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Acute myeloid leukaemia is a type of cancer that affects immature blood cells on the myeloid cell line. AML causes an overproduction of abnormal blast cells (immature white cells), which crowd the bone marrow and prevent it from making normal blood cells.

30 cases per million live birth

RSHAM 45 children (Jan01-Des06)

Each year 50 children

Radiation Exposures
Uncertain, unproven or controversial risk factors

Chemical Exposures

AML
Congenital syndromes Blood Disorders
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Smoking

M0 M1 M2 M3

Undifferentiated acute myeloblastic leukemia Acute myeloblastic leukemia with minimal maturation Acute myeloblastic leukemia with maturation Acute promyelocytic leukemia (APL)

M4

Subdivided M4 Acute myelomonocytic leukemia M4E0 Acute myerlomonocytic leukemia with eosinophilia
Subdivided M5A Acute monocytic leukemia without differentiation M5B Acute monocytic leukemia with differentiation Acute erythroid leukemia Acute megakaryoblastic leukemia
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M5

M6 M7

Proliferation Differentiation

Fatique

Limphadenopathy, Splenomegaliy Hepatomegaly

Fever

Invanding extramedullary site

Bleeding

Peripheral Blood Examination

Bone Marrow Examination

Full Blood Count

Immunophenotyping & Cytogenetic Tests

AML
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Malignancy

ALL, MDS, CML, Bone marrow metastases of solid tumors such as ; neuroblastoma, rhabdomyosarcoma, Ewing sarcoma, NHL

NonMalignancy

Transiet leukemoid reactions, transiet myeloproliferative syndrome, juvenile chronic arthritis, viral induced bone marrow suppresion, aplastic anemia, congenital or acquired neutropenia and autoimmune cytopenia.
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Because AML progresses so quickly, treatment needs to begin as soon as it is diagnosed. Treatment of chemotherapy for AML can be divided into two phases: induction therapy and post-remission therapy For some people very high doses of chemotherapy or radiotherapy are needed to cure, or more effectively treat their AML. As a In these cases a bone marrow or peripheral blood stem cell transplant is used.

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A risk factor is something that increases a person's chance of getting a disease. Some risk factors, like smoking, can be controlled. There is no way to prevent leukemia at this time.

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The most common complication in AML patients is failure of the leukemia to respond to chemotherapy. Death may occur in patients with AML as a consequence of uncontrolled infection or hemorrhage.

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Less than 20% of the patients with a recurrence can be cured in the long term. Five year overall survival generally does not exceed 60%. When a bone marrow donor is not available, the overall survival drops to 35-60%. These prognostic factors include the cytogenetic test, the patient's age, and the white blood cell count. Other important factors include pre-existing blood disorders and a history of treatment with chemotherapy and/or radiation therapy for an earlier cancer.
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came to the Pediatrics Department of RSHAM on 5th June 2011 at 17.30 pm with the main complaint was continuity for chemoteraphy

He is regular patient from Hemato-Oncology Unit in RSHAM with the diagnose of Acute Myeloblastic Leukaemia and had started chemoteraphy since 19th February 2011

MF, boy,5TH years old

chemoteraphy with the medicine Vincristine, cyclophospamide, and Adriamycine

History of medication : chemoterphy agent, blood transfusion (PRC washed), desferal.

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Presence Status: Sensorium: Compos mentis; Body Temperature: 36C, BW: 20 kg, BL: 103 cm. Anemic (-), Dyspnea (-), Icteric (-), Cyanosis (-), Oedema (-). Child growth: BW/BL BW/Age BL/Age : 101,2 % : 98 % : 94,2 %

Localized Status : Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior -/-. Ear/Nose/Mouth: within normal limit Neck : Lymph node enlargement (-), jugular vein pressure: R-2 cmH2O. Chest : Symmetric fusiformic, retraction (-). HR : 102 bpm, regular, murmur -. RR: 26 tpm, regular, ronchi (-) Abdomen : Soepel, peristaltic (+) normal. Liver / Spleen : within normal limit Extremities : Warm, Pulse : 102 bpm, regular, adequate pressure/volume, clubbing finger(-), BP : 90/60 mmHg.
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Working Diagnosis Acute Myeloblastic Leukemia

Therapy Cotrimoxazole 2x240 mg

Normal Diet 1500 kcal with 40 gr protein

Planning of treatment Transfusion PRC 256 cc Vincristin 1,5 mg/m2/week Cyclophospamide 200 mg/m2/week Adriamycine 40 mg/m2/week

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Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite Trombocyte (PLT) 7,80 g % 3,34x106/mm3 3,84x103/mm3 23,40 % 6x103/mm3

Results

Normal Value 11,0 14,1 g % 4,40 4,48 x106/mm3 4,5 13,5 x103/mm3 37 41 % 150 - 450 x103/mm3

MCV
MCH MCHC Liver SGOT SGPT Renal Ureum Creatinin Uric Acid ANC

70,1 fL
23,4 pg 33,3 g %

81 95 fL
25 29 pg 29 31 g %

15 19

< 38 U/L < 41 U/L

16 mg/dL 0,29 mg/dL

< 50 mg/dL 0,32 0,39 mg/dL <7,0

560
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S : Pale (+), fever (-) O: Presence status :Sensorium : Compos mentis, Body temperature : 36,8 C, BW : 20 kg, BL : 103 cm. Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-). Localized status : Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-). Ear/Nose/Mouth: within normal limit Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O. Chest : Symmetric fusiformic, retraction (-) HR : 100-110 bpm, regular, murmur (-) RR : 24-22 tpm, regular, ronchi (-) Abdomen : Soepel, peristaltic (+) normal. Liver / Spleen : within normal limit Extremities : Warm, Pulse : 100 bpm, regular, adequate pressure/volume, clubbing finger, extremities were pallor, BP : 100/60 mmHg. Anogenital : Male, within normal limit
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A : Acute Myeloblastic Leukemia FAB M4 P : - IVFD D5% NaCl 0,45% 20 gtt/i macro

Cotrimoxazole 2 x 240 mg - Normal Diet 1500 kcal with 40 gr protein R : - Vincristin 1,5 mg/m2/week 1,2 mg / IV - Cyclophospamide 200 mg/m2/week 160 mg /IV

Doxorubicin 40 mg/m2/week 32 mg / IV MTX + Dexa-M + Ara-C (8 mg 20 mg 0,8 mg) Miloz amp 15 mg/IT 7 June 2011 Transfusion PRC 175 cc/ 12 hour

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S : Pale (-), fever (-) O: Presence status :Sensorium : Compos mentis, Body temperature : 36,9C, BW : 20 kg, BL : 103 cm. Anemic (+), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-). Localized status : Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-). Ear/Nose/Mouth: within normal limit Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O. Chest : Symmetric fusiformic, retraction (-) HR : 102 bpm, regular, murmur (-) RR : 28 tpm, regular, ronchi (-) Abdomen : Soepel, peristaltic (+) normal. Liver / Spleen : within normal limit Extremities : Warm, Pulse : 100 bpm, regular, adequate pressure/volume, clubbing finger, extremities were pallor, BP : 100/60 mmHg. Anogenital : Male, within normal limit

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A : Acute Myeloblastic Leukemia FAB M4 P : - IVFD D5% NaCl 0,45% 20 gtt/i macro

Cotrimoxazole 2 x 240 mg - Normal Diet 1500 kcal with 40 gr protein R : - Vincristin 1,5 mg/m2/week 1,2 mg / IV - Cyclophospamide 200 mg/m2/week 160 mg /IV Doxorubicin 40 mg/m2/week 32 mg / IV MTX + Dexa-M + Ara-C (8 mg 20 mg 0,8 mg)

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Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) Leukocyte (WBC) Hematocrite 12,72 g % 4,74x106/mm3 3,94x103/mm3 35,50 %

Results

Normal Value 11,0 14,1 g % 4,40 4,48 x106/mm3 4,5 13,5 x103/mm3 37 41 %

Trombocyte (PLT)
MCV MCH MCHC Renal Ureum Creatinin Uric Acid ANC GFR

7x103/mm3
74,90 fL 25,70 pg 34,40 g %

150 - 450 x103/mm3

81 95 fL 25 29 pg 29 31 g %

16 mg/dL 0,29 mg/dL

< 50 mg/dL 0,32 0,39 mg/dL <7,0

430 194,35 96,5 136,9

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S : Pale (-), fever (+) O: Presence status :Sensorium : Compos mentis, Body temperature : 38,3C, BW : 20 kg, BL : 103 cm. Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-). Localized status : Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-). Ear/Nose/Mouth: within normal limit Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O. Chest : Symmetric fusiformic, retraction (-) HR : 112-136 bpm, regular, murmur (-) RR : 24-26 tpm, regular, ronchi (-) Abdomen : Soepel, peristaltic (+) normal. Liver / Spleen : within normal limit Extremities : Warm, Pulse : 100 bpm, regular, adequate pressure/volume, clubbing finger, extremities were pallor, BP : 100/60 mmHg. Anogenital : Male, within normal limit

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A : Acute Myeloblastic Leukemia FAB M4 Induction Phase + Renal Hiperfiltration P :- Transfusion of Trombocyte 2 unit - IVFD D5% NaCl 0,45% 20 gtt/i macro - Cotrimoxazole 2 x 240 mg (three times a week) - Ceftriaxon Injection 1 gr /12 hour Skin test day 1 - Sanmol Syrup 3 x cth II (if fever) - Normal Diet 1500 kcal with 40 gr protein
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S : Pale (-), fever (+), Nausea (-), epistachis (+) O: Presence status :Sensorium : Compos mentis, Body temperature : 38,5C, BW : 20 kg, BL : 103 cm. Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-). Localized status : Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-). Ear/Nose/Mouth: within normal limit Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O. Chest : Symmetric fusiformic, retraction (-) HR : 102-110 bpm, regular, murmur (-) RR : 24-30 tpm, regular, ronchi (-) Abdomen : Soepel, peristaltic (+) normal. Liver / Spleen : within normal limit Extremities : Warm, Pulse : 100 bpm, regular, adequate pressure/volume, clubbing finger, extremities were pallor, BP : 100/60 mmHg. Anogenital : Male, within normal limit

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A : Acute Myeloblastic Leukemia FAB M4 Induction Phase + Renal Hiperfiltration P :- Transfusion of Trombocyte 2 unit 11th June - IVFD D5% NaCl 0,45% 20 gtt/i macro - Cotrimoxazole 2 x 240 mg (three times a week) - Ceftriaxon Injection 1 gr / 12 hour - Sanmol Syrup 3 x cth II (if fever) - Normal Diet 1500 kcal with 40 gr protein

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S : Pale (-), fever (+), Nausea (-), Cough (+), epistaxis (-) O: Presence status :Sensorium : Compos mentis, Body temperature : 38,5C, BW : 20 kg, BL : 103 cm. Anemic (-), Dyspnea (-) , Icteric (-), Cyanosis (-), Oedema (-). Localized status : Head : Eye : Light reflexes (+/+), isochoric pupil, pale conjunctiva palpebra inferior (-/-). Ear/Nose/Mouth: within normal limit Neck : Lymph node enlargement (-), jugular vein pressure : R-2 cmH2O. Chest : Symmetric fusiformic, retraction (-) HR : 113 bpm, regular, murmur (-) RR : 32 tpm, regular, ronchi (-) Abdomen : Soepel, peristaltic (+) normal. Liver / Spleen : within normal limit Extremities : Warm, Pulse : 100 bpm, regular, adequate pressure/volume, clubbing finger, extremities were pallor, BP : 100/60 mmHg. Anogenital : Male, within normal limit

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A : Acute Myeloblastic Leukemia FAB M4 Induction Phase + Renal Hiperfiltration P : - IVFD D5% NaCl 0,45% 20 gtt/I macro - Cotrimoxazole 2 x 240 mg (three times a week) - Ceftriaxon Injection 1 gr / 12 hour - Paracetamol Syrup 3xcth II (if fever) - Ambroxol pulp 3x10mg - Normal Diet 1500 kcal with 40 gr protein

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Complete Blood Count Hemoglobin (Hb) Erytrocyte (RBC) 9,30 g % 3,07x106/mm3

Results

Normal Value 11,0 14,1 g % 4,40 4,48 x106/mm3

Leukocyte (WBC)
Hematocrite Trombocyte (PLT) MCV MCH MCHC ANC GFR

14,24x103/mm3
23,20 % 27x103/mm3 75,50 fL 24,70 pg 31,80 g % 417

4,5 13,5 x103/mm3

37 41 % 150 - 450 x103/mm3 81 95 fL 25 29 pg 29 31 g %

96,5 136,9

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 causes an overproduction of abnormal blast cells (immature white cells)

AML

cannot produce adequate numbers of red cells, normal white cells and platelets

This makes people with AML more susceptible to anaemia, recurrent infections and to bruising and bleeding easily

In this chase

the patient was admitted the main complain history of anaemia and always get transfusion while in hospital, recurrent infections like cough, flu, often fever and also have history of bleeding like epistaxis.

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 diagnosis of AML is made on bone marrow aspirate and biopsy with the presence of Diagnose greater than 30% blasts.

In this case

the patient has AML because he has bone marrow aspirate on 15th February 2011 and presence of an excessive number of blast cells.

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A child with AML

should assessed for anaemia, decreased bleeding or bruising, frequent or repeated infections

the patient was got transfusion for his anaemia and covered his history of bleeding and also got antibiotic for his recurrent infection. This patient should continuing his chemotherapy but his ANC (Absolute Neutrophil Count) less than 500

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Prognosis
Prognosis of childhood acute myeloid leukemia (AML) has improved significantly over the past decades, from nearly no child surviving to a present probability of cure of approximately 60%.

this can only be achieved using very intensive chemotherapy which results in relatively high rates of treatment related deaths and significant late effects

In This Case
the patient was not continuing his chemmotherapy because his ANC less than 500.
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It has been reported that a case of a 5 years old boy diagnosed as Acute Myeloblastic Leukemia. The diagnosis was established based on history talking, clinical manifestation, laboratory finding and bone marrow aspiration. The treatment of this patient are IFVD D5% NaCl 0,45%, Amikacin injection, Cotrimoxazole, Paracetamol, diet 1500 ccal with 40 gr of protein and chemotherapy with the medicine (Vincristine, Cyclophosphamide, and Adriamycin).

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