment include learning difficulties, delayed growth and development, increased risk of other cancers, and effects on the reproductive system.
    • Typically, the effects of treatment are the greatest in the first year of treatment, however, in some children these effects are long-lasting
  • Effects of Radiation Therapy
    • If large areas of the brain receive radiation therapy, the child may lose some brain function and experience problems such as memory loss, personality changes, and difficulty learning at school. While over time, these symptoms may improve, some effects are long-lasting and important to keep in mind as educators of childhood cancer survivors.
  • Effects of Chemotherapy
    • Fatigue
    • Hair loss
    • Mouth sores
    • Loss of appetite
    • Nausea and vomiting
    • Diarrhea
    • Bruising or bleeding
    • Higher susceptibility to infections20 

References

 

  1. National Cancer Institute (2019). Childhood Acute Lymphoblastic Leukemia Treatment  (PDQ)- Patient Version [website]. Retrieved from  https://www.cancer.gov/types/leukemia/patient/child-all-treatment-pdq.
  2. Siegel D.A., Henley S.J., Li J., Pollack L.A., Van Dyne E.A., White A. (2017). Rates and Trends of Pediatric Acute Lymphoblastic Leukemia — United States, 2001–2014. MMWR Morb Mortal Wkly Rep 2017;66:950–954. DOI:  http://dx.doi.org/10.15585/mmwr.mm6636a3
  3. American Cancer Society. (2019). Leukemia- Acute Lymphoblastic- ALL- Childhood:  Statistics [website]. Retrieved from https://www.cancer.net/cancer-types/leukemia-acute-lymphoblastic-all-childhood/statistics
  1. Brown, A.L., de Smith, A.J., Gant, V.U., Yang, W., Scheurer, M.E., Walsh, K.M.,… Rabin,  K.R. (2019). Inherited genetic susceptibility to acute lymphoblastic leukemia in Down syndrome. Blood, 134(15): 1227-1237.  https://doi.org/10.1182/blood.2018890764
  2. Leukemia & Lymphoma Society. (n.d.). Physical Effects [website]. Retrieved from https://www.lls.org/childhood-blood-cancer/long-term-and-late-effects-of-treatment-for-childhood-cancer-survivors/physical-effects
  1. Moore, I.M., Hockenberry, M.J., Krull, K.R. (2013). Cancer-Related Cognitive Changes in Children, Adolescents, and Adult Survivors of Childhood Cancers. Seminars in  Oncology Nursing, 29(4): 248-259. https://doi.org/10.1016/j.soncn.2013.08.005
  2. National Cancer Institute. (2019). Childhood Hodgkin Lymphoma Treatment (PDQ)- Patient Version [website]. Retrieved from  https://www.cancer.gov/types/lymphoma/patient/child-hodgkin-treatment-pdq
  3. Bitsko, M.J., Cohen, D., Dillon, R., Harvey, J., Krull, K., Klosky, J. (2016). Psychosocial Late Effects in Pediatric Cancer Survivors: A Report From the Children’s Oncology Group. Pediatric Blood & Cancer, 63(2): 337-343. https://doi.org/10.1002/pbc.25773
  4. Leukemia & Lymphoma Society. (2013). Non-Hodgkin Lymphoma. Retrieved from https://www.lls.org/sites/default/files/file_assets/nhl.pdf#targetText=It%20is%20distributed%20as%20a,medical%20or%20other%20professional%20services.&targetText=Lymphoma%20is%20a%20general%20term,start%20in%20the%20lymphatic%20system.
  1. Armitage, J. O., Gascoyne, R. D., Lunning, M. A., & Cavalli, F. (2017). Non-Hodgkin lymphoma. Lancet  (London, England),  390(10091), 298–310.https://doi.org/10.1016/S0140-6736(16)32407-2
  1. Sandlund, J. T. (2015). Non-Hodgkin Lymphoma in Children. Current Hematologic Malignancy Reports, 10(3), 237–243. https://doi.org/10.1007/s11899-015-0277-y
  1. American Cancer Society. (2018, June 20). What Are Brain and Spinal Cord Tumors in Children? Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/about/what-are-brain-and-spinal-tumors.html
  1. Arnautovic, A., Billups, C., Broniscer, A., Gajjar, A., Boop, F., & Qaddoumi, I. (2015). Delayed diagnosis of childhood low-grade glioma: Causes, consequences, and potential solutions. Child’s Nervous System, 31(7), 1067–1077. https://doi.org/10.1007/s00381-015-2670-1
  1. American Cancer Society. (2018, June 20). Risk Factors for Brain and Spinal Cord Tumors in Children. Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/causes-risks-prevention/risk-factors.html
  1. American Cancer Society. (2018, June 20). Surgery for Brain and Spinal Cord Tumors in Children. Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/treating/surgery.html
  1. American Cancer Society. (2018, June 20). Radiation Therapy for Brain and Spinal Cord Tumors in Children. Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/treating/radiation-therapy.html
  1. American Cancer Society. (2018, June 20). Chemotherapy for Brain and Spinal Cord Tumors in Children. Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/treating/chemotherapy.html
  1. American Cancer Society. (2018, June 20). Targeted Therapy Drugs for Brain and Spinal Cord Tumors in Children. Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/treating/targeted-therapy.html
  1. American Cancer Society. (2018, June 20). Drugs to Help with Symptoms in Children with Brain or Spinal Cord Tumors. Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/treating/other-drug-treatments.html
  1. American Cancer Society. (2018, June 20). What Happens After Treatment for Children with Brain or Spinal Cord Tumors? Retrieved from https://www.cancer.org/cancer/brain-spinal-cord-tumors-children/after-treatment/follow-up.html

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