NURS 530 Discussion childhood acute lymphocytic leukemia

NURS 530 Discussion childhood acute lymphocytic leukemia

DQ1 Select one of the following discussion prompts to address:

Describe childhood acute lymphocytic leukemia (ALL) and G6PD deficiency and the incidence, pathophysiology, clinical manifestations, evaluation, and treatment of each.

Describe the morphology of erythrocytes, the mechanism, and primary cause of the following anemias: Pernicious anemia, folate deficiency anemia, iron deficiency anemia, thalassemia, and sickle cell anemia.

Describe the most common causes and provide examples for neutrophilia, neutropenia, eosinophilia (i.e., eosinophilia caused by asthma, hay fever, or parasitic infection), eosinopenia, basophilia, monocytosis, monocytopenia, lymphocytosis, and lymphocytopenia.

DQ2 Select one of the following discussion prompts to address:

Discuss the development of coronary artery disease (CAD) and the links to dyslipidemia, hypertension, cigarette smoking, diabetes mellitus, obesity, and sedentary lifestyle. Review the current scholarly literature, and describe the markers and testing of cardiovascular risk and prevention and treatment recommendations.

Describe the pathophysiology of acute rheumatic fever and rheumatic heart disease, and discuss the pathophysiology, clinical manifestations, evaluation (include the revised Jones Criteria), and treatment of rheumatic fever.

Review and summarize the Joint National Committee (JNC) recommendations for the prevention, detection, evaluation, and treatment of high blood pressure. Review the recommendations made by the American Diabetes Association’s 2016 Standards of Medical Care in Diabetes for the control of high blood pressure and summarize the treatment recommendations.

Childhood (also called ALL or acute lymphocytic leukemia) is a of the and . This type of cancer usually gets worse quickly if it is not treated.

Anatomy of the bone. The bone is made up of compact bone, spongy bone, and bone marrow. Compact bone makes up the outer layer of the bone. Spongy bone is found mostly at the ends of bones and contains red marrow. Bone marrow is found in the center of most bones and has many blood vessels. There are two types of bone marrow: red and yellow. Red marrow contains blood stem cells that can become red blood cells, white blood cells, or platelets. Yellow marrow is made mostly of fat.

ALL is the most common type of cancer in children.

Leukemia may affect red blood cells, white blood cells, and platelets.

In a healthy child, the bone marrow makes (immature ) that become mature blood cells over time. A blood stem cell may become a or a stem cell.

A myeloid stem cell becomes one of three types of mature blood cells:

that carry and other substances to all of the body.
that fight and disease.
that form to stop bleeding.

A lymphoid stem cell becomes a cell and then one of three types of (white blood cells):

that make to help fight infection.
that help B lymphocytes make the antibodies that help fight infection.
that attack cancer cells and .

Blood cell development. A blood stem cell goes through several steps to become a red blood cell, platelet, or white blood cell.

In a child with ALL, too many stem cells become lymphoblasts, B lymphocytes, or T lymphocytes. These cells are also called cells. These leukemia cells do not work like normal lymphocytes and are not able to fight infection very well. Also, as the number of leukemia cells increases in the blood and bone marrow, there is less room for healthy white blood cells, red blood cells, and platelets. This may lead to infection, , and easy bleeding.

This summary is about acute lymphoblastic leukemia in children, adolescents, and young adults. See the following summaries for information about other types of leukemia:

Past treatment for cancer and certain genetic conditions affect the risk of having childhood ALL.

Anything that increases your risk of getting a disease is called a . Having a risk factor does not mean that you will get cancer; not having risk factors doesn’t mean that you will not get cancer. Talk with your child’s doctor if you think your child may be at risk.

Possible risk factors for ALL include the following:

Being exposed to before birth.
Being exposed to .
Past treatment with .
Having certain , such as:
- .
- .
- .
- .
- .
- .
- Constitutional mismatch repair deficiency ( in certain that stop from repairing itself, which leads to the growth of cancers at an early age).
Having certain changes in or genes.

Signs of childhood ALL include fever and bruising.

These and other and may be caused by childhood ALL or by other conditions. Check with your child’s doctor if your child has any of the following:

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Easy bruising or bleeding.
(flat, pinpoint, dark-red spots under the skin caused by bleeding).
Weakness, feeling tired, or looking pale.
Bone or pain.
Shortness of breath.
Painless lumps (swollen ) in the neck, underarm, , or .
Pain or feeling of fullness below the ribs.
Loss of .

Tests that examine the blood and bone marrow are used to diagnose childhood ALL.

The following tests and procedures may be used to childhood ALL and find out if leukemia cells have spread to other parts of the body such as the brain or :

and : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient’s health habits and past illnesses and treatments will also be taken.
: A procedure in which a sample of blood is drawn and checked for the following:
- The number of red blood cells and platelets.
- The number and type of white blood cells.
- The amount of (the that carries oxygen) in the red blood cells.
- The portion of the sample made up of red blood cells.
Complete blood count (CBC). Blood is collected by inserting a needle into a vein and allowing the blood to flow into a tube. The blood sample is sent to the laboratory and the red blood cells, white blood cells, and platelets are counted. The CBC is used to test for, diagnose, and monitor many different conditions.
: A procedure in which a blood sample is checked to measure the amounts of certain substances released into the blood by and tissues in the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease.
and : The removal of bone marrow and a small piece of bone by inserting a hollow needle into the hipbone or . A views the bone marrow and bone under a to look for signs of cancer.

Bone marrow aspiration and biopsy. After a small area of skin is numbed, a bone marrow needle is inserted into the child’s hip bone. Samples of blood, bone, and bone marrow are removed for examination under a microscope.

The following tests are done on blood or the bone marrow tissue that is removed:
- : A in which the chromosomes of cells in a sample of blood or bone marrow are counted and checked for any changes, such as broken, missing, rearranged, or extra chromosomes. Changes in certain chromosomes may be a sign of cancer. For example, in –positive ALL, part of one chromosome switches places with part of another chromosome. This is called the “Philadelphia chromosome.” Cytogenetic analysis is used to help diagnose cancer, plan treatment, or find out how well treatment is working.
  
  Philadelphia chromosome. A piece of chromosome 9 and a piece of chromosome 22 break off and trade places. The BCR-ABL gene is formed on chromosome 22 where the piece of chromosome 9 attaches. The changed chromosome 22 is called the Philadelphia chromosome.
- : A laboratory test that uses antibodies to identify cancer cells based on the types of or on the surface of the cells. This test is used to help diagnose specific types of leukemia. For example, the cancer cells are checked to see if they are B lymphocytes or T lymphocytes.
: A procedure used to collect a sample of (CSF) from the . This is done by placing a needle between two bones in the and into the CSF around the and removing a sample of the fluid. The sample of CSF is checked under a for signs that leukemia cells have spread to the brain and spinal cord. This procedure is also called an LP or spinal tap.

Lumbar puncture. A patient lies in a curled position on a table. After a small area on the lower back is numbed, a spinal needle (a long, thin needle) is inserted into the lower part of the spinal column to remove cerebrospinal fluid (CSF, shown in blue). The fluid may be sent to a laboratory for testing.

This procedure is done after leukemia is diagnosed to find out if leukemia cells have spread to the brain and spinal cord. is given after the sample of fluid is removed to treat any leukemia cells that may have spread to the brain and spinal cord.
: An x-ray of the organs and bones inside the chest. An x-ray is a type of energy beam that can go through the body and onto film, making a picture of areas inside the body. The chest x-ray is done to see if leukemia cells have formed a in the middle of the chest.

Certain factors affect prognosis (chance of recovery) and treatment options.

The depends on:

How quickly and how low the leukemia cell count drops after the first month of treatment.
Age at the time of diagnosis, sex, , and .
The number of white blood cells in the blood at the time of diagnosis.
Whether the leukemia cells began from B lymphocytes or T lymphocytes.
Whether there are certain changes in the chromosomes or genes of the leukemia cells.
Whether the child has Down syndrome.
Whether leukemia cells are found in the cerebrospinal fluid.
The child’s weight at the time of diagnosis and during treatment.

Treatment options depend on:

Whether the leukemia cells began from B lymphocytes or T lymphocytes.
Whether the child has standard-risk, high-risk, or very high–risk ALL.
The age of the child at the time of diagnosis.
Whether there are certain changes in the chromosomes of lymphocytes, such as the Philadelphia chromosome.
Whether the child was treated with before the start of .
How quickly and how low the leukemia cell count drops during treatment.

For leukemia that (comes back) after treatment, the prognosis and treatment options depend partly on the following:

How long it is between the time of diagnosis and when the leukemia comes back.
Whether the leukemia comes back in the bone marrow or in other parts of the body.

Risk Groups for Childhood Acute Lymphoblastic Leukemia

KEY POINTS

In childhood ALL, risk groups are used to plan treatment.
Sometimes childhood ALL does not respond to treatment or comes back after treatment.

In childhood ALL, risk groups are used to plan treatment.

There are three in childhood . They are described as:

Standard (low) risk: Includes children aged 1 to younger than 10 years who have a count less than 50,000/µL at the time of .
High risk: Includes children 10 years and older and/or children who have a white blood cell count of 50,000/µL or more at the time of diagnosis.
Very high risk: Includes children younger than age 1, children with certain changes in the , children who have a slow to initial treatment, and children who have of after the first 4 weeks of treatment.

Other factors that affect the risk group include the following:

Whether the leukemia began from or .
Whether there are certain changes in the or genes of the .
How quickly and how low the leukemia cell count drops after initial treatment.
Whether leukemia cells are found in the at the time of diagnosis.

It is important to know the risk group in order to plan treatment. Children with high-risk or very high–risk ALL usually receive more anticancer and/or higher of anticancer drugs than children with standard-risk ALL.

Sometimes childhood ALL does not respond to treatment or comes back after treatment.

childhood ALL is that does not respond to initial treatment.

childhood ALL is cancer that has (come back) after it has been treated. The leukemia may come back in the and , brain, , , or other parts of the body.

Treatment Option Overview

KEY POINTS

There are different types of treatment for childhood acute lymphoblastic leukemia (ALL).
Children with ALL should have their treatment planned by a team of doctors who are experts in treating childhood leukemia.
The treatment of childhood ALL usually has three phases.
Four types of standard treatment are used:
- Chemotherapy
- Radiation therapy
- Chemotherapy with stem cell transplant
- Targeted therapy
Treatment is given to kill leukemia cells that have spread or may spread to the brain, spinal cord, or testicles.
New types of treatment are being tested in clinical trials.
- Immunotherapy
Treatment for childhood acute lymphoblastic leukemia may cause side effects.
Patients may want to think about taking part in a clinical trial.
Patients can enter clinical trials before, during, or after starting their cancer treatment.
Follow-up tests may be needed.

There are different types of treatment for childhood acute lymphoblastic leukemia (ALL).

Different types of treatment are available for children with (ALL). Some treatments are (the currently used treatment), and some are being tested in . A treatment clinical trial is a meant to help improve current treatments or obtain information on new treatments for patients with . When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.

Because cancer in children is rare, taking part in a clinical trial should be considered. Some clinical trials are open only to patients who have not started treatment.

Children with ALL should have their treatment planned by a team of doctors who are experts in treating childhood leukemia.

Treatment will be overseen by a , a doctor who specializes in treating children with cancer. The pediatric oncologist works with other health professionals who are experts in treating children with and who specialize in certain areas of . These may include the following :

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Pediatric intensivist.
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The treatment of childhood ALL usually has three phases.

The treatment of childhood ALL is done in phases:

: This is the first phase of treatment. The goal is to kill the leukemia in the and . This puts the leukemia into .
/: This is the second phase of treatment. It begins once the leukemia is in remission. The goal of consolidation/intensification is to kill any leukemia cells that remain in the body and may cause a .
: This is the third phase of treatment. The goal is to kill any remaining leukemia cells that may regrow and cause a relapse. Often the cancer treatments are given in lower than those used during the remission induction and consolidation/intensification phases. Not taking medication as ordered by the doctor during maintenance therapy increases the chance the cancer will come back. This is also called the continuation therapy phase.

Four types of standard treatment are used:

Chemotherapy

Chemotherapy is a cancer treatment that uses to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or into a or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (). When chemotherapy is placed directly into the (intrathecal), an , or a body such as the , the drugs mainly affect cancer cells in those areas (). is treatment using more than one anticancer drug.

The way the chemotherapy is given depends on the child’s . Children with high-risk ALL receive more anticancer drugs and higher doses of anticancer drugs than children with standard-risk ALL. is used to treat childhood ALL that has spread, or may spread, to the brain and .

See for more information.

Radiation therapy

is a cancer treatment that uses high-energy or other types of to kill cancer cells or keep them from growing. uses a machine outside the body to send radiation toward the area of the body with cancer.

External radiation therapy may be used to treat childhood ALL that has spread, or may spread, to the brain, spinal cord, or . It may also be used to prepare the bone marrow for a .

Chemotherapy with stem cell transplant

Chemotherapy is given to kill cancer cells. In children 3 years and older, is given with chemotherapy. Healthy cells, including blood-forming cells, are also destroyed by the cancer treatment. Stem cell transplant is a treatment to replace the blood-forming cells. (immature blood cells) are removed from the blood or bone marrow of a and are frozen and stored. After the patient completes chemotherapy and radiation therapy, the stored stem cells are thawed and given to the patient through an . These stem cells grow into (and restore) the body’s blood cells.

Stem cell transplant is rarely used as initial treatment for children and with ALL. It is used more often as part of treatment for ALL that relapses (comes back after treatment).

See for more information.

Stem cell transplant. (Step 1): Blood is taken from a vein in the arm of the donor. The blood flows through a machine that removes the stem cells. Then the blood is returned to the donor through a vein in the other arm. (Step 2): The patient receives chemotherapy to kill blood-forming cells. The patient may receive radiation therapy (not shown). (Step 3): The patient receives stem cells through a catheter placed into a blood vessel in the chest.

Targeted therapy

is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells. Targeted therapies usually cause less harm to normal cells than chemotherapy or radiation therapy do. There are different types of targeted therapy:

(TKIs) therapy: This treatment blocks the , tyrosine kinase, that causes stem cells to develop into more than the body needs. and are TKIs used in the treatment of children with –positive ALL. is a TKI that is being studied in the treatment of newly high-risk ALL.
Monoclonal antibodies are made in the laboratory to treat many diseases, including cancer. As a cancer treatment, these can attach to a specific target on cancer cells or other cells that may help cancer cells grow. The antibodies are able to then kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, , or material directly to cancer cells. and are monoclonal antibodies being studied in the treatment of childhood ALL. Blinatumomab is also being studied in the treatment of standard-risk ALL.

How do monoclonal antibodies work to treat cancer? This video shows how monoclonal antibodies, such as trastuzumab, pembrolizumab, and rituximab, block molecules cancer cells need to grow, flag cancer cells for destruction by the body’s immune system, or deliver harmful substances to cancer cells.
therapy: This treatment is a type of targeted therapy that blocks the action of proteasomes in cancer cells. Proteasomes remove proteins no longer needed by the cell. When the proteasomes are blocked, the proteins build up in the cell and may cause the cancer cell to die. is a type of proteasome inhibitor therapy used to treat relapsed childhood ALL. Bortezomib is also being studied in the treatment of standard-risk or high-risk patients.

New kinds of targeted therapies are also being studied in the treatment of childhood ALL.

See for more information.

Treatment is given to kill leukemia cells that have spread or may spread to the brain, spinal cord, or testicles.

Treatment to kill leukemia cells or the spread of leukemia cells to the brain and spinal cord (; CNS) is called CNS-directed therapy. Chemotherapy may be used to treat leukemia cells that have spread, or may spread, to the brain and spinal cord. Because standard doses of chemotherapy may not cross the to get into the that surrounds the brain and spinal cord to reach the leukemia cells in the CNS, the cells are able to hide in the CNS. Systemic chemotherapy given in high doses or intrathecal chemotherapy (into the cerebrospinal fluid) is able to reach leukemia cells in the CNS. Sometimes external radiation therapy to the brain is also given.

Intrathecal chemotherapy. Anticancer drugs are injected into the intrathecal space, which is the space that holds the cerebrospinal fluid (CSF, shown in blue). There are two different ways to do this. One way, shown in the top part of the figure, is to inject the drugs into an Ommaya reservoir (a dome-shaped container that is placed under the scalp during surgery; it holds the drugs as they flow through a small tube into the brain). The other way, shown in the bottom part of the figure, is to inject the drugs directly into the CSF in the lower part of the spinal column, after a small area on the lower back is numbed.

These treatments are given in addition to treatment that is used to kill leukemia cells in the rest of the body. All children with ALL receive CNS-directed therapy as part of induction therapy and consolidation/intensification therapy and sometimes during maintenance therapy.

If the leukemia cells spread to the testicles, treatment includes high doses of systemic chemotherapy and sometimes radiation therapy.

New types of treatment are being tested in clinical trials.

This summary section describes treatments that are being studied in . It may not mention every new treatment being studied. Information about clinical trials is available from the .

Immunotherapy

is a treatment that uses the patient’s immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer. This cancer treatment is a type of .

: This treatment changes the patient’s (a type of immune system cell) so they will attack certain proteins on the surface of cancer cells. T cells are taken from the patient and special are added to their surface in the laboratory. The changed cells are called (CAR) T cells. The CAR T cells are grown in the laboratory and given to the patient by infusion. The CAR T cells multiply in the patient’s blood and attack cancer cells. CAR T-cell therapy is being studied in the treatment of childhood ALL that has relapsed (come back) a second time.

CAR T-cell therapy. A type of treatment in which a patient’s T cells (a type of immune cell) are changed in the laboratory so they will bind to cancer cells and kill them. Blood from a vein in the patient’s arm flows through a tube to an apheresis machine (not shown), which removes the white blood cells, including the T cells, and sends the rest of the blood back to the patient. Then, the gene for a special receptor called a chimeric antigen receptor (CAR) is inserted into the T cells in the laboratory. Millions of the CAR T cells are grown in the laboratory and then given to the patient by infusion. The CAR T cells are able to bind to an antigen on the cancer cells and kill them.

Treatment for childhood acute lymphoblastic leukemia may cause side effects.

For information about that begin during treatment for cancer, see our page.

Regular exams are very important. from cancer treatment that begin after treatment and continue for months or years are called .

Late effects of cancer treatment may include the following:

Physical problems, including problems with the heart, , , or bones, and . When is given with chemotherapy drugs called , the risk of late heart effects is lessened.
Changes in mood, feelings, thinking, learning, or memory. Children younger than 4 years who have received radiation therapy to the brain have a higher risk of these effects.
(new types of cancer) or other , such as , , , and .

Some late effects may be treated or controlled. It is important to talk with your child’s doctors about the possible late effects caused by some treatments. See the summary on .

Patients may want to think about taking part in a clinical trial.

For some patients, taking part in a may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the .

Many of today’s standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.

Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.

Patients can enter clinical trials before, during, or after starting their cancer treatment.

Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from (coming back) or reduce the of cancer treatment.

Clinical trials are taking place in many parts of the country. Information about clinical trials supported by NCI can be found on NCI’s webpage. Clinical trials supported by other organizations can be found on the website.

Follow-up tests may be needed.

Some of the tests that were done to the cancer or to find out the of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests.

Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your child’s has changed or if the cancer has (come back). These tests are sometimes called tests or check-ups.

and is done during all phases of treatment to see how well the treatment is working.

Treatment of Childhood Acute Lymphoblastic Leukemia (Standard Risk)

For information about the treatments listed below, see the section.

The treatment of newly diagnosed standard-risk childhood (ALL) during the , /, and phases always includes . When children with a poor to treatment are in after remission induction , a using from a may be done. When children with a poor response to treatment are not in remission after remission induction therapy, further treatment is usually the same treatment given to children with .

is given to the spread of to the brain and .

Treatments being studied in for standard-risk ALL include combination chemotherapy with or without with a ().

Use our to find NCI-supported cancer clinical trials that are accepting patients. You can search for trials based on the type of cancer, the age of the patient, and where the trials are being done. about clinical trials is also available.

Treatment of Childhood Acute Lymphoblastic Leukemia (High Risk)

For information about the treatments listed below, see the section.

The treatment of newly diagnosed high-risk childhood (ALL) during the , /, and phases always includes . Children in the high-risk ALL group are given more anticancer and higher of anticancer drugs, especially during the consolidation/intensification phase, than children in the standard-risk group.

and are given to or treat the spread of to the brain and . Sometimes to the brain is also given.

Treatments being studied in for high-risk ALL include new with or without or . is also being studied.

Treatment of Childhood Acute Lymphoblastic Leukemia (Very High Risk)

For information about the treatments listed below, see the section.

The treatment of newly diagnosed very high–risk childhood (ALL) during the , /, and phases always includes . Children in the very high–risk ALL group are given more anticancer than children in the high-risk group. It is not clear whether a during first will help the child live longer.

and are given to or treat the spread of to the brain and . Sometimes to the brain is also given.

Treatments being studied in for very high–risk ALL include new with or without .

Treatment of Childhood Acute Lymphoblastic Leukemia (Special Groups)

For information about the treatments listed below, see the section.

T-cell childhood acute lymphoblastic leukemia

The treatment of newly diagnosed childhood (T-ALL) during the , /, and phases always includes . Children with T-ALL are given more anticancer and higher of anticancer drugs than children in the newly standard-risk group.

and are given to or treat the spread of to the brain and . Sometimes to the brain is also given.

Infants with ALL

The treatment of infants with newly diagnosed during the , /, and phases always includes . Infants with ALL are given different anticancer and higher of anticancer drugs than children 1 year and older in the standard-risk group. It is not clear whether a during first will help the child live longer.

and are given to or treat the spread of to the brain and .

Treatments being studied in for infants with ALL include for infants with a certain change.

Children 10 years and older and adolescents with ALL

The treatment of newly diagnosed in children and (10 years and older) during the , /, and phases always includes . Children 10 years and older and adolescents with ALL are given more anticancer and higher of anticancer drugs than children in the standard-risk group.

and are given to or treat the spread of to the brain and . Sometimes to the brain is also given.

Treatments being studied in for children 10 years and older and adolescents with ALL include new anticancer agents and with or without . is also being studied.

Philadelphia chromosome–positive ALL

The treatment of newly diagnosed –positive childhood during the , /, and phases may include the following:

and with a ( or ) with or without a using from a .

and are given to or treat the spread of to the brain and .

Treatments being studied in for Philadelphia chromosome–positive childhood ALL include a new of targeted therapy (imatinib mesylate) and combination chemotherapy with or without a stem cell transplant.

Treatment of Refractory or Relapsed Childhood Acute Lymphoblastic Leukemia

For information about the treatments listed below, see the section.

of childhood (ALL) that comes back in the may include the following:

with or without ().
, using from a .

There is no standard treatment for the treatment of childhood ALL.

Other treatments for refractory or relapsed childhood ALL may include the following:

( or ).
.

Standard treatment of relapsed childhood ALL that comes back outside the bone marrow may include the following:

and with to the brain and/or for that comes back in the brain and spinal cord only.
Stem cell transplant for cancer that has in the brain and/or spinal cord.
Combination chemotherapy and radiation therapy for cancer that comes back in the only.

Some of the treatments being studied in for relapsed childhood ALL include:

A new of combination chemotherapy and targeted therapy (blinatumomab).
A new type of .
CAR T-cell therapy.

To Learn More About Childhood Acute Lymphoblastic Leukemia

For more information from the about childhood acute lymphoblastic leukemia, see the following:

For more childhood information and other general cancer resources, see the following:

NURS 530 Discussion childhood acute lymphocytic leukemia