Lymphoblastic lymphoma

Summarize

1. General

● OVERVIEW: Lymphoblastic lymphomas are a group of malignant tumors originating from immature precursor T or B lymphocytes, and are one of the most common pathological types of non-Hodgkin's lymphoma in children.

●Presentation: The typical clinical picture of T lymphoblastic lymphoma is characterized by an anterior mediastinal mass that presents with varying degrees of airway compression, while B lymphoblastic lymphoma develops with no obvious gender-specific features.

● Treatment: Lymphoblastic lymphoma is treated with multi-agent combination chemotherapy, with the main chemotherapy regimen being the NHL-BFM-90/95 regimen, and only the high-risk group requires local radiotherapy.

● Prognosis: The 5-year event-free survival (EFS) rate for lymphoblastic lymphoma is approximately 75% to 90%.

2. Definition of disease

Lymphoblastic lymphoma (LBL) is a group of malignant tumors originating from immature precursor T or B lymphocytes, and is one of the most common pathological types of non-Hodgkin lymphoma (NHL) in children. Lymphoblastic lymphoma is currently classified as a precursor lymphocytic tumor by the World Health Organization (WHO) because it shares similar clinical and laboratory features with acute lymphocytic leukemia (ALL), including cytomorphology, immunophenotype, genotype, cytogenetics, and clinical presentation and prognosis. If this type of disease starts clinically as a neoplastic lesion without bone marrow and peripheral blood infiltration, or if less than 25% of the bone marrow is tumorigenic lymphoblastoid cells, the diagnosis is lymphoblastic lymphoma, otherwise it is acute lymphoblastic leukemia.

Epidemiological

epidemiological

Lymphoblastic lymphomas account for approximately 35% to 40% of non-Hodgkin's lymphomas in children, of which approximately 70% to 80% are T-lymphoblastic lymphomas (T-LBL). These lymphoblastic lymphomas occur in older children, with a median age of onset of 9-12 years. Males are more prevalent, with a male-to-female ratio of approximately (2.5-3):1. The other type of lymphoblastic lymphoma is B-lymphoblastic lymphoma (B-LBL), which occurs at a younger age, with a median age of less than 6 years.

4. Type of disease

1) Disease typing

According to the immunophenotype, it can be classified into T-lymphoblastic lymphoma (T-LBL) and B-lymphoblastic lymphoma (B-LBL).

● T-lymphoblastoid lymphoma

T-lymphoblastoid lymphoma is a T-cell tumor. Of the T-cell tumors, 85% to 90% present as lymphoblastic lymphoma, with a minority presenting as acute lymphoblastic leukemia.

:: B-lymphoblastoid lymphoma

B lymphoblastic lymphoma is a B-cell tumor. In contrast to T-cell tumors, more than 85% of tumors composed of B-lymphocytes present as acute lymphoblastic leukemia, and only 10-20% are lymphoblastic lymphomas.

2) Disease Staging

The main reference for staging lymphoblastic lymphoma is the Revised International Pediatric Non-Hodgkin Lymphoma Staging System (IPNHLSS):

● Phase I

Single tumors (lymph nodes, extranodal bone or skin tumors), except mediastinal and abdominal masses.

● Phase II

Single extranodal tumor with regional lymph node invasion;

Regional invasion of ≥2 lymph nodes ipsilateral to the diaphragm;

Primary tumor of the gastrointestinal tract (often in the ileum) ± associated mesenteric lymph node involvement with complete tumor resection;

If accompanied by malignant ascites or tumor spread to adjacent organs should be designated as stage III.

● Phase III

≥2 extranodal tumors (including extranodal bone or extranodal skin) above and/or below the diaphragm;

Regional invasion of ≥2 lymph nodes above and below the diaphragm;

Any intrathoracic tumor (mediastinum, hilar, lung, pleura, or thymus);

Intra-abdominal or retroperitoneal lesions, including the liver, kidneys, and/or ovaries, are not considered for resection;

Any paraspinal or extradural lesion located without regard to the presence or absence of lesions elsewhere;

Single bone lesions with concomitant extra-nodal invasion and/or regional lymph node invasion.

● Phase IV

Any of the above lesions accompanied by CNS invasion (stage IV CNS), bone marrow invasion (stage IV BM) or central and bone marrow invasion (stage IV BM+CNS) were detected using conventional morphologic methods.

3) Disease grouping

There is no uniform standard for risk stratification of lymphoblastic lymphoma, which in principle is determined by combining clinical stage, tumor cytogenetic characteristics, and response to treatment. In the early stage of treatment, the risk grouping should be determined as low-risk group, medium-risk group and high-risk group according to the risk factors.

● Low-risk group

Stage I and II patients who do not have high-risk factors (except for stage II patients in the presence of spontaneous lysis of early tumors or huge masses).

:: Medium-risk group

Stage III and IV patients who do not have risk factors.

:: High-risk groups

The assessment of efficacy on day 33 of induction Ia (VDLP) in patients in the intermediate-risk group meets any of the following points:

○Tumor shrinkage <70%.

○Myeloid lymphoma cells >5%.

○Lymphoma cells were still found in the cerebrospinal fluid.

○Tumor progression.

or residual or progressive tumor activity after completion of the induction regimen.

Etiolog & Risk factors

1. General

Lymphoblastic lymphoma is associated with a variety of genetic abnormalities, including antigen receptor genes, chromosomal abnormalities, inactivation of oncogenes, and activation of oncogenes, etc. The exact pathogenesis of the disease is still unclear and requires further study.

2. Underlying causes

The main causes of lymphoblastic lymphoma are chromosomal abnormalities and gene rearrangements, which lead to abnormal function of genes related to cell proliferation and differentiation, and uncontrolled cell division and proliferation, resulting in the formation of tumors.

Classification & Stage

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Clinical manifestations

1. General

The main symptoms of most patients with lymphoblastoid lymphoma are coughing, chest tightness, shortness of breath, and dyspnea due to an anterior mediastinal mass.

2. Typical symptoms

● Common symptoms of T-lymphoblastoid lymphoma:

Typical clinical symptoms of T-lymphoblastoid lymphoma are anterior mediastinal mass, which often compresses the airway, resulting in symptoms such as cough, chest tightness, shortness of breath, dyspnea, etc. The mediastinal mass may also compress the esophagus, resulting in difficulty in swallowing; if the mass presses on the superior vena cava, the venous reflux may be impeded, leading to edema of the neck, face, and upper limbs, i.e. "superior vena cava syndrome"; if the mass invades the pericardium, it may lead to malignant pericardial effusion and pericardial tamponade. If the mass encroaches on the pericardium, it can lead to malignant pericardial effusion and pericardial tamponade.

T-lymphoblastoid lymphoma tends to progress rapidly, with about 90% or more of cases in stage III-IV by the time they are diagnosed.

● Common symptoms of B lymphoblastoid lymphoma:

Common manifestations of B-lymphoblastoid lymphoma are enlarged lymph nodes, multiple red nodules on the skin, masses in the bone, etc. In rare cases, mediastinal and pleural masses, and infiltration of the inner kidneys and gastrointestinal tract may be present.

3. Accompanying symptoms

1) Hyperuricemia

If a patient with lymphoblastoid lymphoma has a rapidly proliferating tumor, there is a risk of manifestations of tumor lysis syndrome, i.e., increased uric acid, increased blood potassium, and decreased renal function. Patients with underlying renal failure more often develop hyperuricemia and tumor lysis syndrome.

2) Increased serum lactate dehydrogenase levels

Patients with lymphoblastic lymphoma sometimes present with increased serum lactate dehydrogenase (LDH) levels, which may be due to a high tumor load and extensive hepatic infiltration, or may be associated with rapid tumor proliferation.

Clinical Department

1. General

In addition to the clinical characteristics of the patients, all patients with lymphoblastoid lymphoma (LBL) are diagnosed by histopathologic, immunophenotypic, cytogenetic, and molecular biological testing through biopsy of the involved tissues. The diagnosis is confirmed in all patients by tumor tissue or bone marrow case biopsy [6].

2. Consultation room

Pediatric Hematology-Oncology, Pediatric Oncology, Oncology, Hematology, Pediatrics

Examination & Diagnosis

1. Diagnostic basis

According to the World Health Organization (WHO) 2016 Classification of Tumors of Lymphohaematopoietic Tissues, patients with lymphoblastic lymphoma require biopsy of the tumor tissue or involved bone marrow for histopathological, immunophenotypic, cytogenetic, and molecular biology testing to confirm the diagnosis.

2. Relevant inspections

1) Medical history and physical examination

The doctor will ask the patient for a complete medical history, including current major symptoms, medical history, past medical history, family history, growth and development, and vaccination history.

The doctor will also perform a physical examination, including measurement of vital signs, examination of superficial lymph nodes throughout the body, liver, spleen, and abdominal signs, as well as a specialty checkup.

2) Pathologic examination

Suspicious lymph nodes are usually completely excised or cut for biopsy, or puncture biopsy if excision or cutting of the sample is not possible.

Simultaneous bone puncture of both sites is performed, and the bone marrow samples taken are examined by smear, immunophenotyping, chromosomal and genetic tests, and bone marrow biopsy may also be performed.

Specific methods of pathologic examination include general morphologic analysis, immunohistochemical staining (IHC), chromosomal karyotyping, fluorescence in situ hybridization (FISH), quantitative RT-PCR for fusion genes, flow cytometric analysis, immunoglobulin heavy chain and T-cell receptor (IgH/TCR) assays, and second-generation sequencing (NGS).

3) Laboratory tests

● Peripheral blood cells: Patients with lymphoblastic lymphoma may have normal or mildly elevated white blood cells and may have anemia, mostly normocytic normochromic. When bone marrow is involved, there may be an elevated or decreased total white blood cell count and naïve cells in the peripheral blood, which may be associated with anemia and/or thrombocytopenia.

● Blood biochemistry: liver and kidney function, lactate dehydrogenase (LDH), and electrolytes are mandatory. Often manifested as increased uric acid and lactate dehydrogenase, these two indicators are suggestive of disease remission and prognosis.

● Coagulation: Includes items such as prothrombin time (PT), activated partial thromboplastin time (APTT), thromboplastin time (TT), fibrinogen (FIB), D-dimer, and fibrin (pro)degradation products (FDP). Patients with lymphoblastic lymphoma may have coagulation abnormalities with decreased prothrombin and fibrinogen, leading to prolonged prothrombin time and bleeding.

●Other items: C-reactive protein (CRP), immune function (humoral + cellular immunity), virological indexes [Hepatitis B Virus, Hepatitis E Virus, Syphilis Spirochete, Epstein-Barr Virus (EBV), Cytomegalovirus (CMV), Torch Antibody], routine urinalysis, routine bowel movement, and.

4) Central nervous system examination

Cranial magnetic resonance imaging (MRI), routine cerebrospinal fluid, biochemical tests, and dump films to look for tumor cells are used to see if the tumor is invading the central nervous system (brain and spinal cord). Sometimes spinal cord enhancement MRI may also be performed.

5) Imaging

The main imaging tests for lymphoblastic lymphoma are electrocardiogram, cardiac ultrasound, enhanced CT of chest + abdomen + pelvis, PET-CT or PET-MRI if available, and corresponding ultrasound (neck, abdomen, digestive tract, testis or uterus, ovaries, pelvis, groin, axilla, mediastinum, and site of tumor).

The thymus reaches its maximum size in children at approximately 10 years of age, so anterior mediastinal masses in children must be differentiated from the normal thymus, which may need to be done by CT and/or other imaging.

5. Differential diagnosis

1) Differentiation from Burkitt's lymphoma

Histomorphologically, Burkitt's lymphoma is similar to lymphoblastoid lymphoma in that both are composed of medium-sized, monomorphic tumor cells, and both may show "starbursts". However, in lymphoblastic lymphoma samples, only focal "starbursts" are occasionally seen, whereas in Burkitt's lymphoma, "starbursts" are often seen throughout the tumor tissue, and the molecular markers expressed by the tumor cells and the genetic characteristics are also different.

2) Small cell malignant tumor of non-lymphohematopoietic system

There are some small round cell tumors, such as Ewing sarcoma, neuroblastoma, and small cell undifferentiated carcinoma, which are easily misdiagnosed if when the molecular features of the tumor show CD99 positivity while LCA, CD3, and CD20 are negative, due to the similar age of onset and similar cellular features to lymphoblastoid lymphoma in children. It can be differentiated by various antigens, such as neuroendocrine markers (CgA, Syn).

3) Differentiation from thymoma

Since thymoma is usually located in the anterior superior mediastinum, and pathologically also shows diffuse growth of lymphocytes and positive TdT, it may sometimes be confused with lymphoblastic lymphoma. However, thymoma rarely occurs in children and adolescents and can be differentiated on the basis of its histomorphology, which is different from that of lymphoblastic lymphoma.

4) Differentiation from teratoma

Teratomas may occur within the mediastinum, most often in the anterior mediastinum. The diagnosis can be established by X-ray if the tumor contains dense material such as calcified cartilage, bone, teeth and other tissues.

5) Differentiation from other mediastinal tumors

Neurogenic tumors, fibromas, lipomas, and lymphangiomas occurring in the mediastinum need to be differentiated by clinical presentation, location of the tumor in the mediastinum, imaging features, and pathological examination.

Clinical Management

1. General

The mainstay of treatment for childhood lymphoblastic lymphoma is a multi-drug combination of chemotherapy and rarely radiation.

2. Chemotherapy

1) Chemotherapy regimen

The more recommended regimen for chemotherapy of lymphoblastic lymphoma is the NHL-BFM-90/95 regimen. This regimen is approximately 2 years in length, and the disease is categorized into low-risk, intermediate-risk, and high-risk groups based on risk.

The chemotherapy regimen for the low-risk group was divided into 3 phases: induction, consolidation and maintenance. The regimen used in the induction phase was induction regimen I (VDLP regimen + CAM regimen), the regimen used in the consolidation phase was consolidation regimen M (mercaptopurine + high dose methotrexate), and the maintenance regimen was mercaptopurine + methotrexate.

The chemotherapy regimen for the intermediate-risk group was divided into 4 phases: induction, consolidation, re-induction and maintenance. The regimen used in the induction and reinduction phases was induction regimen I, the consolidation phase regimen was consolidation regimen M, and the maintenance regimen was mercaptopurine + methotrexate.

The chemotherapy regimen for the high-risk group was divided into four stages: induction, intensive consolidation, re-induction and maintenance, with selective local radiotherapy between the re-induction and maintenance stages. The regimen used in the induction and re-induction phases was induction regimen I, the intensive consolidation phase regimen was intensive consolidation regimen (Block1+Block2+Block3 regimen), and the maintenance regimen was mercaptopurine+methotrexate. Allogeneic hematopoietic stem cell transplantation can be considered after intensive consolidation therapy for patients with conditions.

2) Adverse Reactions

Acute reactions to chemotherapy for childhood lymphoblastoid lymphoma depend on the specific chemotherapeutic agent used. For example, vincristine can cause neurotoxicity and doxorubicin is cardiotoxic.

In addition, myelosuppression, the most common dose-limiting acute toxicity of multiagent chemotherapy, can be treated with transfusions of red blood cells and platelets or administration of colony-stimulating factor/granulocyte colony-stimulating factor (commonly known as a "leukostimulating injection").

Chemotherapy-induced neutropenia and immunosuppression increase the risk of infection, so appropriate treatment needs to be given quickly if infection occurs.

When the patient's cellular immune system is compromised and further affected by myelosuppression, he or she becomes more susceptible to shingles and chickenpox infections. Therefore, prophylactic treatment is required for children who have not been vaccinated against varicella prior to chemotherapy if they are exposed to a varicella-infected person. If chickenpox or shingles develops, antiviral therapy should be started immediately.

In addition, chemotherapy may trigger nausea and vomiting. These reactions can be minimized with 5-hydroxytryptamine receptor antagonist antiemetics or premedication with benzodiazepines.

3. Radiotherapy

Lymphoblastic lymphoma is sensitive to chemotherapy, and patients usually do not require conventional radiotherapy; only high-risk patients require selective local radiotherapy depending on their condition.

4. Hematopoietic stem cell transplantation

If the patient is insensitive to chemotherapy, or if there are definite residual lesions on midterm evaluation, or if there are genes with a poor prognosis, the patient may be treated with chemotherapy according to the high-risk group protocol, followed by allogeneic hematopoietic stem cell transplantation.

For patients who have relapsed or progressed on therapy, allogeneic hematopoietic stem cell transplantation is required as soon as possible if complete remission or partial remission can be achieved with salvage therapy to gain access to transplantation.

5. Cutting-edge treatment

1) Cutting-edge treatment for T-lymphoblastoid lymphoma

i) Nelarabine (Arranon)

Nelarabine is a selective inhibitor of DNA synthesis in T-lymphoblasts, thus causing T-lymphoblast death, and is a potent T-cell-specific cytotoxic agent that can be used in the treatment of refractory, relapsed T-lymphoblast lymphoma therapy either as monotherapy or in combination with other cytotoxic agents. Studies in children and adults are ongoing. Ⅰ

ii) Daratumumab

Daremumab is an antibody against a molecule called CD38. CD38 is stably expressed before and after chemotherapy or on relapsed T-lymphoblastic lymphoma cells and may be a good therapeutic target. The treatment of T-lymphoblastoma with dalimumab is still being explored.

iii) Other cutting-edge therapies

For example, PI3K inhibitors, mTOR inhibitors, and dual PI3K-mTOR inhibitors combined with glucocorticoids in the high-risk group of patients with PTEN deficiency are also under investigation for treatment. In addition, the overcoming of glucocorticoid resistance by ruxolitinib (ruxolitinib) is also being explored.

2) Cutting-edge treatment of B-lymphoblastoid lymphoma

i) Tyrosine kinase inhibitors (TKI)

Tyrosine kinase inhibitors are used to treat Philadelphia chromosome-positive (Ph+) lymphoblastic lymphoma. The first-generation tyrosine kinase inhibitor, imatinib, is 70% effective as a single agent and has a complete remission rate of 90% when combined with chemotherapy. Second-generation dasatinib and nilotinib are available for patients who are resistant to imatinib. Dasatinib and nilotinib have the property of crossing the blood-brain barrier and are more effective than imatinib.

ii) CAR-T therapy

CAR-T therapy can be used to treat relapsed/refractory end B lymphoblastoid lymphoma with a complete remission rate of 70% to 92%, which is highly efficacious and can be bridged to transplantation after remission.

iii) Other cutting-edge therapies

Bispecific antibodies (Blinatumomab), bortezomib ((Bortezomib), etc., are effective in the treatment of relapsed/refractory B-lymphoblastic lymphoma.

Prognosis

1. General

The 5-year event-free survival (EFS) rate for lymphoblastic lymphoma is approximately 75% to 90%.

2. Sequelae

Radiotherapy during treatment increases the incidence of secondary tumors in patients, which may occur many years after treatment has ended. Therefore, patients with lymphoblastic lymphoma need to be followed up with review and cancer screening after a certain age.

3. Complications

1) superior vena cava compression syndrome and/or airway obstruction

Approximately 10% of patients with T-lymphoblastoid lymphoma may develop severe airway obstruction (with or without superior vena cava compression syndrome), which can be life-threatening in severe cases.

In such patients, surgical biopsy under general anesthesia should be avoided; upper extremity infusion should be avoided in patients with superior vena cava compression syndrome. Dyspnea can be relieved by a prednisone or VP chemotherapy regimen, followed by pathologic examination by as minimally invasive an operation as possible in order to confirm the diagnosis.

2) Tumor lysis syndrome

Since lymphoblastic lymphoma is sensitive to chemotherapy, when the tumor is high loaded, there will be a large number of tumor cell lysis and necrosis during the treatment, causing tumor cell lysis syndrome, which manifests as symptoms of hyperuricemia, hypophosphatemia, hypocalcemia, hypomagnesemia, and uric acid crystals blocking the renal tubules, which may lead to acute renal failure in severe cases, and needs to be aggressively prevented and treated.

In general, patients with high tumor load, preexisting hyperuricemia prior to chemotherapy, renal impairment, and oligohydramnios are at high risk for developing tumor lysis syndrome and require aggressive preventive and therapeutic measures.

4. Recurrence/metastasis

Approximately 10% to 20% of progressive lymphoblastic lymphoma (LBL) are refractory or relapsed cases. Once relapsed after remission, the disease tends to be aggressive and rapidly progressive, with a poor prognosis and an overall survival rate of 10-30%.

Treatment of refractory relapsed lymphoblastic lymphoma consists primarily of re-induction chemotherapy and hematopoietic stem cell transplantation. The goal of induction chemotherapy is to achieve a stable second remission as soon as possible so that hematopoietic stem cell transplantation can be performed as early as possible.

Follow-up & Review

1. General

Complete the treatment as prescribed by the doctor, maintain good living habits and a clean living environment, and take care to prevent infection. Regular follow-ups should be made after completion of treatment in order to monitor recurrence and long-term adverse effects.

2. Review

The first review evaluation is performed 3 months after discontinuation of medication, with a review of routine bone marrow, genetic testing, and microscopic residual lesion (MRD) testing. In addition, tumor evaluation by imaging is required, including ultrasound, CT, etc., with PET-CT being the best. Review of immune function and electrocardiogram, cardiac ultrasound, liver and kidney function, and lactate dehydrogenase (LDH) are also required.

For the first 2 years after stopping the drug, a review is required every 3 months. In the third year after discontinuation of the drug and thereafter, a review is required every six months, and endocrine hormone and cognitive function tests may be added as appropriate.

Routine

1. Home care

Since patients undergoing treatment often have a reduced immune system, it is important to take care to prevent infections. Pay attention to washing hands frequently, keeping food and drinking water clean and hygienic, and good living hygiene habits. Keep the living environment neat and clean, open the windows regularly to keep the air circulating. Do not put fresh flowers and potted flowers indoors for the time being. Garbage cans should be covered and garbage should not be stored for more than 2 hours. At the same time, contact between patients and infected patients should be minimized, and attention should also be paid to the infection of accompanying persons. If someone in the family has a cold, contact with the patient should be avoided as much as possible; if contact with the patient is necessary, hand washing (with soap or hand sanitizer), wearing a mask and other protective measures must be done. At the same time, parents should pay attention to daily observation of the patient's condition and seek medical attention as soon as possible if there are signs of infection or fever.

2. Daily life management

1) Diet

Whether during or after treatment, it is recommended to provide patients with a nutritious and balanced diet, guaranteeing the intake of high-quality proteins (e.g., meat, eggs, milk, poultry, fish and shrimp, soybeans and soybean products, quinoa, etc.), as well as more grains and cereals and fruits and vegetables, and dairy products and nuts in moderation, in order to ensure the intake of other nutrients. At the same time should eat less refined rice and white flour, deep-processed snacks and processed meat tumors, control oil and salt.

In addition, during the treatment period, patients will have a reduced immune system and should avoid expired, spoiled, unclean and potentially food-safe foods. Specific dietary advice can be obtained from the dietitian at your hospital.

2) Movement

The patient needs to be guaranteed a sleep schedule. Regular and quality sleep is helpful for recovery and immunity. A suitable sleep environment (usually dimly lit, quiet, and at the right temperature) may be helpful in improving the patient's quality of sleep.

If the patient's physical condition permits, you can encourage and assist the patient to do some activities. Moderate exercise is helpful in preventing muscle atrophy, enhancing physical strength and endurance, and promoting appetite.

Appropriate regular exercise is recommended after the patient finishes treatment. If available, consider 30-60 minutes of moderate-intensity exercise per day (e.g., brisk walking, bicycling, yoga, table tennis, etc.), or a moderate amount of high-intensity exercise per week (e.g., running, swimming, jumping rope, aerobics, basketball, etc.).

3) Lifestyle

A healthy lifestyle, such as a balanced diet and moderate exercise, is the most important and effective means of preventing these diseases.

4) Emotional psychology

The process of treatment can be very challenging for patients and requires attention to their mental health. Especially for children, the physical changes and pain caused by the disease and treatment, the lack of external peer contact due to isolation during the treatment period, falling behind in school, and the fear of not being accepted by peers all affect the mental health of the patient. Parents need to guide the patient to face the disease with a positive attitude, accept the physical changes, and encourage the patient to maintain external contact and play with classmates and friends while ensuring hygiene during treatment, and to return to school and reintegrate into the society as early as possible when conditions permit. If the patient has a psychological disorder, a psychiatrist can be called in to intervene.

3. Daily condition monitoring

In the course of treatment, it is necessary to observe the side effects caused by the treatment, as well as the complications and the regression of the patient's condition, and consult the doctor in time when side effects and complications appear. After the completion of treatment, it is necessary to observe the delayed complications, the growth and development of pediatric patients, the recurrence of the disease, and adhere to regular follow-up. When new symptoms or complications appear, consult your doctor promptly.

4. Special Considerations

(1) Precautions in case of low platelets

If the patient's platelets are too low (usually below 20x109 /L), care needs to be taken to avoid bleeding by staying away from sharp, prickly toys and objects, and avoiding all impact-intensive sports (e.g., bouncing, soccer, basketball, etc.). When eating, avoid bones and other foods that tend to poke the mouth, and use a soft-bristled brush when brushing teeth. At the same time, for younger children, should try to avoid violent crying to avoid intracranial hemorrhage. In addition, pay attention to keep the patient's bowels clear, and do not self-administer anal suppositories or measure anal temperature to avoid rectal bleeding. Do not give the patient medications that tend to cause bleeding, such as aspirin or ibuprofen, unless advised by a doctor. Some over-the-counter cold medicines may have ingredients such as ibuprofen that require special attention.

(2) Dietary precautions during treatment with menthol drugs

Due to the potential for pancreatitis to be induced by menadione analogs (e.g., menadionease), it is necessary to limit the patient's fat intake from 3 days prior to the start of the medication to 3-5 days after discontinuation of the medication. During this period, particular attention should be paid to the restriction of animal fats and oils high in saturated fats (lard, tallow, butter and fatty fats) and to the choice of foods lower in fat or supplementation with suitable fats.

It should be noted that a low-fat diet does not mean a fat-free diet, and a completely fat-free diet can cause essential fatty acid deficiency and affect the patient's health. Attention should also be paid to ensure that the patient's protein intake (such as lean meat, fish and shrimp, chicken breast, egg white, etc.).

(3) Maintaining case records

Pediatric patients are at risk for long-term side effects and secondary tumors, which may occur many years after the end of treatment, and which are related to the regimen and dosage of treatment. Therefore, it is important to keep a record of all the patient's visits and treatments for future reviews and referrals.

5. Prevention

Since the exact cause of lymphoblastic lymphoma is still unclear, there is no corresponding preventive method. In addition, parents can pay attention to the early symptoms of lymphoblastic lymphoma and seek early medical treatment once it is detected, so as to achieve early detection and early treatment and strive for the best treatment effect.

Cutting-edge Therapeutic & Clinical Research

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References

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