Results
Seven patients were identified and included, three female, four male.All children were between two years and four years, all had a diagnosis of ALL.None of the patients had any underlying comorbidities prior to their diagnosis of ALL. (table 1)
Symptom onset in five of the patients was during induction chemotherapy after just 2-4 weekly doses of vincristine. In two cases vcp was diagnosed later during blocks of vincristine containing chemotherapy. In both cases vcp was preceded by other signs of neuropathy including very poor mobility, ptosis and a squint. In all patients vocal cord paralysis presented as increased work of breathing and stridor. Six patients sustained bilateral and one patient a left, unilateral vcp.Of the bilateral cases, four required surgical tracheostomy and the remaining three were managed conservatively with no need for airway protection. All patients recovered from vocal cord paralysis despite all but one patient receiving further vincristine. Regimes and doses were adjusted to a level of vincristine exposure deemed necessary by the treating haematologist to achieve long term leukaemia remission. Chemotherapy regimes were modified in all cases to reduce vincristine exposure and in some cases patients were switched to an alternative chemotherapy regime not containing vincristine for consolidation and interim maintenance phases of treatment. Doses in induction and consolidation phases were omitted from the time of diagnosis of vcp.
Vincristine was reintroduced in all patients with tracheostomies for the intensive phases of chemotherapy. One patient without a tracheostomy was given vinblastine instead of vincristine as the risk of neurotoxicity is felt to be lower with this agent.
No patients were given the usual monthly vincristine doses in the prolonged maintenance phase of treatment.
All children with tracheostomies were eventually decannulated up to one year following the surgery at a point where no further vincristine was planned. One patient developed subglottic stenosis and whilst decannulated may require laryngotracheal reconstruction for impaired exercise tolerance.
There have been no cases of leukaemia relapse in this patient cohort