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Cancers in Children

Lynn Kennell

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Introduction Focus on 4 Broad types of Cancer

LEUKEMIAS: ALL, ANLL

BONE CANCERS: OSTEOGENIC SARCOMA

BRAIN TUMORS: INFRATENTORIAL SUPRATENTORIAL

WILM’S TUMOR

Cardinal Signs & Sx of Cancer in Children

OVERT SYMPTOMS: A mass Purpura, pallor Weight loss Whitish reflex in the eye Recurrent of persistent

infection Vomiting in the early

morning

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COVERT SYMPTOMS:Bone PainHeadache Persistent lymphadenopathyChange in balance or gaitChange in personalityFatigueGeneral malaise

Diagnosis Initially, do CBC, Chem Profile (CMP) with liver

function test LP is routine for leukemia, brain tumors, and

others to rule out brain/CNS metastasis. Bone marrow aspiration-confirms dx and can be

used to assess for relapse CT, MRI, PET scans are all helpful in pinpointing

the tumor or extent of the disease if tumors are involved.

Biopsy of the tumor—conclusive and determines type

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Leukemias-2 types

Acute Lymphocytic Leukemia (ALL)

Acute Nonlymphocytic Leukemia (ANLL)

Cell Surface Immunologic Markers---a form of classification of cell morphology in the

diagnosis of leukemia

CALLA Antigens Common Acute Lymphocytic

Leukemia Antigen If cells are identified as CALLA+

the child has an increased survival rate

These are a GOOD THING!

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PATHOLOGY Primary pathology: decreased # of functional

WBC’s but total # of immature WBC’s (blasts) is increased. See pathology flowsheet in syllabus.

Bone Marrow Depression:

1. Anemia: d/t decreased RBC’s

2. Infection: d/t decreased effectiveness of WBC’s

3. Bleeding: d/t decreased platelets

4. Physiologic fractures: d/t increased # of cells in bone marrow, thinning & weakening of bone

5. Pain: d/t increased # leukemic cells in periosteum

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Pathology (cont’d)

CNS Dysfunction: d/t leukemic cells crossing the blood/brain barrierSX: Increased intracranial pressure: Headache, vomiting, irritability Papilledema, nuchal rigidity Lethargy

Also known as leukemic meningitis

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Pathology (cont’d) EXTRA MEDULLARY INFILTRATION

leads to the following ORGAN INVOLVEMENT:

1. Hepatomegaly

2. Splenomegaly

3. Lymph Node Enlargement

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Pathology (cont’d)

GENERALIZED HYPERMETABOLISM:

Also known as “cellular starvation””

1. Muscle wasting 2. Fatigue 3. Anorexia 4. Weight loss

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Phases of Chemotherapy Remission InductionRemission Induction: Goal: complete absence of leukemic cells

as evidenced by <5% blast cells in bone marrow.

ALL ANLL

Corticosteroids: primarily

PREDNISONE

Doxyrubicin or Daunomycin

Vincristine Cytosine

L-Asparaginase Others

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Phases of Chemotherapy (cont’d) Intensification or Consolidation therapyIntensification or Consolidation therapy

Goal: to further decrease the # of leukemic cells

Consists of pulses of chemotherapy

L-asparaginase

High-dose Methotrexate

Intermittent dose of Methotrexate & Cytarabine

Methotrexate & MP

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Phases of Chemotherapy (cont’d) CNS PROPHYLAXISCNS PROPHYLAXIS:|

Goal: Treatment is directed at those anatomic areas that are protected to some degree from systemic chemotherapy

Triple Intrathecal Administration: 1. Methotrexate– used in all 3 phases of Tx 2. Cytarabine 3. Hydrocortisone

Cranial irradiation– now reserved for high risk and those with CNS involvement

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Phases of Chemotherapy (cont’d) MAINTENANCE phaseMAINTENANCE phase Goal is to preserve remission by preventing

the reappearance of leukemic cells. Child is usually on chemotherapy for 2.5 – 3 years.

ALL ANLL

6-Mercaptopurine-- daily

Ara-C

Methotrexate--IM 6 Thioguanine

Prednisone-- monthly

6-Mercaptopurine (MP)

Vincristine--monthly

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Phases of Chemotherapy (cont’d) REINDUCTION FOLLOWING RELAPSEREINDUCTION FOLLOWING RELAPSE Goal: get child back in remission. Each relapse gives a poorer prognosis Testes are a common site of relapse d/t

resistance to chemotherapy

ALL

Prednisone

Vincristine

Other combinations

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Bone Marrow Transplantation(BMT)

For ALL, BMT is usually only indicated if chemotherapy is UNSUCCESSFUL

For ANLL, BMT may be considered with first remission because of poorer prognosis

See handout in syllabus on process of preparation and receiving BMT

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Nursing Care (see careplan pp.1470-1472)

Prepare family for procedures– painful diagnostic tests & chemo

Provide emotional support

Recognize side effects of drugs

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Nursing Care (cont’d)

Monitor for infections, bleeding, mucosal ulcerations, pain* especially note need for careful oral care in all patients receiving chemotherapy

Prepare child in an age-appropriate fashion for all procedures.

Osteogenic Sarcoma

Etiology-- OS is the most frequently encountered bone cancer in children. peak incidence between 10-25 years

Primary tumor sites: metaphysis(wider part of the shaft of long bones by the

epiphyseal growth plate) of long bones, especially of the lower extremities;

> 1/2 occur in the femur

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. Medical Management- - still controversial **Surgery-- Traditionally, radical surgical resection or

amputation has been recommended. Amputation ~ 3” above the proximal tumor margin or above

the joint proximal to the involved bone. For some pts., limb salvage procedures may be

indicated. This involves tumor resection and prosthetic replacement of the involved bone.

Chemotherapy-- such drugs as high dose Methotrexate, adriamycin, bleomycin, actinomycinD, ifosfamide, cyclophosphamide, and cisplatin may be used alone or in combination before and after surgery.

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Nursing Considerations:

Support the family during the dx and the decision about tx.

BE HONEST with the child about the dx and tx. Nurses do not usually inform families of dx, but should be available for clarification, reinforcement and emotional support.

Offer only as much information as the child can absorb at a given time. Allow for questions, and follow-up.

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Nursing Considerations (continued)

Care for a child with a prosthesis is similar to any person, except that compliance and understanding may take a little longer.

Phantom limb pain-- common after amputation may be manifested as itching, pain, tingling, burning, and/or cramping in the area of the amputated leg. Acknowledge the sensations as real. Amitriptyline (Elavil) may be used to pain.

Support through referral to national organization as Candlelighters Childhood Cancer Foundation would be helpful to families

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Ewing Sarcoma

is another bone tumor but it arises from the bone marrow rather than the osseous tissue (as in osteogenic sarcoma).

Treatment is more commonly intensive irradiation of the bone and combined chemotherapy.

Amputation is NOT routinely recommended.

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Brain Tumors

Infratentorial—Posterior 1/3 of the brain, primarily in the cerebellum or brainstem.

Supratentorial—less frequent, located in the anterior 2/3 of the brain, mainly the cerebrum.

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Etiology--cause is often unknown the most common solid tumors that occur in children and

are 2nd only to leukemias as a form of cancer. May be benign or malignant.

Infratentorial-- 30% of tumors occur in the posterior third of the brain, primarily in the cerebellum or brainstem. Sx are from ICP.

Supratentorial-- < frequent; located in the anterior 2/3 of the brain, mainly the cerebrum.

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Types--

The type of cell from which the tumor originates helps to classify it histologically.

Common names: medulloblastoma, cerebellar astrocytoma, brainstem glioma, ependyomas.

Astrocytoma, is the most common Glial brain tumor in children

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Symptoms-- often R/T increased intracranial pressure (ICP)

Headache-- especially worse on arising Vomiting-- unrelated to feeding Neuromuscular changes-- incoordination or clumsiness,

+ Babinski sign after age two Behavioral changes-- irritability, appetite, fatigue, failure

to thrive, lethargy Cranial nerve involvement-- most common: head tilt,

visual defects Vital sign changes: pulse and respirations, BP,

widened pulse pressure, hypo or hyperthermia Other: seizures, cranial enlargement or bulging fontanel at

rest (only in young children whose skull sutures have not yet fused),

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Diagnosis--

Thorough hx and attention to details is essential.

MRI is most common diagnostic procedure to determine the location and extent of the tumor.

 CT scan-- may also be used. Lumbar puncture is NOT recommended due to risk of brainstem herniation in light of ICP.

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Treatment--all 3 of the following may or may not be used depending on tumor type and size.

Surgery-- total removal of tumor without neurological damage is the goal.

Radiation-- used to tx most tumors and to shrink the size of the tumor before attempting surgical removal.

Chemotherapy-- being used more frequently

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Nursing Considerations- Assess for signs and sx-- establish a baseline of data for pre and

post operative evaluation. Vital signs are assessed routinely along with a neurological

assessment, and head circumference in infants and young children. Detail all sx as HA, N/V, etc.

Prepare child and family for Diagnostic Procedures Teach in an age-appropriate manner about x-rays & MRI’s etc. Clarify child’s understanding of what is a brain tumor and why tx is

necessary. Avoid giving false reassurance to parents re: outcomes following

surgery. There are no guarantees. Be honest yet hopeful. Teach about surgery-- shaving area of the head, dressing post-op,

need for frequent assessments, etc.

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Prevent post operative complications

Assessment-- VS, neuro ‘s, watch for temp secondary to hypothalamus or brainstem involvement during surgery.

 Positioning– For INFRATENTORIAL surgery, keep flat or on left or right

side. Pillows are placed beside child’s back not head to maintain position.

For SUPRATENTORIAL surgery, may have HOB to promote CSF drainage.

Fluid regulation-- monitor carefully I & O. For Infratentorial surgeries, keep NPO at least 24 hrs or longer if child’s gag reflex is depressed or he is comatose. For supratentorial surgeries, feedings may be resumed as soon as the child is alert. If vomiting occurs, make NPO to decrease risk of ICP.

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Comfort measures--

Headache may be severe secondary to ICP.

Maintain quiet environment; avoid any jarring of the bed, and prevent anything which might ICP.

Ice bag to the head may be soothing. Opioids may be used if monitored

closely. Prevent constipation with stool

softeners/laxatives.

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Support child and family Be present at time of discussion of prognosis so that

clarification can be done later of any misconceptions of what was said initially.

Encourage verbalization of feelings re: guilt they may feel, fears, etc.

Collaborate together in telling the child. Honesty preop will help in discussion post-op.

Prognosis

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Promote return to optimal functioning-- goal is to return to “normal Life”.

Need multidisciplinary approach with parents, doctors/case managers, school nurse, teachers to make transition smooth for the child.

 Need also to be open to discuss feelings about death and dying if prognosis is poor.

Integrate hospice care if indicated.

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Wilm’s Tumor—Nephroblastoma, a tumor that arises in the kidney

INCIDENCE & ETIOLOGY: Most common malignancy of the kidney in children

and accounts for 5-6% of all childhood cancer.

Usually presents between 2-3 years of age.

> prevalent in females than males.

Etiology is often unknown.

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Pathophysiology A fast-growing tumor of the kidney that

is usually encapsulated by a thin membrane that can easily be torn or broken.

2 Categories describe the histology: Favorable responsive to therapy with

good prognosis Unfavorable less responsive to

therapy with poorer prognosis Metastasis can occur to lungs, liver,

brain, bones, or to the unaffected kidney.

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Diagnosis

Any abdominal mass needs a timely & thorough work-up.

Rapidly growing tumors often migrate to the point of least resistance and may be found in the renal veins or inferior vena cava.

Abdominal CT Scan or MRI will give a clearer preoperative view of the abdomen.

Diagnosis is confirmed at surgery when a biopsy is performed.

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Nursing Alert A precaution is to limit manipulation of the

abdomen or liver in children with Wilm’s Tumor that might cause spread of malignant cells should the encapsulated mass rupture.

A sign placed on the child’s crib or bed that warns all health care providers to avoid palpation of the abdomen, and instructions to caregivers to use caution when handling and bathing their child can prevent trauma to the tumor.

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Treatment Surgical Resection—nephrectomy

Chemotherapy Dactinomycin (Actinomycin D) Vincristine Doxorubicin

Radiation Today, only done with metastatic dz,

residual tumor after resection, and recurrent tumors

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Nursing Care

Support the family when the initial diagnosis is made because surgical treatment is usually quick followed by chemotherapy.

Pain management post-op is essential to care

Careful assessment of I and O to ensure that there is adequate intake with chemotherapy

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Nursing Care cont’d

Careful management of nausea, vomiting, & constipation 2ndary to chemotherapy is critical as well.

Wound care and activity restrictions should be reviewed.

Review side effects of radiation if part of treatment: altered growth, scoliosis, & possible secondary malignancies

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Prognosis Continues to improve. Largely

dependent on histology and staging

Overall 5 year survival rate is 90% (online reference)

Early diagnosis and treatment is essential to better outcome.

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Be sure to review the Module on Perceptions of Death and Dying in Children and take the quiz on line in Reggienet.