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Leukaemia (suspected) - investigations and initial management

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Investigations for suspected Leukaemia

In addition to the routine investigations (see new diagnosis -work up of the oncology patient), do the following investigations for suspected leukaemia. Discuss enrolment on appropriate COG biology study.

 ALL - blood for TPMT (thiopurine methyltransferase) mutations (only done routinely in Christchurch)
In Christchurch send for functional and genetic analysis to Molecular Pathology Laboratory, Christchurch School of Medicine. Auckland does this test as required only.
VZV serology done routinely in Auckland.
If febrile
investigate and treat as for febrile neutropenic patient regardless of the neutrophil count.
BM aspirate
Presentation marrows may be very difficult to aspirate and should be done by an experienced person.
Request microscopy, cell markers, molecular studies and cytogenetics (and any tests required by protocols the patient may be enrolled on).
Obtain consent to store marrow specimen indefinitely (Christchurch only).
On aspirate slides, record initial and surname, NHI # and date of aspirate.  (Done by laboratory staff in Auckland)
BM trephine
Ideally obtain on all newly diagnosed patients with leukaemia. In Auckland, trephines are done routinely only where aspiration is difficult.
If there is any doubt as to the quality of the aspirate slides then roll the trephine on slide, take some for tissue culture medium and the rest in formalin. In Auckland this will be done by the special haematology scientists.
Ensure platelet count > 50 (for diagnostic LP) and coagulation is within normal limits. The diagnostic sample should be done by the most experienced person available as contamination of the CSF with blood may be associated with CNS relapses
Collect 10 drops in each of 3 tubes labelled 1, 2, 3, for cell count protein/glucose and haematology cytospin. In Auckland, the third tube is filled at least half way so specimen is available for immunophenotyping if this is indicated.
Delay initial LP until diagnosis is confirmed so that protocol defined IT chemo (MTX, CYT or TIT) can be given. In practice, this only happens if there is doubt about the diagnosis from the peripheral blood film.
Central venous line
If diagnosis is established from blood results, insert at time of LP/BM.
It is important to know type of leukaemia because:

- AML: double lumen Hickman line

- ALL: PICC or single lumen Port initially depending on clinical situation. A formal access will be needed later if a PICC is inserted but this is often preferable in the acute situation due to availability. 
Toxicity evaluation
Anthracyclines - obtain baseline echo for fractional shortening

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Document Control

  • Date last published: 09 March 2016
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network
  • Author(s): Amanda Lyver, Tim Prestidge
  • Owner: Amanda Lyver
  • Review frequency: 2 years