Pediatric Cancers

Pediatric Cancers

• Cause is mostly unknown

• Difficult to diagnose

• Leukemia & brain tumors are the top 2 cancers

Cardinal S/S

• Overt Signs

  • Directly observable

  • More noticeable

• Covert signs

  • Hidden

  • Harder to notice

• Children often present w/ advanced disease

  • Presenting w/ metastasis much more frequently than adults

Cardinal S/S (Overt Signs)

• Pallor

• Weight loss

• Persistent fever

• A mass

• Purpura

• Whitish reflection in the eye

• Early morning vomiting

Cardinal S/S (Covert Signs)

• Headache

• Bone pain

• Persistent lymphadenopathy

• Change in balance, gait, &/or personality

• Fatigue

• Malaise

Diagnostic Tests

• Bone Marrow Aspiration

  • Iliac crest, sternum

  • Diagnosis & monitoring of effectiveness of therapy

• Biopsy

  • Identifies, classifies, & stages

• Lab

  • CBC

• Special tests

  • Alpha-fetoprotein, VMA or HVA, elevated Catecholamines

  • PET scan

Cancer Tx

• Chemotherapy

• Radiation

• Other

  • Hematopoietic Stem Cell Transplantation (HSCT)

  • Steroid Therapy

  • Biologic Agents

Chemotherapy

• Non-selectively kills rapidly dividing cells

• Other areas impacted

  • Bone marrow

  • Gi

  • Skin

• Unique protocols

  • Type of cancer

  • Stage & cellular characteristics

• Central line:

  • CVL

  • Port (Under the skin, Bent needle)

  • PICC line

Adverse Effects of Chemotherapy (General)

• Most common Sx

  • Pain

  • Nausea

  • Fatigue

• Bone marrow suppression peaks 7-14 days after chemo

• Greatest concern is infection

• BM suppression causes:

  • Neutropenia

  • Anemia

  • Thrombocytopenia

Care of the Neutropenic Child

• Screen visitors

• Wear masks

• No live plants in the room

• IV care

  • Maintain sterility of central lines

  • Prevent line infections

• Freq. temp.

  • Often the only sign of infection

• Timely administration of antibiotics if signs of infection

• Meticulous mouth care

• NO live vaccines

Care of the Thrombocytopenic Child (Assess)

• Increased bruising

• Signs of bleeding

  • Urine

  • Stool

  • Gums

Care of the Thrombocytopenic Child (Avoid)

• Activities that could cause injury

• NO rectal medications or temps.

• AVOID Aspirin/ NSAIDS

Care of the Thrombocytopenic Child (Use)

• A soft bristle brush

• Care during shaving

• Caution during lab draws

  • Hold pressure for prolonged time

Adverse Effects of Chemotherapy (GI Tract)

• N/V

  • Assess fluid/ electrolytes

  • Prophylactic, scheduled individualized antiemetics

  • Ondansetron (Zofran)

  • Aprepitant (Emend)

• Anorexia

  • Associated w/ nausea & change in taste

  • High protein, high calorie foods

  • May needs NG or G-tube feedings

• Stomatitis

  • Mouth care before/ after meals

  • NS or plain water mouth rinse

• Rectal Ulcers

  • Warm, sitz bath

  • Meticulous cleaning of area

• Constipation

Adverse Effects of Chemotherapy (Others)

• Hemorrhagic Cystitis

  • Bladder inflammation leading to blood in the urine

  • Increase fluid > 1.5 times normal maintenance rate

  • Encourage frequent voiding

• Alopecia

  • Very challenging for older school-age & teens

  • Ice cap during chemo

  • Alternative hair accessories

  • Hair will grow back after Tx

• Fatigue

  • Educate patient & family

Radiation Therapy (Frightening)

• Big, loud machine

• Alone in the room

• Have to be still

• May need skin marking on the radiation area

Radiation Therapy (Interventions/ Prep,)

• Tour of the department

• Child-friendly facility

• Pictures/ Talk to other children

• Work w/ child life therapist

• Sedation may be needed

• Less radiation used than w/ adults

Adverse Effects of Radiation Therapy

• Used more cautiously in children due to tissues, bones, & organs being more vulnerable to adverse effects

• Radiation is NOT a Tx of choice in children < 3 years of age

  • Can be cognitively devastating

• Side effects usually appear 7-10 days after initiation of therapy

  • Fatigue

  • Burns to the skin at the site

    • Redness, darkening, peeling, increased sensitivity

  • Hair loss

  • N/V, anorexia

Radiation Therapy (Nursing Care)

• Assess the child’s skin daily at the Tx site

• Aloe vera lotion or aqueous creams only

  • AVOID perfumed lotions & soap

• Meticulous mouth & skin care

• Adequate nutrition & fluid intake

• Antiemetics

• Diphenhydramine or hydrocortisone 1% cream for itching

• Sunscreen

  • Skin is photosensitive

Other Cancer Therapeutics

• Hematopoietic Stem Cell Transplantation (HSCT)

• Steroid Therapy

• Biologic Agents

Other Cancer Therapeutics (HSCT)

• Hematopoietic Stem Cell Transplantation

• Stem cells can differentiate into any type of hematologic cell

• Healthy bone marrow cells are transfused into the patient’s blood & migrate to bone marrow

Other Cancer Therapeutics (Steroid Therapy)

• Leukemia Tx & to control N/V

• Have many side effects

  • Immunosuppression

Other Cancer Therapeutics (Biologic Agents0

• Used to enhance cell recovery

• Colony-stimulating factors (CSFs), Filgrastim (Neupogen)

  • Stimulate WBC recovery

• Epogen (Epoetin alfa)

  • Stimulates RBC recovery

• Reduced need for blood products

Leukemia

• Most common cancer

  • 1/3 of all cases

• Disorder of the bone marrow

• Overproduction of abnormal WBCs

  • Lymphoblasts

• Suppresses normal cell formation in bone marrow

  • Leading to decreased RBC, WBC, & platelets

• Acute leukemias are more common in children

• Cause is generally unknown

  • May be a genetic factor

Types of Leukemia

• Acute Lymphoblastic Leukemia (ALL)

• Acute Myelogenous Leukemia (AML)

Types of Leukemia (ALL)

• 77%

• Immature Lymphocytes

• More common in boys

• 90% survival rate at 5 years

Types of Leukemia (AML)

• 25%

• Immature Myelocytes

• 50% long-term survival rate

Leukemia (S/S)

• Bone/ joint pain

  • Hallmark classic sign

• Hepatosplenomegaly

• Bone marrow suppression

  • Anemia

  • Leukopenia or leukocytosis

  • Thrombocytopenia

Leukemia (Diagnosis)

• Initial CBC

  • The higher the WBC at initial diagnosis = The worse the disorder will be

• Confirmatory bone marrow aspiration & biopsy

• LP

  • Checks for CNS involvement

• Therapeutic mngmnt.

  • Chemotherapy

Leukemia (Tx)

• Involves 3 phases

  • Painful procedure over time

• Induction

• Consolidation

• Maintenance

Leukemia (Tx Induction Phase)

• To induce remission

• < 5% blast cells in the bone marrow

• 98% of cases achieve remission by 1 month

• Frequent bone marrow aspirations & LP

  • To track effectiveness of chemo

Leukemia (Tx Consolidation Phase)

• Therapy to maintain remission

Leukemia (Tx Maintenance Phase)

• Maintenance chemo given over 2-3 years

Brain Tumors

• Most common solid tumor & second most prevalent malignancy in children

• Mortality rate is close to 30%

  • 70% will be long-term survivors but many will have functional neurologic deficits

Brain Tumors (S/S)

• Based on location, size of the tumor, & child’s age

• Headache upon arising (Waking up in the morning)

• Vomiting unrelated to feeding

Brain Tumors (Nursing Care)

• Attention to:

  • Neuro exam

  • VS

• Preventing increased ICP

• Pre- & post-op care & education

Brain Tumors (Diagnosis)

• MRI

• CT

• PET Scan

• LP

• Presence of Alpha-fetoprotein or HCG

Brain Tumors (Tx)

• Surgical Removal

  • If possible

  • Based on location

• Radiation

  • > 3 years of age

• Chemotherapy

  • In children < 3 years

Neuroblastoma

• Mainly occurs in the adrenal gland

• Tumor on the adrenal gland

  • Above the kidney

• Abdominal mass crosses the midline

• 90% diagnosed before 5 years of age

• The younger the kid, the better the outcomes tend to be

Neuroblastoma (S/S)

• Pain

• Abdominal mass crosses the midline

• Elevated urine, HVA, VMA

  • 24 hr urine culture

Neuroblastoma (Tx)

• Surgical removal w/ radiation & chemo

Osteosarcoma & Ewing’s Sarcoma

• Highly malignant bone cancers

  • Found mostly in teens

Osteosarcoma & Ewing’s Sarcoma (S/S)

• Intermittent pain that progressively worsens

• Mass at the tumor site

• Limp or pathologic fracture at tumor site

Osteosarcoma & Ewing’s Sarcoma (Labs/ Diagnostics)

• CT

• MRI

• Biopsy

• Elevated serum alkaline phosphate (ALP)

• Elevated lactate dehydrogenase (LDH)

Osteosarcoma & Ewing’s Sarcoma (Tx)

• Osteosarcoma Tx

  • Chemo

  • Surgical excision

  • Chemo for additional year

• Ewing’s Sarcoma Tx

  • Chemo

  • Surgical excision

  • Radiation

Rhabdomyosarcoma

• Soft tissue tumor

  • Originates in tissues that become bones/ muscles

Rhabdomyosarcoma (S/S)

• Often an asymptomatic mass

• Locations

  • Head/ neck

  • Urinary tract

  • Extremities

Rhabdomyosarcoma (Tx)

• Chemo

• Surgical removal of tumor depending on location

• Further chemo

• Radiation if there is residual disease

Nephroblastoma “Wilm’s Tumor”

• Kidney cancer

• Tumor

• 90% survival rate

Nephroblastoma “Wilm’s Tumor” (S/S)

• Fast growing abdominal mass

• Firm, Non-tender, UNILATERAL

• Hematuria

• HTN

Nephroblastoma “Wilm’s Tumor” (Diagnosis)

• Renal or abdominal US, CT, MRI

• Negative HVA & VMA

Nephroblastoma “Wilm’s Tumor” (Nursing Mngmnt.)

• Do NOT palpate tumor

• Surgical removal

  • Removal of the tumor & the affected kidney

• Radiation

• Chemo

Retinoblastoma

• Rare, malignant tumor of embryonic retinal cells

  • Hereditary component in some cases

• 90% of cases in children < 5 years

• Goal

  • Save the child’s life & preserve the eye w/ useful vision

• May have to remove the eye to save the child’s life

• 95% cure if detected early

Retinoblastoma (S/S)

• Leukocoria “Cat’s eye”

  • Abnormal white or yellow reflection in the retina

• Strabismus

  • Cross-eyed

• Pain, redness, inflammation of the eye

Retinoblastoma (Diagnosis)

• CT/MRI to visualize the tumor