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Living with Childhood Cancer: Pediatric Leukemia & Lymphoma

Online Health Chat with Dr. Rabi Hanna

July 26, 2011


Introduction

Cleveland_Clinic_Host: Childhood cancer is one of medicine's true success stories. Currently, 80 percent of children and adolescents diagnosed with cancer survive their disease and go on to live productive lives. Two of the most common forms of childhood cancer -- acute lymphocytic leukemia (ALL) and Hodgkin’s lymphoma -- have even higher cure rates.

Leukemia is a type of cancer that develops in the bone marrow. Unlike other cancers, leukemia does not cause tumors. Instead, it causes an overproduction of abnormal white blood cells, which is carried throughout the body. Lymphoma is one of the most common cancers in children, adolescents, and young adults. It is a disease that develops in lymphoid tissue -- found in the lymph, lymph nodes and lymph vessels, and tonsils, spleen and thymus gland.

We no longer face grim survival rates for childhood cancers such as leukemia and lymphoma. Thanks in large part to clinical trials, ALL, Hodgkin’s lymphoma, and other childhood cancers are highly treatable today. When you consider Cleveland Clinic Children's Hospital for your child's cancer care, you are in the very best of hands. Our team of pediatric hematologists/oncologists, radiation oncologists, surgeons, radiotherapists, and cancer nurses provides leading-edge, coordinated, family-friendly care for children and teens.

We use state-of-the-art diagnostic and treatment methods and offer access to the latest research protocols to strive for the best possible outcome for your child. Our Children's Hospital is ranked among the "Best Children's Hospitals" by U.S. News & World Report. And as a "hospital within a hospital" at Cleveland Clinic, we can offer children access to the extraordinary resources of Taussig Cancer Institute.

Rabi Hanna, MD, is Director of Pediatric Bone Marrow Transplantation in Cleveland Clinic Children’s Hospital Department of Pediatric Hematology and Oncology. He is board certified in Pediatrics and board certified in Pediatrics Hematology/Oncology. Dr. Hanna earned his medical degree from Aleppo University Faculty of Medicine in Aleppo, Syria. His post-graduate training includes a pediatric residency at Duke University Medical Center in Durham, North Carolina, and a pediatric hematology-oncology fellowship at Fred Hutchinson Cancer Research Center and Seattle Children’s Hospital in Seattle, Washington.

His specialty interests include treatment of children with malignant and non-malignant disorders who need hematopoietic stem cell transplantation to consolidate the treatment for their malignant disease or to restore normal hematological and immunologic function. He is especially interested in identifying successful conditioning treatment with fewer side effects, especially for non-malignant diseases such as hematological diseases (sickle cell disease, thalassemia major, severe aplastic anemia, Fanconi anemia, etc.) or primary immune deficiency disorders, such as severe combined immune deficiency, Wiskott-Aldrich syndrome, and IPEX. He is also interested in clinical research aimed at identifying genetic factors that affect outcomes post bone marrow transplantation from unrelated donor.

If your child has been diagnosed with leukemia or lymphoma, it can be a scary and emotional time. As a parent, you likely have many questions and concerns about your child’s diagnosis and the best treatment and services available. Join us as Dr. Hanna answers your questions about childhood leukemia and lymphoma, and educates you on the latest treatments and services available at Cleveland Clinic Children’s Hospital.

To make an appointment with Dr. Hanna or any of the pediatric specialists at Cleveland Clinic Children's Hospital, please call 216.444.KIDS (5437) or visit clevelandclinicchildrens.org.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Rabi Hanna. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.


Causes

ElizabethM: What is the cause of childhood leukemia or lymphoma? Is it inherited, does it have environmental causes, or what?

Dr__Rabi_Hanna: The causes of childhood cancers are largely unknown. A few conditions -- such as Down syndrome, other specific chromosomal and genetic abnormalities, and ionizing radiation exposures -- explain a small percentage of cases. Environmental causes of childhood cancer have long been suspected by many scientists, but have been difficult to pin down, partly because cancer in children is rare and because it is difficult to identify past exposure levels in children, particularly during potentially important periods such as pregnancy or even prior to conception. In addition, each of the distinctive types of childhood cancers develops differently -- with a potentially wide variety of causes and a unique clinical course in terms of age, race, and gender, and many other factors. Sometimes, cancer could be caused by an inherited gene abnormality, as in retinoblastoma or in P53 gene mutations.


Symptoms

pbt: What are the symptoms of childhood leukemia?

Dr__Rabi_Hanna: Leukemia symptoms usually include fever, weight loss, and many others symptoms similar to those of other childhood cancers. They can be recognized using the term "CHILD CANCER":

C: Continued, unexplained weight loss
H: Headaches, often with early morning vomiting
I: Increased swelling or persistent pain in bones, joints, back, or legs
L: Lump or mass, especially in the abdomen, neck, chest, pelvis, or armpits
D: Development of excessive bruising, bleeding, or rash
C: Constant infections
A: Whitish color behind the pupil
N: Nausea that persists or vomiting without nausea
C: Constant tiredness or noticeable paleness
E: Eye or vision changes that occur suddenly and persist
R: Recurrent or persistent fevers of unknown origin


Types

scully: A friend of mine was diagnosed with leukemia recently. She is 22. She told me it is the childhood form of leukemia. What does this mean? How is the childhood form of leukemia different the other forms?

Dr__Rabi_Hanna: There are types of leukemia that are more common in childhood than adulthood. For example, Pre-B ALL is more common in children whereas Ph+ ALL is more common in adult leukemia. Your friend may have a type of leukemia that is more often seen in children than in adults. Also central nervous system (CNS) involvement in childhood leukemia is more common that adulthood. Nowadays, we classify the leukemia depending on the abnormal make-up of the cells (abnormal cytogenetics) and flow cytometry of the leukemia cells, rather than the population that it effects.

hattie: Can you define the different stages for non-Hodgkin’s lymphoma (NHL) and what they mean in terms of prognosis?

Dr__Rabi_Hanna: NHL in children first is divided into different types, and depending on the type there are different stages.

  • Lymphoblastic lymphomas -
  • B-cell lymphoma: which could be Small noncleaved cell lymphomas (SNCCLs) or Burkitt’s lymphomas (Burkitt-like lymphomas) , or Diffuse large B-cell lymphomas.
  • Anaplastic Large cell lymphomas (LCLs)

Please refer to www.cancer.gov for more details about types and stages of childhood lymphoma. Also visit clevelandclinicchildrens.org for more information.


Treatment

curious_k: How is chemotherapy given to children? What other treatments are available in place of chemotherapy?

Dr__Rabi_Hanna: Chemotherapy medications could be pills or it may need to be given intravenously. Sometimes we give it intrathecally (inside the fluid surrounding the brain and spine) depending on the type of cancer and the type of chemotherapy needed to treat the patient.

Regarding your question about chemotherapy alternatives, not all childhood cancers require therapy with chemotherapy. Sometimes, we just observe the tumor, or surgery alone may be enough to cure the cancer, or radiation therapy. But many childhood cancers will require a combination of therapies (chemotherapy, surgery, and occasionally radiation therapy).

kasie_s_mom: My 7-year-old daughter was recently diagnosed with acute lymphoblastic leukemia. Her prognosis is good, but it was so difficult to hear the news and start moving through the phases. She is in the phase of therapy called consolidation. She will be in treatment and remission for 2½ years. Is this the same for adults or is it chronic? What can I do to help her get through this?

Dr__Rabi_Hanna: I cannot imagine how hard it is to have a child with leukemia, but it will become easier as the therapy goes on. Your physician will become part of your family.

The treatment for adults could be different from the pediatric protocol; and even in pediatrics, it is somewhat different depending on the type of leukemia and the cytogenetics. The best help you could do is to continue to support her, and be her advocate, similar to what you are doing already.

guardian_angel: My daughter was diagnosed with acute myeloid leukemia (AML) in October last year. She gained remission pretty quickly in February following induction chemotherapy. She received chemotherapy, though, on a lesser intensity until the end of April. We found out yesterday that she relapsed. She goes back to the hospital this week for both chemotherapy and radiotherapy. Is this normal? It seems so soon!

Dr__Rabi_Hanna: AML has a high risk of relapse despite the fact that a patient could achieve remission after induction. The treatment plan for AML involves intense chemotherapy +/- bone marrow transplantation. BMT depends on the cytogenetics detected in the leukemia cells. For example, did your doctor detect any abnormal cytogenetics in the bone marrow leukemia cells, such as monosomy 7, etc.? Also in general, after patient relapse, there will be a need for bone marrow transplantation because conventional chemotherapy alone usually will not provide a cure.


Bone Marrow Transplant

cassidy_2: My nephew is scheduled for a bone marrow transplant. Can you please explain the procedure and the side effects?

Dr__Rabi_Hanna: Bone marrow transplantation is a procedure that is used to replace abnormal or dysfunctional bone marrow cells that produce the blood cells (white blood cells, red blood cells, and platelets). It can be used for the treatment of malignant diseases, such as leukemia, that are not responding to conventional chemotherapy treatment, or it could also be used to treat blood disease, such as thalassemia, and immunodeficiency disorders, where white blood cells are not working appropriately.

There are different types of bone marrow transplant depending on the source of blood stem cells used (i.e., bone marrow, peripheral blood stem cells, or umbilical cord blood) and depending on the preoperative regimen used to get rid of the "abnormal or dysfunctional cells" in the bone marrow.

I will talk about general timelines and side effects for bone marrow transplant (BMT).

1- Preoperative regimen: This could be chemotherapy only or chemotherapy plus radiation therapy. During this period that precedes the BMT procedure, the patient is usually in the hospital, and the side effects are related to the chemotherapy +/- radiation.

2 - Infusion of bone marrow/peripheral blood stem cells/umbilical cord blood: Usually, this is very safe procedure and looks like a "blood or platelets" transfusion. The side effects are usually related to allergic reaction, hemolysis, and sometimes fluid overload.

3- The pancytopenia period: Usually the patient will have very low blood cells (white blood cells, red blood cells, platelets) after the preoperative regimen and will require RBC and PLT transfusion. The patient will be at risk for infection (bacterial, viral, fungal) during this period until the new bone marrow engrafts and starts to produce new cells. This period varies depending on the type of conditioning therapy and also depending on the source of hematopoietic stem cell.

abcd123: My sister was just diagnosed with leukemia and her doctor says I may have to donate bone marrow. Can you give me some information on what this entails?

Dr__Rabi_Hanna: Bone marrow transplant could be the life-saving procedure for many patients who have relapsed or have refractory leukemia that is not responding to conventional chemotherapy. Sometimes it is indicated for very high risk leukemia.

The bone marrow transplant goal is to eliminate the abnormal "leukemia" cells in the bone marrow and replace them with healthy bone marrow stem cells from a donor. The donor should be appropriately HLA-matched to the patient. The best option is when a family member (usually a sibling) is HLA-matched, and then we work up the donor to make sure he or she is healthy to donate bone marrow. The bone marrow donation involves evaluation by a physician to determine that you are healthy and able to undergo general anesthesia in order to do bone marrow harvesting, which is series of bone marrow aspiration from your hip bone: "posterior iliac crest."

The procedure is very safe and well-tolerated. Donors are usually asleep during the procedure and then they are discharged to home after a few hours of observation. Side effects include pain at the bone marrow harvest site (usually bilaterally) and mild anemia that could cause some fatigue for a few days.

dan: Can an adult bone marrow donor be a match for a child or is this age specific?

Dr__Rabi_Hanna: Yes. All the unrelated donors are usually adults. We accept children as donors only if they are family members.

dan: I am on the bone marrow registry. What is involved for the donor if I am a match regarding the actual procedure?

Dr__Rabi_Hanna: At first I would like to thank you for being on the bone marrow registry. Without you we cannot offer this life-saving treatment to many patients.

If you are a match to a patient, first the NMDP (National Marrow Donor Program) will contact you to confirm that you still would like to donate and confirm your HLA (human leukocyte antigen) typing. If it is a match then you will get a physical exam and blood work at an NMDP center to evaluate your health and confirm that you are eligible to donate and healthy enough to be able to donate.

The day of bone marrow donation (harvest) you will have general anesthesia, and then a trained bone marrow transplant physician will perform a series of bone marrow aspirates from your "hip bone," posterior iliac crest, from both sides. It uses special needle to aspirate bone marrow.


General Questions

nystrom: You have used the term 'cytogenetics' a few times when talking about AML. What does this mean?

Dr__Rabi_Hanna: Cytogenetic analysis is a key component to the evaluation of all patients with newly diagnosed or suspected acute myeloid leukemia (AML). Cytogenetics refers to the analysis of the chromosomes, which carry the genes inside the cells. (We usually have 23 pairs of chromosomes, a total of 46 chromosomes inside each cell). Through many different techniques, we can detect abnormal chromosomes due to missing parts or a possible change in location, or sometimes additional chromosomes. With these new techniques we are able to detect the abnormal genes.

The different abnormalities could have different prognoses; for example, AML with monosomy 7 (which means missing one chromosome 7) is highly aggressive AML, and that usually requires bone marrow transplant.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Rabi Hanna is now over. Thank you again Dr. Hanna for taking the time to answer our questions today about childhood cancers.

Dr__Rabi_Hanna:Thank you for your time. Good bye


More Information

To make an appointment with Dr. Hanna or any of the pediatric specialists at Cleveland Clinic Children's Hospital, please call 216.444.KIDS (5437) or visit clevelandclinicchildrens.org.

A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.

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This chat occurred on 7/26/2011

This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.


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