Child with Cancer (NUR 320) – Comprehensive Exam Study Notes

Epidemiology & Etiology of Childhood Cancer

• Second leading cause of death in the pediatric population (after unintentional injuries)
• Etiology is largely unknown
  • Current theory: multifactorial interaction among
  • Genetic alterations
  • Environmental exposures (radiation, toxins, viral triggers, etc.)
  • Immune‐system dysfunction or inadequate tumor surveillance
• Psychosocial / developmental overlay
  • Diagnosis collides with critical growth stages ⇒ regression, altered body image, school disruption
  • Family-centered care is ethically imperative; parents/guardians are primary partners in decision-making
  • Family stressors: financial strain, anticipatory grief, caregiver role strain, cultural/spiritual questions

Fundamental Tumor Biology

• Neoplasm = any new growth or tumor
• Tumors classified as benign or malignant
  • Benign: localized, usually encapsulated, non-invasive
  • Malignant:
  • Life-threatening potential
  • Invasion of contiguous tissue
  • Metastasis via blood, lymph, or CSF
  • Cells poorly differentiated / anaplastic

Clinical Presentation – Pediatric Specifics

• Pediatric cancers often present with covert, nonspecific complaints ("the cold that lingers")
• Typical red-flag signs & symptoms
  • Mass or swelling
  • Purpura / unexplained bruising
  • Pallor or anemia-related fatigue
  • $\downarrow$ weight (unintentional)
  • Persistent or projectile vomiting
  • Recurrent or low-grade fevers
  • Bone or joint pain, limp
  • Headache (especially a.m.)
  • Lymphadenopathy (firm, non-tender nodes)
  • Gait, personality, or balance changes
  • General fatigue / malaise
• NCLEX-style recall: fatigue, headache, weight loss, lymphadenopathy are classic; polydipsia is NOT

Diagnostic Work-Up

• Laboratory studies
  • CBC: pancytopenia, leukocytosis, or isolated cytopenias
  • Chemistry: electrolyte shifts, $\uparrow$ uric acid, $\downarrow$ albumin
• Procedures
  • Bone-marrow aspiration/biopsy (posterior iliac crest; prone with pillow)
  • Lumbar puncture (evaluate CNS involvement; intrathecal chemo route)
• Imaging modalities
  • X-ray, ultrasound, CT, MRI, PET
• Pathology / flow cytometry for definitive cell typing

Nursing Considerations for Invasive Procedures

• Obtain informed consent; developmentally appropriate explanations (use play/visual aids)
• Sedation for young or anxious children; allow parental presence
• Positioning: prone with small pillow under hips for marrow aspiration
• Coping techniques: singing, counting, deep breathing during needle entry (<10 sec discomfort)
• Post-procedure
  • Pressure dressing if platelet count <50{,}000/\text{mm}^3
  • Monitor VS, puncture site for hemorrhage or infection

Treatment Modalities Overview

• Surgery (curative, debulking, biopsy)
• Radiation therapy (external beam, fractionated doses)
• Chemotherapy (multi-agent protocols)
• Biologic / immunotherapy (e.g., monoclonal antibodies, CAR-T)
• Complementary & alternative modalities (massage, art therapy) – evaluate evidence & safety
• Hematopoietic stem-cell transplant (HSCT) – autologous or allogeneic

Central Venous Access Devices (CVADs)

• Long-term routes: Port-a-Cath, PICC, tunneled catheters
• Access with non-coring (Huber) needle; sterile technique imperative
• Teaching: flushing schedule, infection-prevention, swimming restrictions, when to seek help

Chemotherapy Essentials

• Mechanism: cytotoxic to rapidly dividing cells ⇒ high collateral on GI mucosa, hair follicles, marrow
• Routes: PO, IV, IM, SQ, intrathecal
• Setting: inpatient, outpatient clinic, or home infusion
• Common adverse effects
  • Bone-marrow suppression: thrombocytopenia, neutropenia, anemia
  • Nausea / vomiting (anticipatory, acute, delayed)
  • Mucositis / stomatitis
  • Alopecia
  • Photosensitivity, fatigue, diarrhea
• Nursing priorities
  • Reverse isolation & neutropenic precautions (ANC <500/\text{mm}^3)
  • Strict infection control; no fresh flowers, raw produce
  • Transfusion support (PRBCs, platelets)
  • Bleeding & injury prevention; soft toothbrushes, no rectal temps
  • Nutrition: high-calorie, high-protein; TPN if necessary
  • Pain & nausea management (opioids, antiemetics BEFORE chemo)
  • Sun protection, activity clustering, developmentally appropriate play

Preparing & Administering Chemotherapy (OSHA High-Alert)

• Verify height & weight ⇒ calculate body-surface area (BSA) $\text{m}^2$
• Double-check dose with 2nd RN, cross-reference protocol (COG, institutional)
• Review CBC within $48$ h; hold if counts below threshold
• Confirm CVAD patency; new peripheral IV for vesicants
• Have emergency meds & extravasation kits at bedside
• Don appropriate PPE per OSHA/NIOSH

Radiation Therapy – Key Points

• Delivered in fractionated doses to limit toxicity
• Acute side-effects
  • Fatigue
  • Dermatitis / skin breakdown in radiation field
  • Alopecia in field
  • Nausea / vomiting, anorexia
  • Myelosuppression
• May also see late effects months–years later (endocrine dysfunction, secondary malignancies)

Stem-Cell / Bone-Marrow Transplant (HSCT/BMT)

• Stem-cell sources: bone marrow, peripheral blood, cord blood
• Autologous (self) vs allogeneic (matched donor)
• Infused cells migrate to marrow ⇒ restore hematopoiesis
• Common acute toxicities: mucositis, profuse diarrhea, fevers, epistaxis
• Core nursing care
  • Strict neutropenic isolation; positive-pressure room if available
  • GVHD surveillance (rash, liver dysfunction, diarrhea)
  • Antirejection / immunosuppressant management
  • Nutritional, emotional, and developmental support

Pediatric Oncologic Emergencies

• Tumor Lysis Syndrome (TLS)
  • Rapid lysis ⇒ release of $K^+$, phosphate, uric acid; $\downarrow$ calcium
  • Risk of renal failure; maintain aggressive hydration, allopurinol/rasburicase, monitor labs & urine output
• Hyperleukocytosis (> $100\times10^9/\text{L}$) ⇒ viscosity, stroke risk
• Superior Vena Cava (SVC) Syndrome ⇒ facial/upper-body edema, respiratory compromise
• Spinal-Cord Compression ⇒ back pain, motor loss, bladder dysfunction
• Disseminated Intravascular Coagulation (DIC) ⇒ bleeding & microthrombi; support with blood products, treat trigger

General Acute Side Effects Across Therapies

• Infection / sepsis
• Hemorrhage
• Anemia & fatigue
• Nausea / vomiting (anticipatory, acute, delayed)
• Altered nutrition & weight loss
• Mucositis / ulcerations of GI tract
• Neurotoxicity / peripheral neuropathies
• Hemorrhagic cystitis (e.g., cyclophosphamide metabolite acrolein) ⇒ MESNA prophylaxis, hydration
• Steroid-related: mood swings, hyperglycemia, cushingoid appearance

Acute Leukemias

• Malignancy of marrow & lymph tissues ⇒ “liquid tumors”
• Most common childhood cancer (<$15$ yrs)
• Pathophysiology: uncontrolled proliferation of immature blasts crowding healthy cells ⇒ pancytopenia

Acute Lymphoblastic Leukemia (ALL)

• Accounts for majority; $5$-yr disease-free survival >$85\%$
• Diagnostics
  • CBC: pancytopenia, $\uparrow$ lymphocytes
  • Bone-marrow aspirate: $\geq25\%$ lymphoblasts (confirmatory)
  • LP: evaluate CNS spread
  • Flow cytometry: B- vs T-cell lineage
• Clinical staging (I–IV) by node & organ involvement (diagram review)
• Therapy: multi-phase chemotherapy per Children’s Oncology Group (induction, consolidation, maintenance); potential HSCT
• Focused Nursing Issues
  • Infection control (ANC monitoring)
  • Hemorrhage & bruising surveillance, nose-bleed management
  • Nutrition: high-calorie, antiemetics, weight tracking
  • Psychosocial: alopecia preparation, school re-entry facilitation

Lymphomas

• Malignancies of lymphoid tissue
• Two main entities
  • Hodgkin Lymphoma (HL)
  • Typically localized, single node chain
  • Reed-Sternberg cells pathognomonic
  • Non-Hodgkin Lymphoma (NHL)
  • Rapid, diffuse, often mediastinal mass
• “B-symptoms”: night sweats, fever, >10\% weight loss
• Painless, firm lymphadenopathy; hepatosplenomegaly; abdominal pain (NHL)
• Treatment: risk-adapted chemo ± radiation; monitor TLS risk

Overview of Solid Tumors

• Brain & CNS tumors
• Neuroblastoma
• Bone & muscle tumors (Osteosarcoma, Ewing sarcoma, Rhabdomyosarcoma)
• Wilms tumor (nephroblastoma)
• Retinoblastoma
• Germ-cell & hepatic tumors

Brain Tumors

• Most common solid pediatric tumor
• Presentation
  • Early-morning headache, vomiting
  • Abnormal neuro exam; cranial nerve deficits
  • $\uparrow$ intracranial pressure (ICP): papilledema, behavior change, decreased pulse pressure
• Diagnostics: MRI preferred; CT, PET, LP (cautious), tissue biopsy
• Management: surgical resection, chemo, targeted radiation
• Post-op Nursing
  • Neuro checks, ICP control, positioning, fluid balance, comfort
  • Family emotional support & rehabilitation planning

Neuroblastoma

• Arises from sympathetic chain (neural crest)
• Often diagnosed as abdominal mass; can metastasize (bone, skin, orbit – “raccoon eyes”)
• Symptoms: protuberant abdomen, limping, jerks, eyelid droop, facial edema
• Diagnostics: biopsy, CT/MRI, catecholamine metabolite (HVA/VMA) elevations
• Treatment: multimodal – chemo, surgery, radiation, HSCT, immunotherapy
• Nursing: pain control, peri-op care, mobility support, parental coping

Bone & Muscle Tumors

• Osteosarcoma
  • Peak adolescence; distal femur > prox tibia > prox humerus
  • Pain, swelling, decreased ROM
• Ewing Sarcoma
  • Flat bones (pelvis, ribs, vertebrae)
  • Systemic symptoms (fever, weight loss)
• Rhabdomyosarcoma
  • Soft-tissue tumor from mesenchyme (<$10$ yrs common)
• Multidisciplinary diagnosis (imaging, biopsy)
• Treatment: limb-sparing surgery, amputation (osteosarcoma), chemo, radiation
• Nursing: body-image counseling, prosthetic training, pain & function restoration

Wilms Tumor (Nephroblastoma)

• Most frequent renal malignancy
• Classic sign: painless abdominal mass; do NOT palpate vigorously (risk of rupture & seeding)
• Metastasis commonly to lungs
• Diagnostics: CT/MRI, UA, labs; staging I–V
• Treatment: nephrectomy, chemo ± radiation
• Pre-op: gentle handling, blood-pressure control; Post-op: output, infection, education on solitary kidney care

Retinoblastoma

• Malignancy of retinal cell layer; >90\% diagnosed <5 yrs
• Hallmark: leukocoria (“cat’s-eye” reflex) in photos, absent red reflex
• Other: strabismus, vision loss, orbital inflammation
• Diagnostics: fundoscopic exam under sedation, ocular US, CT/MRI
• Treatment: chemo, focal radiation, cryotherapy; enucleation if advanced
• Nursing: family preparation for prosthesis, genetic counseling (RB1 mutation)

Other Tumors

• Germ-cell tumors: gonadal/extragonadal (testes, ovaries, sacrococcyx, mediastinum); surgical resection is cornerstone
• Liver tumors
  • Hepatoblastoma (infants/young) & Hepatocellular carcinoma (5–15 yrs)
  • Surgery primary; transplant consideration

Survivorship & Late Effects

• Overall long-term survival now >$80\%$
• Late effects
  • Secondary malignancies (e.g., AML after etoposide)
  • Endocrine: growth hormone deficiency, infertility
  • Cardiac: anthracycline-induced cardiomyopathy
  • Neurocognitive impairment, psychosocial challenges
• Lifelong, risk-based follow-up
  • Screening, surveillance, health-promotion education (diet, exercise, smoking avoidance)
• Role of nurse: transition planning, advocacy, health-literacy reinforcement

Patient & Family Education Principles

• Continuous dialogue: diagnosis comprehension, treatment phases, expected side effects
• Skills teaching: CVAD care, medication administration, infection warning signs
• Encourage participation & shared decision-making
• Provide written & digital resources; connect with support groups, school liaison
• Address ethical considerations: assent, fertility preservation, advance directives in older adolescents

Ethical, Philosophical, & Practical Highlights

• Informed consent & child assent evolve with developmental stage
• Balance cure with quality of life; palliative care integration when appropriate
• Cultural sensitivity in discussing prognosis, complementary therapies
• Financial toxicity & healthcare disparity awareness

Quick Reference – Numerical Pearls

• ALL $5$-yr DFS >85\%
• Neutropenia cutoff: ANC <500/\text{mm}^3
• Platelet precaution threshold: <50{,}000/\text{mm}^3
• Hyperleukocytosis: WBC >100\times10^9/\text{L}
• Majority of retinoblastoma cases present $<5$ yrs; $>90\%$ cured if localized

Mnemonic Aids

• “CHILD CANCER” for warning signs (Children’s Oncology Group mnemonic):
  • Continued, unexplained weight loss
  • Headaches with early-morning vomiting
  • Increased swelling / persistent pain (bones, joints)
  • Lump or mass (abdomen, neck, etc.)
  • Development of whitish color behind pupil
  • Constant infections
  • Aches in bones, joints, back
  • Neurologic changes (balance, gait)
  • Constant fever
  • Excessive bruising, bleeding
  • Recurrent / persistent nausea

Summary

• Pediatric oncology nursing demands holistic care: biomedical precision + psychosocial scaffolding.
• Early recognition, protocol-driven treatment, meticulous supportive care, and family partnership yield high cure rates and improved lifelong outcomes.