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Evidence-based recommendationQuestion mark transparent.png Grade
AYAs should be referred immediately to a specialist if they have unexplained petechiae or hepatosplenomegaly.
Evidence-based recommendationQuestion mark transparent.png Grade
The presence of one or more of the following symptoms and signs requires consideration of investigation with FBC and blood film:
  • Pallor
  • Fatigue
  • Unexplained irritability
  • Unexplained fever
  • Persistent or recurrent upper respiratory tract infections
  • Generalised lymphadenopathy
  • Persistent or unexplained bone pain
  • Unexplained bleeding or bruising.

If the FBC or blood film indicates leukaemia then an urgent specialist referral should be made.


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Symptoms and signs

Leukaemia usually presents with a relatively short history of weeks rather than months in adolescents and young adults (AYAs).[1] It is typically indicated by hepatomegaly, splenomegaly, petechiae, purpura, mucosal bleeding and palpable lymphadenopathy (for acute lymphoid leukaemia (ALL)).[2] Pallor, fatigue, fever, persistent or unexplained bone pain (for ALL) and abnormal bleeding or bruising (for acute myeloid leukaemia (AML)) are all symptoms.[2] Other possible symptoms include irritability, upper respiratory tract infections, headache and anorexia.[1]

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Clinical assessment

AYAs presenting with unexplained petechiae or hepatosplenomegaly should be referred to a specialist immediately.

General practitioners (GPs) should initiate investigations with FBC and blood film in AYAs presenting with other key symptoms and signs (pallor, fatigue, unexplained irritability, unexplained fever, persistent or recurrent upper respiratory tract infections, generalised lymphadenopathy, persistent or unexplained bone pain or unexplained bruising). If the FBC or blood film indicates leukaemia then an urgent specialist referral should be made.

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Risk factors

Risk factors for leukaemia are known to include genetic disorders such as Down Syndrome, neurofibromatosis, Fanconi syndrome and Bloom syndrome as well as ionising radiation in utero.[3][4][5] Individuals with Down syndrome have nearly a 20-fold increased risk of leukaemia.[6]

AML has been associated with chemotherapy and ALL with therapeutic post-natal ionising radiation and higher socio-economic status.[3]

However, leukaemia can occur in AYAs without any of these risk factors.

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  1. 1.0 1.1 National Collaborating Centre for Primary Care. Referral Guidelines for Suspected Cancer. Clinical guideline 27. London: National Institute for Health and Clinical Excellence; 2005.
  2. 2.0 2.1 Bleyer A. CAUTION! Consider cancer: common symptoms and signs for early detection of cancer in young adults. Semin Oncol 2009 Jun;36(3):207-12 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19460578.
  3. 3.0 3.1 Adolescent and Young Adult Working Party of the Statewide Cancer Clinical Network. South Australian Adolescent and Young Adult Cancer Care Pathway: Optimising outcomes for all adolescent and young adult South Australians with a cancer diagnosis. Adelaide: South Australia Department of Health; 2010.
  4. New Zealand Guidelines Group. Suspected cancer in primary care: guidelines for investigation, referral and reducing ethnic disparities. Wellington: New Zealand Guidelines Group; 2009.
  5. Linet MS, Wacholder S, Zahm SH. Interpreting epidemiologic research: lessons from studies of childhood cancer. Pediatrics 2003 Jul;112(1 Pt 2):218-32 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12837914.
  6. Goldacre MJ, Wotton CJ, Seagroatt V, Yeates D. Cancers and immune related diseases associated with Down's syndrome: a record linkage study. Arch Dis Child 2004 Nov;89(11):1014-7 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15499053.

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