Pediatric Oncology

Definition of childhood cancer

a group of chronic diseases characterized by uncontrolled growth and spread of abnormal cells which, if not adequately treated, results in the death of the patient

Cause of childhood cancer

mostly. unknown

virus

• EBV, HPV

genetic links

no proof of environmental agents

• chemicals, pesticides, electromagnetic fields

Hematologic malignancies

cancer of the blood

• leukemia

• lymphoma

solid tumors (sarcomas)

cancer of the bone, organs, or tissues

solid tumors

Diagnosis

lab work

• CBC/blood chemistries

Tests and procedures

• biopsy

• bone marrow aspirate

• lumbar puncture

• bone scan/ct scan

x-ray, echo, PET, MIBG

Leukemias

malignancy of bone marrow or blood forming tissues

bone marrow makes

• rbc

• wbc

• platelets

Leukemia cells

• Blasts: immature and dont work

• dont work properly, crowd out healthy blood cells

most common childhood cancer

• Acute Lymphoblastic leukemia

• acute myeloid leukemia

Genetic predisposition

• down syndrome

Lymphomas 

cancer of the immune system 

immune system stores fighter cells (lymphocytes)

lymphoma

• cells dont work properly to protect the body

• crowd healthy cells of the immune system

• may involve any subpopulation of lymphoid cells

types

• hodkings disease 

  • associated with EBV

• non-hodgkins

Lymph nodes

Epitrochlear (elbow) and supraclavicular nodes actually pathologic

concerning for cancer and is a trigger that something is wrong 

Wilms tumor

Epidemiology

• most common

  • malignant renal

  • intrabdominal tumor

  • non-tender, firm flank mass not crossing midline, in healthy appearing child 

Etiology 

• primordial cells

  • initiate abnormal structure 

• associated with other GI abnomalies 

DO NOT PALPATE ABDOMEN 

• if you press down on mass, it can burst and spread cancer everywhere

Rhabdomyosarcoma

most common soft tissue sarcoma of childhood

• malignant tumor of embryonic mesenchyme 

two major types in children

• embryonal

  • common in younger children 

  • orbit, head/neck, GI system

• alveolar 

  • common in adolescents

  • arms and legs 

Retinoblastoma

originates in the retina

• immature retinoblasts change to cancer cells

first cancer to have genetic identified

• associated with tumor suppression gene 

  • mutation of RB1 gene

in a picture, tumor near retina blocks the flash and it looks white

Osteosarcoma

most common

bone forming mesenchyme

• metaphysis 

• long bone 

• femur

Ewing Sarcoma

Second most common

marrow space

• shaft of long bone

• pelvis

• chest wall

soft tissue involvement (around the bone)

Neuroblastoma

tumor arising from neural crest tissue

• all r/t sympathetic nervous system s/s

Cranial tumors 

most common cause of childhood cancer mortality 

Primary

• arise from normal cells within the brain

• benign vs malignant 

Secondary 

• originate outside CNS

• hematogenous spread

• always malignant 

challenges of cranial tumors

blood-brain barriers

surgical inaccessibility

Chemotherapy

kills rapidly dividing cells

defined by mechanism of action

combination therapy 

• two or more agents have greater response than when used alone 

• act in different phases of cell cycle

Administration

• usually through central line

• inpatient vs outpatient

General side effects of chemotherapy

hematopoietic

• myelosuppression 7-10 days following

hypersensitivity

neuro

cardiopulmonary

• cardiomyopathy

reprodutive

Precautions when administering chemo 

vesicant 

anaphylaxis

education

specialized training to administer

Surgery

variety of uses in treatment

• diagnosis 

• tumor removal 

• support throughout treatment

side effects

• constipation

• headaches

• n

• pain

• specific to tumor location

Open surgery

removes whole tumor

primary surgery

remove all or most at one time

may need chemo first to shrink it

second look

examine efficacy of treatment

may remove any remaining tumor

supportive care

central line 

g tube

radiation

action of emitting radiant energy 

• destroys cancer cells in localized area

goals

• acute management of symptoms

• curative

• palliative

Side effects

• primarly localized to the specific area

Nurse care

• symptom management

Hematopoietic stem cell transplant purpose

to replace diseased, damaged, or absent stem cells within healthy stem cells

Allogenic stem cell transplant

stem cells from alternative donor

autologous stem cell transplant

patients own stem cells

assessment

generally WDL for most systems

kids look pretty well 

typical s/s

• alopecia

• pallor/fatigue

• petechiae/bleeding

• s/s of infection

• pain

Brain tumor assessment

neuro checks

neuroblastoma assessment

BP

diarrhea/constipation

Bone tumor assessment

limb circumfrence

favor/guarding limb

GI complications assessment

mouth integrity

I and O, daily weight

bowel sounds

rectal skin integrity

emesis

Absolute neutrophil count

ANC: WBC x (%of bands+ % of SEGS)

>2000 normal

<1500 neutropenic 

<500 severely neutropenic 

Fever monitoring

>100.4 times 2 (60 minutes apart) or 101+ once

after being admitted to hospital, do blood cultures, IV antibiotics, fluids, labs/vitals 

fevers with neutropenia → high risk for sepsis

General nursing considerations

avoid NSAID treatment

• increase bleeding risk with low platlets

Avoid rectal temperature, rectal exams

• risk for infection

Myelosuppression

bone marrow activity is decreased, resulting in fever rbc. wbc, and platelets

Myelosuppression infection

prevenetion

GCSF

• bulk immune system

treat

• blood cultures

• antibiotics

• fluids 

Myelosuppression anemia

assess

• s/s

labs

treat

• PRBC infusion

• symptomatic 

Myelosuppression hemorrhage

prevention

• avoid skin punctures

• assess

control 

• platelet infusion

  • reserved for active bleeding or high risk of bleeding

• education 

GI complications

N/V/Diarrhea

• profound

• treat before during and after

Anorexia/weight loss

• difficult for parents to understand

• cant make kids eat

• treat

  • oral meds

  • TPN 

  • G tube

Mucosal ulcerations

GI cell damage

compounds anorexia 

treat

• bland, soft

• toothettes

• sodium bicard mouthwash

• local anesthetics

• peridex

Neuropathies

constipation

• admin stool softeners

Foot drop

• footboards

• careful ambulation

Jaw/bone apin

• soft liquid diet

• pain meds

Hemorrhagic cystitis

increase fluid intake

frequent urination

administer bladder protectant before during and after chemo

Alopecia 

education

side efftect

hair regrows in 3-6 months

Tumor lysis syndrome

Hyperuricemia

hyperphosphatemia 

hypocalcemia

hyperkalemia

nurse assessment

• Strict I & O

  • monitor edema and weight gain

• monitor neuro status, cardiac function

Nurse care

• monitor labs

• hyperhydrate patient, no K in IVF

• allopurinol/rasburicase

• possible leukopheresis

Neurological changes seizures

caused by CNS irritation

leads to changes in 

• consciousness

• behavior

• motor function

• sensation

• autonomic function

nurse care

• anticonvulsants

• labs

• treat underlying cause

  • prevent harm to child 

Cerebral vascular accidents

impaired blood supply to the brain with subsequent ischemia

nurse care:

steriods

hyperosmolar solution

platelets

neuro assessment 

Developmental considerations

family systems

• role of parents, siblings, grandparents

• stressors

school and friends

• school liason 

regression is common with illness at all ages 

fear

• losing hair/appearance changes

• isolation/missing out

• death