Ch 50 lecture
Chapter 50: The Child with Cancer
Overview of Childhood Cancers by Age Group
The prevalence of specific tumor sites varies significantly with age in children:
Less than years old: Acute leukemia is the most common, followed by central nervous system (CNS) tumors.
to years old: Acute leukemia remains the most common.
to years old: Acute leukemia, lymphoma, and brain/CNS tumors are the most common.
to years old: Lymphoma is the most common.
Etiology of Cancer
Cancer development is multifactorial and can be attributed to:
Genetic mutations.
Environmental factors.
Immune system and gene abnormalities.
Chromosomal abnormalities.
There is a known genetic component to many cancers. For example, a family history of breast cancer prompts testing for BRCA and BRCA genes, and a family history of colon cancer necessitates earlier colonoscopies due to increased risk.
Manifestations of Cancer
Cancer symptoms are often generalized and can be subtle, leading to late diagnosis in some cases (e.g., pancreatic cancer presenting with only three years to live):
Pain.
Cachexia (significant weight loss).
Anemia.
Frequent infections.
Bruising and petechiae.
Neurological symptoms.
Presence of a palpable mass, which is a key sign in conditions like Wilms tumor.
Diagnostic Tests for Cancer
Diagnosis involves a combination of tests to identify cancer and rule out other conditions:
Blood Tests: Carcinoembryonic antigen (CEA) is one marker that can be checked.
Complete Blood Count (CBC): Evaluates white blood cells (WBCs) to assess the body's fighting capacity, platelet counts for clotting, and hemoglobin levels for anemia. The absolute neutrophil count () is critical, with levels less than indicating a high risk for infection.
Bone Marrow Aspiration and Biopsy: Performed to assess bone marrow health and detect the presence of immature (blast) cells. The absence of immature blast cells, such as in aplastic anemia, indicates bone marrow dysfunction.
Lumbar Puncture (LP): Examines cerebrospinal fluid (CSF) for malignant cells and can also rule out infections like meningitis.
Imaging: X-rays, magnetic resonance imaging (MRI), and computed tomography (CT) scans are used to visualize tumors and assess their extent.
Biopsy: Of the tumor itself, for definitive diagnosis.
Note on Procedures: CT scans can be frightening for children, requiring sedation to ensure stillness. Restraints are generally not used as they can increase agitation.
Cancer Management and Therapy
Cancer care in children is managed by a pediatric oncologist, a specialist in this field. Therapy can be singular or a combination of approaches:
Surgery: To remove the tumor.
Chemotherapy: Systemic treatment using drugs to kill cancer cells.
Radiation Therapy: Uses high-energy rays to kill cancer cells.
Stem Cell Transplantation: To replace diseased bone marrow.
Complementary Therapies: Used alongside conventional treatments.
End-of-Life Care:
Palliative Care: Focused on comfort and improving quality of life, can be started early in the disease process.
Hospice Care: Typically for patients with a prognosis of three to six months, focusing on comfort when curative treatment has ceased.
Side Effects of Chemotherapy and Nursing Considerations
Chemotherapy does not differentiate between good and bad cells, leading to significant side effects:
Immunosuppression: Killing WBCs increases the risk of infection, necessitating strict infection control measures.
Anemia: Reduction in red blood cells.
Weight Loss and Nutritional Issues: Due to extreme nausea, vomiting, and mouth ulcers (stomatitis), making nutrition difficult.
Alopecia: Hair loss.
Growth and Development Delays: Due to lack of energy and the systemic effects of the disease and treatment.
Supportive Care
Comprehensive support is crucial for the child and family:
Infection Control: Essential due to immunosuppression.
Pain Management: Cancer can be very painful.
Nutrition: Aggressive nutritional support is often needed.
Emotional and Psychological Support: Parents often require the most emotional care, as children tend to be resilient. Support is also needed for the child and other caretakers.
Spiritual Needs: Address spiritual aspects of illness.
Normalization: Allowing children to be kids and express emotions through play.
Oncologic Emergencies
Two critical emergencies require prompt recognition and intervention:
1. Tumor Lysis Syndrome (TLS)
(Refer to page , Table in the textbook for more details)
TLS occurs when cancer cells break down rapidly, releasing their intracellular contents into the bloodstream. This leads to severe electrolyte imbalances:
Hyperuricemia: High uric acid levels (treated with allopurinol, similar to gout management).
Hyperkalemia: High potassium levels, which can cause peaked T waves on an EKG and cardiac arrhythmias.
Hyperphosphatemia: High phosphate levels.
Hypocalcemia: Low calcium levels, as phosphate and calcium are inversely related. This can manifest as neurologic and mental changes (e.g., positive Trousseau's and Chvostek's signs).
Consequences: Metabolic acidosis, cardiac arrhythmias, impaired renal function, neurological and mental changes.
Nursing Interventions:
Vigorous Hydration: Administer fluids to promote elimination of excess electrolytes. Monitor intake and output (I&Os) closely to prevent over- or under-hydration.
Daily Weight: To monitor fluid balance.
Electrolyte Correction: Administer specific electrolytes or medications to correct imbalances (e.g., diuretics to excrete potassium).
Cardiac Monitoring: EKG monitoring for hyperkalemia.
Renal Function Monitoring: May require dialysis in severe cases.
Neurological Assessment: Monitor for mental status changes related to hypocalcemia.
Medication Side Effects: Monitor for any adverse effects of administered medications.
2. Space Occupying Lesion
(Also on page in the textbook)
This emergency occurs when a growing tumor compresses vital structures, leading to significant dysfunction:
Spinal Cord Compression: Can cause neurological deficits.
Increased Intracranial Pressure (ICP) and Brain Herniation: If the tumor is in the brain.
Seizures.
Massive Hepatomegaly: Enlargement of the liver.
Superior Vena Cava (SVC) Syndrome: Obstruction of the SVC by a tumor, impairing venous return from the upper body.
Interventions (based on location and symptoms):
Decrease ICP: If brain is affected.
Decrease Spinal Cord Compression.
Seizure Precautions: If seizures are present.
GI Obstruction Management: Such as placing an NG tube.
Cardiac Monitoring: EKG for cardiac involvement.
Respiratory Monitoring: saturation for respiratory compromise.
Specific Types of Childhood Cancers
Solid Tumors
Brain and Central Nervous System (CNS) Tumors
Most common solid malignancy in children.
Nonspecific Symptoms: Headache (thunderclap, worst headache of life, or associated with orgasm), morning vomiting, irritability, changes in level of consciousness (), non-responsive pupil, cranial nerve palsies, nystagmus (involuntary eye movement), head tilting. These often point to increased ICP.
Treatment: Surgery, radiation, chemotherapy.
Neuroblastoma
A tumor of the CNS (though often arising from adrenal glands or other nerve tissue).
Treatment: Surgery, chemotherapy, radiation, stem cell transplant.
Wilms Tumor (Nephroblastoma)
Tumor of the kidney.
Key Sign: Palpable abdominal mass; do NOT palpate the abdomen once suspected, as it can cause tumor rupture and seeding.
Treatment: Surgery, radiation, chemotherapy.
Osteosarcoma
Tumor of the bones.
Treatment: Surgery and chemotherapy.
Ewing Sarcoma
Tumor of the long bones.
Goal: To save the affected limb, avoiding amputation.
Treatment: Surgery, chemotherapy, and radiation.
Hematologic Malignancies
Leukemia (Acute Lymphoblastic Leukemia (ALL) and Acute Myeloid Leukemia (AML))
Most commonly diagnosed cancer in children under years old.
Cancer of the blood-forming organs, characterized by abnormal white blood cells.
Affects multiple body systems.
Treatment: Required for a very long time.
Monitor For: Bleeding, bruising, petechiae, signs of infection, and tumor lysis syndrome.
Impact on Nutrition: Chemotherapy often causes anorexia, vomiting, and diarrhea, making nutritional support vital.
CNS Involvement: Tumors can infiltrate the brain, requiring careful monitoring.
Pain and Bone Marrow Suppression: Managed with pain control and infection prevention.
Coping: Child and family require extensive education and support, including standard hand washing, infection prevention strategies, and oral care.
Hodgkin Disease (Hodgkin Lymphoma)
Disorder of the lymphoid system, typically involving one or several lymph nodes.
Diagnosis: Characterized by the presence of Reed-Sternberg cells (a key differentiator from Non-Hodgkin Lymphoma).
Treatment: Based on the stage of the disease, often involves chemotherapy.
Non-Hodgkin Lymphoma
Different types exist.
Distinction from Hodgkin Disease: Lacks Reed-Sternberg cells.
Other Pediatric Cancers
Rhabdomyosarcoma
Soft tissue tumor that can occur anywhere with soft tissue (e.g., GI tract, eyes, abdomen, extremities, muscles around the eyes and neck).
Common in children under years old.
Treatment: Surgery, radiation, and chemotherapy.
Retinoblastoma
Cancer of the retina.
Key Sign: Leukocoria (a white pupil – not to be confused with leukorrhea, which is vaginal discharge).
Treatment: Radiation is almost always used. Chemotherapy may be used but is sometimes ineffective, potentially leading to enucleation (surgical removal of the eye).
Overall Nursing Care for Children with Cancer
Conduct thorough psychological and physiological assessments.
Collaborate closely with the family and the medical team.
Interventions are based on assessments and managing the side effects of therapy.
Key priorities include preventing infection, ensuring adequate nutrition, and providing emotional and psychological support.
Monitoring for oncologic emergencies like tumor lysis syndrome and space-occupying lesions is paramount.