The role of routing in the diagnosis of acute leukemia in children: an observational retrospective non-randomized study

BACKGROUND: Acute leukemia is the commonest malignancy of childhood with an incidence rate of about 55–62 per 1 million under 18 years of age. Early diagnosis of acute leukemia is difficult due to the non-specificity of primary symptoms, which are often hidden under the “masks” of other diseases. This problem is especially relevant for regions with a population of up to 100 thousand people, where a case of acute leukemia in children occurs every 2–5 years causing too low oncological alertness among pediatricians.

AIM: Assess the delay in diagnosis depending on the areas of residence in the Tver region and area remoteness from the Tver Regional Clinical Children’s Hospital (Tver, Russia).

MATERIALS AND METHODS: The analysis included 35 patients hospitalized in the Department of Oncology and hematology of the Tver Regional Clinical Children’s Hospital for the period from 2018 to 2023. The diagnoses were: acute lymphocytic leukemia (C91.0) — 30 (86%) patients, acute myeloid leukemia (C92) — 3 (9%) patients, and acute leukemia of unspecified cell type (C95.0) — 2 (5%) patients. The mean age was 61 months (5.1 years). Thrombocytopenia and anemia at the time of diagnosis were found in 76% and 78%, respectively. Leukocytosis (> 20×10⁹/L) was observed in 58%, leukopenia (<3.5×10⁹/L) in 15% of patients. In 97% of cases blasts (2% to 95%) were detected in peripheral blood. In the city of Tver (Group 1) and the Tver region (Group 2), 16 (46%) and 19 (54%) patients were identified, respectively. The mean age of patients in Group 1 is 28.6 months, and in Group 2 — 72.3 months (p=0.1).

RESULTS: In Groups 1 and 2, acute lymphocytic leukemia was diagnosed in 14 (88%) and 16 (84%), respectively (p=0.6); acute myeloid leukemia — in 1 (6%) and 2 (11%), respectively (p=0.7); acute leukemia of unspecified cell type — in 1 (6%) and 1 (5%) cases, respectively (p=0.95). Delay of diagnosis in the general group (n=35) was observed as follows: <2 weeks — in 21 (60%) cases; 2–4 weeks — in 7 (20%) cases; 4–8 weeks — in 4 (11%) cases: >8 weeks — in 3 (9%) cases. Comparison of the time of delayed diagnosis among patients living in the city of Tver versus the Tver region yielded following results: <2 weeks in 7 (44%) vs 13 (68%) cases; 2–4 weeks — in 6 (38%) vs 3 (17%), 4–8 weeks — in 1 (6%) vs 1 (5%); >8 weeks — in 2 (12%) vs 2 (10%) cases, respectively (p=0.37). There was no significant impact of the distance of the residence place from the level 3 children’s hospital providing specialized care on the time of diagnosis. With the patients’ distance of <50 km from the clinic, the diagnosis delay of <2 weeks, 2–4 weeks, 4–8 weeks and >8 weeks was observed in 36%, 36%, 21% and 7% of cases, respectively. With the distance of 50–100 km, the diagnosis was made in the period of 2–4 weeks in 100% of cases. With the removal of >100 km the diagnosis delay of <2 weeks, 2–4 weeks, 4–8 weeks, >8 weeks was observed in 30%, 30%, 20% and 20%, respectively (p=0.78).

CONCLUSION: The distance from the third-level hospital did not affect the period of diagnosis of acute leukemia in children. We believe this is achieved by holding daily on-line conferences with country hospitals and out-patient departments followed by the rapid hospitalization of children with suspected oncohematological disorders in the specialized department.