CLINICAL PROFILE OF PATIENTS WITH CHILDHOOD

LEUKEMIA AGED 19 YEARS OLD AND BELOW

ADMITTED AT EASTERN VISAYAS REGIONAL
MEDICAL CENTER, DEPARTMENT OF PEDIATRICS
FROM JANUARY 1, 2011 TO DECEMBER 31, 2015

A Research Protocol presented to the Department of

Pediatrics

Submitted by:
Abbie Dorothy M. Florentin
April 2016
INTRODUCTION

The leukemias are the most common malignant neoplasms in childhood, accounting for
about 31% of all malignancies that occur in children <15 years of age. Each year leukemia is
diagnosed in approximately 3,250 children < 15 years of age in the USA, an annual incidence of
4.5 cases per 100,000 children. Acute lymphoblastic leukemia (ALL) accounts for about 77% of
cases of childhood leukemia, acute myelogenous leukemia (AML) for about 11%, chronic
myelogenous leukemia (CML) for 2 3%, and juvenile myelomonocytic leukemia (JMML) for1
2%.
The leukemias may be defined as a group of malignant diseases in which genetic
abnormalities in a hematopoietic cell give rise to an unregulated clonal proliferation of cells. The
progeny of these cells have a growth advantage over normal cellular elements, because of their
increased rate of proliferation and a decreased rate of spontaneous apoptosis. The result is a
disruption of normal marrow function and, ultimately, marrow failure.1
Leukemia accounted for almost 50% of the total incidence of childhood cancer in the
Philippines. In Metro Manila, Acute Lymphoid Leukemia (ALL) comprised 65% of all
leukemias among children (0-14 years), and 79% of ALL occurred between the ages 1- 9 years.
The 5-year relative survival rate of Metro Manila children with ALLwas lower (34%) compared
to Asian American (87%) and Caucasian children (86%) in the United States. This is also mainly
due to poor access to treatment.
The country is densely populated and the average life expectancy of its population is 68
years. Children under 15 account for 36% of the population. Cancer incidence data for the
country are derived from the two population based cancer registries: Rizal and Manila, which
both cover about 14% of the childhood population. The crude rate for childhood cancer in the
Philippines is 103 annual new cases per million children, which allows prediction of a minimum
of 3500 new cases of childhood cancer. This is the equivalent of almost10 children who will be
diagnosed with cancer each day.2

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OBJECTIVES OF THE STUDY

This study will be conducted to determine the clinical profile of patients with childhood
leukemia admitted at Eastern Visayas Regional Medical Center, Department of Pediatrics from
January 1, 2011 to December 31, 2015.
Specifically, this study aims to:
1. Determine the demographic profile of patients with childhood leukemia admitted
admitted at Eastern Visayas Regional Medical Center, Department of Pediatrics from
January 1, 2011 to December 31, 2015 as to:
a. Age
b. Sex
c. Geographic Distribution
d. Socioeconomic Status
2. Identify the clinical features of patients with childhood leukemia admitted at Eastern
Visayas Regional Medical Center, Department of Pediatrics from January 1, 2011 to
December 31, 2015 as to:
a. Chief Complaint
b. Physical Examination findings
3. Enumerate the diagnostic work-up of patients with childhood leukemia admitted at
Eastern Visayas Regional Medical Center, Department of Pediatrics from January 1, 2011
to December 31, 2015, as follows:
a. Baseline Leukocyte count
b. Baseline Hemoglobin level
c. Differential Count
c. Baseline Platelet count
d. Bone Marrow Aspiration
4. Determine the possible factor predisposing to childhood leukemia of patients with
admitted at Eastern Visayas Regional Medical Center, Department of Pediatrics from January
1, 2011 to December 31, 2015 as to:
a. Genetic conditions
b. Environmental factors
c. Infection
5. Determine the status of patient after being diagnosed with childhood leukemia admitted
at Eastern Visayas Regional Medical Center, Department of Pediatrics from January 1,
2011 to December 31, 2015 as to:
a. If patient underwent chemotherapy
b. Refused Chemotheraphy and went on HAMA

c. Transfered to higher center

d. Expired
SIGNIFICANCE OF THE STUDY
This study is an initial attempt to determine the clinical profile of patients with childhood
leukemia admitted at Eastern Visayas Regional Medical Center, Department of Pediatrics from
January 1, 2011 to December 31, 2015. For us pediatrician, this will serve as baseline data and
documentation of childhood leukemia in our locality.
SCOPE AND LIMITATION
This study will be limited to the pediatric patients aged 19 years old and below who were
admitted at Department of Pediatrics at Eastern Visayas Regional Medical Center in Tacloban
City from January 1, 2011 to Deceber 31, 2015, and who were diagnosed with childhood
leukemia based on Bone Marrow Cytology.

OPERATIONAL DEFINITION OF VARIABLES

Socioeconomic Status will be based on the occupation of the parents and their monthly income
and will be categorized based on the Family Income and Expenditure Survey (FIES) of the
National Statistical Coordination Board (NSCB).
1. High income class are families or people earning an average of P200,000 a month or
P2.4 million a year.
2. Middle income class is said to earn an average of P36,934 per month
3. Low income class earns an average of P9,061 per month.
Melena discharge of black, tarry stools resulting from a haemorrhage in the upper alimentary
tract.
Epistaxis - nosebleed
Hematochezia passage of bloody stools
Anemia haemoglobin level of < 8 mg/dl

Thrombocytopenia platelet count of <150,00/ul.

Leukocytosis
Leukopenia
Neutropenia an absolute neutrophil count <1500 u/L
Lymphocytosis

REVIEW OF RELATED LITERATURE

Acute leukemia occurs when a hematopoietic stem cell undergoes malignant

transformation into a primitive, undifferentiated cell with abnormal longevity. These lymphoid

cellsproliferate, replacing normal marrow tissue and hematopoietic cells and inducing anemia,
thrombocytopenia, and granulocytopenia. Because they are bloodborne, they can infiltrate
various organs and sites, including the liver, spleen, lymph nodes, CNS, kidneys, and gonads.3
Leukemia is one of the commonest of childhood cancers, and accounts for one third of total
childhood malignancies. The annual incidence of leukemia is 42.1/million white children and
24.3/million black children. Approximately 20,500 new cases in adults, and 2500 in children are
dignosed annually in United States alone, and the disease causes about 15900 deaths a year.
Like all other neoplasias, the etiology of leukemia also remains elusive. However, certain
etiologic factors like viruses, radiations, toxic chemicals, and heredity and congenital disorders
have worth mentioning roles. Down Syndrome, Li Fraumeni Syndrome, Ataxia
telangiectasia, Wiscot Aldrich Syndrome are some of the genetic syndrome and inherited
disorders that increases risk of a child having leukemia.4
Exposure to high levels of radiation is a risk factor for childhood leukemia.The possible
risks from fetal or childhood exposure to lower levels of radiation, such as from x-ray tests or CT
scans, are not known for sure. Some studies have found a slight increase in risk, while others
have found no increased risk. Any risk increase is likely to be small, but to be safe, most doctors
recommend that pregnant women and children not get these tests unless they are absolutely
needed.5
Exposure to chemicals such as benzene (a solvent used in the cleaning industry and to
manufacture some drugs, plastics, and dyes) may cause acute leukemia in adults and, rarely, in
children. Several studies have found a possible link between childhood leukemia and household
exposure to pesticides, either during pregnancy or early childhood. Some studies have also found
a possible increased risk among mothers with workplace exposure to pesticides before birth.6
Leukemias clinically present with fever, pallor, bruising, bleeding and bone pains,
occurring in any combination. Anemia, petechiae, bruising, ecchymosis, lymphadenopathy,
visceromegaly and bone tenderness are common signs of eukemia7

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METHODOLOGY

RESEARCH DESIGN AND SELECTION OF SUBJECTS

This is a descriptive retrospective study involving a five years review of hospital records of all
pediatric leukemia patients aged 19 years old and below who were admitted at Eastern Visayas
Regional Medical Center, Department of Pediatrics from January 1, 2011 to December 31, 2015.
Study population
All pediatric patients admitted at Eastern Visayas Regional Medical Center, Department of
Pediatrics from January 1, 2011 to December 31, 2015, diagnosed to have childhood leukemia
thru Bone Marrow Aspiration Biopsy will be included as the subjects of the study.
Those pediatric patients with leukemia like picture such as presenting with fever, pallor, bruising
and did not underwent Bone Marrow Aspiration will be excluded from the study.

DATA COLLECTION METHOD

This study will involve a five year review of the hospital records of all the eligible pediatric
patients with childhood leukemia admitted at Eastern Visayas Regional Medical Center from
January 1, 2011 to December 31, 2015 after an approval from the Chief of Hospital of the
Eastern Visayas Regional Medical Center to retrieve all the charts of the involved patients from
the Records Section.
From the attached face sheet and written clinical history in the charts, the following demographic
profile of the patients will be noted: (1) age; (2) gender; (3) actual place of residence of the
patients.
From the attached written clinical history, the following data will be gathered: (1) chief
complaint; (2) physical examination findings such as pallor, bruising, lymphadenpaothies,
visceromegaly, bone tenderness; (3) socioeconomic status; (4) possible etiologic factors such as
exposure to infection, genetic conditions and environmental factors.
From the attached physician orders and laboratory results, the following parameters will be
noted: (1) Baseline Hemoglobin level; (2) Baseline Leukocyte count; (3) Differential count (4)
Baseline Platelet count; (5) Bone Marrow Aspiration; (6) the final outcome (Underwent
chemotherapy, Refused chemotherapy and went on HAMA, or mortality).

DATA COLLECTION TOOL

Study questionnaire
CLINICAL PROFILE OF PATIENTS WITH CHILDHOOD LEUKEMIA ADMITTED AT
EASTERN VISAYAS REGIONAL MEDICAL CENTER, DEPARTMENT OF
PEDIATRICS FROM JANUARY 1, 2011 TO DECEMBER 31, 2015
1.
2.
3.
4.

Subject No: _______

Name (initials): _____
Age (in years): ______
Sex:
1. Male
2. Female
5. Residence:
1. Leyte
1.1 1st District
1.2 2nd District
1.3 3rd District
1.4 4th District
1.5 5th District
2. Southern Leyte
2.1 1st District
2.2 2nd District
3. Biliran
4. Samar
4.1 1st District
4.2 2nd District
5. Eastern Samar
6. Northern Samar
5.1 1st District
5.2 2nd District
6. Socioeconomic Status:
1. High income class
2. Middle income class
3. Low income class
7. Chief complaint:
1. Fever
2. Easy Bruising
3. Pallor
4. Bleeding
4.1 Epistaxis
4.2 Gum bleeding
4.3 Melena
4.4 Hematochezia
5. Abdominal enlargement
6. Weight loss

8. Physical Examination Findings:

1. Pallor
2. Bruising
3. Lymphadenopathies
4. Visceromegaly
4.1 Hepatemegaly
4.2 Splenomegaly
4.3 Hepatosplenomegaly
5. Bone tenderness
9. Etiology/Predisposing Factors:
1. Genetic/hereditary conditions
1.1 Downs Syndrome
1.2 Fanconi Syndrome
1.3 WAS
2. Environmental factors
2.1 Radiation
2.2 Toxic Chemicals
3. Infection
10. Laboratory Results:
1. Baseline Hemoglobin Level
1.1 Normal
1.2 Anemia
2. Baseline Leukocyte Count
2.1 Normal
2.2 Leukocytosis
2.3 Leukopenic
3. Differential Count
3.1 Neutropenia
3.2 Lymphocytosis
3.3 Monocytosis
3.4 Presence of Blast Cells
4. Baseline Platelet count
4.1 Normal
4.2 Thrombocytopenia
4.3 Thrombocytosis
5. Bone Marrow Cytology
5.1 Acute Lymphoblastic Leukemia
5.2 Acute Myelogenous Leukemia
5.3 Chronic Myelogenous Lekemia
5.4 Juvenile Myelomonocytic Leukemia
11. Outcome
1. Underwent chemotherapy
2. Refused Chemotherapy and went on Home Against Medical Advised
3. Transferred to higher center for second opinion
4. Died
DATA PROCESSING

The data that will be gathered on each patient will be encoded using MS Excel with the use of a
code system based on the presence and absence of the variables identified.

DATA ANALYSIS
The data will be analysed using a descriptive statistical tool such as construction of frequency
distribution and percentage computation.
Table 1. Sociodemographic Profile of Patients with Childhood Leukemia admitted at EVRMC,
Department of Pediatrics
Demographic Profile
Age:
0 - < 1 y.o
1 5 y.o.
6-10 y.o.
More than 10 y.o.
Sex:
Male
Female
Socioeconomic Status:
High income class
Middle income class
Low income class
Residence:
Leyte
1st District
2nd District
3rd District
4th District
5th District
Southern Leyte
1st District
2nd District
Biliran
Samar
1st District
2nd District
Eastern Samar
Northern Samar
1st District

Number of Patients

Percentage

2nd District

Table 2: Clinical Profile of Patients with Childhood Leukemia admitted at EVRMC, Department
of Pediatrics
Clinical Profile
Chief complaint:
Fever
Easy Bruising
Pallor
Bleeding
Epistaxis
Gum bleeding
Melena
Hematochezia
Abdominal enlargement
Weight loss

Number of Patients

Percentage

Physical Examination
Findings:
Pallor
Bruising
Lymphadenopathies
Visceromegaly
Hepatomegaly
Splenomegaly
Hepatosplenomegaly
Bone tenderness

Table 3: Possible Etiology or Prediposing Factors of Patients with Childhood Leukemia admitted
at EVRMC, Department of Pediatrics
Number of Patients
Genetic/hereditary conditions
Downs Syndrome
Fanconi Syndrome
WAS

Frequency

Environmental factors
Radiation
Toxic Chemicals

Table 4: Diagnostic Features of Patients with Childhood Leukemia admitted at EVRMC,

Department of Pediatrics
Diagnostic Features
Baseline Hemoglobin Level
Normal
Anemia (<8mg/dl)

Number of Patients

Frequency

Baseline Leukocyte Count

Normal
Leukocytosis
Leukopenic
Baseline Differential Count
Neutropenia
Lymphocytosis
Monocytes
Presence of Blast Cells
Baseline Platelet count
Normal
Thrombocytopenia
Bone Marrow Cytology
ALL
AML
CML
JMML

Table 5: Outcome of Patients Diagnosed with Childhood Leukemia admitted at EVRMC,

Department of Pediatrics
Outcome
Underwent chemotherapy
Refused Chemotherapy and
went on HAMA
Transferred to higher center

Number of Patients

Frequency

for second opinion

Died

ETHICAL CONSIDERATIONS
The study will involve a review of the medical records of the patients with childhood leukemia
who were admitted at Eastern Visayas Regional Medical Center, Department of Pediatrics. An
approval of the study will be obtained from the Chairman of the Pediatrics Department of the
hospital as well as from the Head of the Research Committee of the department. A formal letter
will be sent to Eastern Visayas Regional Medical Center and to the Head of the Records Section.
A written formal consent will no longer be obtained from the parents of the subjects. The name
of the subjects will not be revealed; only their initials will appear in the document.

REFERENCES
1. Tubergen David, Bleyer Archie, Ritchey Kim. Nelson Textbook of Pediatrics 19th ed: The
Leukemias. Singapore: Elsevier; 2012. P1732

2. Lecciones, Julius. The global improvement of childhood cancer care in the Philippines.
Cancer Control
3. Rytting, Michael. The Merck Manuals