Health alterations class 14: cellular regulation (cancer in children)

Most common childhood cancers

1. Leukemia

2. Lymphoma

3. Neuroblastoma

Leading cause of death from disease in children 1-19

Cancer, approximately 129/1 million kids

Most prevalent type of cancer

leukemia (then tumors involving the CNS, then lymphomas)

What gender has a slightly higher percentage of occurrence of cancer

Males (1.2/1)

How often are children with cancer cured

80% of the time

Cancer cure definition

Used when child is 5 years off treatment (scanned every year, if no cancer for 5 years then considered cure)

Prevention of childhood cancer

No known means of preventing childhood cancer

Diagnostic evaluation of cancer in children

1. Complete history (pregnancy, immunizations, growth…)

2. Review of symptoms

3. Physical exam

4. Lab tests (blood work, CBC with differentials)

5. Imaging studies (x ray, ct, MRI)

6. Biopsy (what type of cancer)

What does treatment of cancer in children usually consist of

Chemotherapy, radiation, surgery, bone marrow transplant (not done on children in NL), biological response modifiers (and clinical trials)

Leukemia

Cancer of the blood forming cells that are abnormal and immature

Who has the best prognosis with Leukemia

Children age 1-9 (younger is better) with a WBC count <50 on diagnosis

Two types of Leukemia

1. ALL-acute lymphoblastic Leukemia

2. AML-acute myelogenous Leukemia

ALL prognosis

90% are cured

AML prognosis

70% are cured

Children at a greater risk (20 times) of developing ALL

Children with trisomy 21 (Down syndrome)

Teaching of parents of children with Down syndrome

Teach parents signs and symptoms and to monitor from an early age

Pathophysiology of Leukemia

Unrestricted proliferation of immature WBCs in the blood forming tissues of the body

What organs are most severely affected by leukaemia

Liver and spleen

Even though Leukemia is an overproduction of WBCs, the acute form can cause

Low leukocyte count

How does cellular destruction take place in Leukemia

By infiltration and subsequent competition for metabolic elements

Bone marrow aspiration prep for children

1. Numbing cream on area

2. Sedation

3. Drill into bone

4. Look at sample under microscope

5. Give Tylenol after

Lumbar puncture preparation

Numb area and sedate

Signs of a low WBC count (warning sign of Leukemia)

1. Infection risk (fever)

2. Getting sick often

3. Frequent ear/throat infections

4. Viruses

Signs of a low platelet count (warning sign of Leukemia)

1. Bleeding

2. Bruising

3. Nose/gum bleeds

4. Petichiae

5. Enlarged lymph nodes

6. Enlarged liver/spleen

Signs of a low RBC count (warning sign of Leukemia)

1. Anemia

2. Pallor

3. Fatigue

Signs of Leukemia invading bone marrow

1. Limb pain

2. Fractures

Signs of Leukemia invading the CNS

1. Increased ICP

2. Vomiting

3. Headache

4. Loss of balance

5. Seizures

6. Lethargy

What can happen if Leukemia invades the testes, prostate or ovaries

May cause infertility. If a teenager, may freeze eggs/sperm for later in life

Diagnosis of Leukemia

Based on history and physical exam/manifestations

Definitive diagnosis of Leukemia

Need bone marrow aspiration or biopsy

What does lumbar puncture evaluate

Central nervous system involvement

Consequences of Leukemia

1. Anemia from decreased RBCs

2. Infection from neutropenia

3. Bleeding tendencies from decreased platelet production

Why do children often get prescribed higher doses of drugs than adults

Because their body can handle it better, no wear and tear yet, systems work better

Why should pts experiencing hair loss from chemo not shave their head

Because it increased their risk of infection (razor burn or cut)

Considerations for care of patients with chemotherapeutic agents

1. Use thicker gloves

2. Cover toilet when flushing

3. Can affect fetus if pregnant

4. Can affect fertility

Stomatitis

If visible in mouth, they are present in the whole GI tract

Stomatitis and eating

Makes eating painful, don’t force food, whatever they can eat is good, many need tube

Cranial radiation in peds

Can’t stay still so may need anaesthesia, may be multiple times a week

Chemo and cranial radiation

Chemo may be done with or without cranial radiation

Why does hair loss occur with chemo

Because it targets fast acting cells

Leukemia prognosis

Children diagnoses between 2-9 have a better prognosis than those diagnosed before 2 or after 10

Identified factors for determining prognosis

1. Initial WBC count

2. Age at time of diagnosis

3. Types of cell involved

4. Sex of the child

5. Karotype analysis

Considerations for rectal care in children with cancer

1. Skin break down may occur due to the excretion of chemo drugs

2. Don’t take rectal temp

3. May not be potty trained

Decreased RBCs with cancer

1. May need blood infusion (oncologist decides level)

2. Can have lower levels than an adult

Considerations for decreased platelets

1. At an increased bleeding risk

2. Avoid activities such as hockey, football, skating etc

3. Avoid bloodwork or IM injections unless absolutely necessary

4. Mouth care!

Considerations for decreased WBC count

1. Restrict visitors

2. No public places

3. Clean and sterilize

4. No live plants

5. No live vaccines, may need to be reimmunized after

Why are central lines used over an IV in children with cancer

Drugs can be harder on the veins

Nursing care of cancer

1. Prepare child and family for producers (happens quickly)

2. Pain management

3. Prevent complications of myelosuppressiom (infection, hemorrhage, anemia)

4. Manage problems of drug toxicity/chemotheraoy (N/V, anorexia, mucosal ulceration, neuropathy, hemorrhagic cystitis, alopecia, steroid effects, mood changes)

5. Provide emotional support

Pain management in children with cancer

Not worried about addiction, using approach of no child should feel pain

How to deal with anorexia/ lack of appetite in children with cancer

Relax food pressures, whatever they can eat is good

How to manage nausea and vomiting in children with cancer

Give antiemetic at least 30 minutes before treatment to avoid N/V

Mouth care in children with cancer

Super important! Preventing ulcers

Third most common group of malignancies in children and adolescents (more prevalent in males)

Lymphomas

Lymphoma

Hodgkins disease, malignancy of the lymphoid system (primarily involving the lymph nodes)

Key sign of lymphoma

Cervical lymph node swelling

Where do lymphomas often metastasize to

Spleen, liver, bone marrow, lungs and other tissue

What age group is lymphoma present in

Teens (15-19)

Survival rates for stage 1 and 2 lymphoma

85-95%

Survival rates for stage 3 and 4 lymphoma

70-90%

Stage 1 lymphoma

Lymph node region (neck)

Stage 2 lymphoma

2 or more lymph node regions (ex: neck and armpit)

Stage 3 lymphoma

Multiple regions on both sides of diaphragm (lower and upper body, ex: neck and groin)

Stage 4 lymphoma

Diffuse involvement including liver (both diaphragm sides and liver)

Class A Hodgkin’s disease

Asymptomatic, have a lump it it isn’t painful

Class B Hodgkin’s disease

Fever, night sweats, unexplained weight loss of 10% or more over previous 6 months, cough, abdominal discomfort, anorexia, pruritus, nausea (Lump and more effects)

What lymphoma occurs more frequently in children less than 14+

Non Hodgkin’s

Non Hodgkin’s clinical appearance

1. Disease is usually diffuse rather than nodular

2. Cell type is undifferentiated or poorly differentiated

3. Dissemination occurs early, often and rapidly

4. Mediastinal involvement and invasion of meninges are common

Main difference between Hodgkin’s and non Hodgkin’s

Hodgkin’s: just the lymph nodes until stage 4

Non Hodgkin’s: Involvement beyond the lymph nodes before stage 4. Generally there’s involvement of areas such as abdomen, mediastinum, bone marrow, lungs, bone and brain

Non Hodgkin’s lymphoma

Malignancy of the lymphocyte precursors in the bone marrow and thymus

3 main types of NHL

1. Small non cleaved

2. Lymphoblastic

3. Large cell

Small non cleaved NHL

B cells (less than 25% lymphoblastic in bone marrow)

Lymphoblastic NHL

T cells

Large cell NHL

B cell, T cell, indeterminate

Diagnostic evaluation for lymphoma

1. Lymph node biopsy for diagnosis and staging (NHL/HL?, A/B site?, if non cervical radiation may be used to shrink it first)

2. Bone marrow aspiration and lumbar puncture

Therapeutic management of lymphoma

1. Radiation, used to shrink tumors down

2. Chemo, used with or without radiation

Lung tumor considerations/treatment

1. Pt may have breathing issues so no anaesthesia

2. Shrink with chemo or radiation before biopsy (because of breathing issues)

Main issue with a lung tumor

Breathing! (Therefore anaesthesia may not be able to be used until tumor is shrunk)

Most common malignant extracranial solid tumor of childhood

Neuroblastoma

Where do most Neuroblastoma tumors develop

The adrenal gland or retroperitoneal sympathetic chain

Where is the adrenal gland

Sits on top of the kidneys

Why does Neuroblastoma typically have a poorer prognosis

Because of the location of the tumor (adrenal gland-on top of kidney) so often don’t realize it’s there until it’s progressed (may pick up child and feel a lump in their side)

Other sites Neuroblastomas can occur

Head, neck, chest, pelvis

Why are Neuroblastomas called silent tumors

Because metastasis may have already occurred before diagnosis

How do approximately 2/3 of Neuroblastomas present

With metastic disease to the bone marrow, lymph nodes, bone, skin or liver

Objective of Neuroblastoma diagnostic treatment

To locate the primary site and sites of metastatis (because often spreads before diagnosis)

Neuroblastoma diagnostic evaluation

1. Signs and symptoms (depends in location and stage)

2. Radiological studies

3. Bone marrow evaluation

4. MIBG scanning

What is MIBG scanning used for (neuroblastoma)

To determine the involvement of bone, bone marrow and soft tissue

Therapeutic management of Neuroblastoma

1. Accurate clinical staging to establish treatment plan

2. Surgery to remove tumor and obtain biopsy’s

3. Radiation, chemo

4. Stem cell rescue

Neuroblastoma prognosis

In general, the younger the child is at diagnosis the better. May have spontaneous regression as embryonic cells mature and with development of active immune system

What mouthwash may be used for oral care on cancer patients

Normal saline (won’t irritate ulcers)