Transcript Document

Cancers in
Children
Lynn Kennell
7/21/2015
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Introduction
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Focus on 4 Broad types of Cancer
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LEUKEMIAS:
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BONE CANCERS:
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BRAIN TUMORS:
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WILM’S TUMOR
ALL, ANLL
OSTEOGENIC SARCOMA
INFRATENTORIAL
SUPRATENTORIAL
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Cardinal Signs & Sx of
Cancer in Children
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OVERT SYMPTOMS:
A mass
 Purpura, pallor
 Weight loss
 Whitish reflex in the eye
 Recurrent of persistent
infection
 Vomiting in the early
morning
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COVERT SYMPTOMS:
Bone Pain
Headache
Persistent
lymphadenopathy
Change in balance or
gait
Change in personality
Fatigue
General malaise
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Diagnosis
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Initially, do CBC, Chem Profile (CMP) with liver
function test
LP is routine for leukemia, brain tumors, and
others to rule out brain/CNS metastasis.
Bone marrow aspiration-confirms dx and can be
used to assess for relapse
CT, MRI, PET scans are all helpful in pinpointing
the tumor or extent of the disease if tumors are
involved.
Biopsy of the tumor—conclusive and determines
type
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Leukemias-2 types
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Acute Lymphocytic
Leukemia (ALL)
Acute Nonlymphocytic
Leukemia (ANLL)
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Cell Surface Immunologic Markers--a form of classification of cell morphology in the
diagnosis of leukemia
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CALLA Antigens
Common Acute Lymphocytic
Leukemia Antigen
 If cells are identified as CALLA+
the child has an increased survival
rate
 These are a GOOD THING!
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PATHOLOGY
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Primary pathology: decreased # of functional
WBC’s but total # of immature WBC’s (blasts) is
increased. See pathology flowsheet in syllabus.
Bone Marrow Depression:
1. Anemia: d/t decreased RBC’s
2. Infection: d/t decreased effectiveness of WBC’s
3. Bleeding: d/t decreased platelets
4. Physiologic fractures: d/t increased # of cells in
bone marrow, thinning & weakening of bone
5. Pain: d/t increased # leukemic cells in
periosteum
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Pathology (cont’d)
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CNS Dysfunction: d/t leukemic cells
crossing the blood/brain barrier
SX: Increased intracranial pressure:
Headache, vomiting, irritability
Papilledema, nuchal rigidity
Lethargy
Also known as leukemic meningitis
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Pathology (cont’d)
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EXTRA MEDULLARY INFILTRATION
leads to the following ORGAN
INVOLVEMENT:
1. Hepatomegaly
2. Splenomegaly
3. Lymph Node Enlargement
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Pathology (cont’d)
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GENERALIZED HYPERMETABOLISM:
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Also known as “cellular starvation””
1. Muscle wasting
2. Fatigue
3. Anorexia
4. Weight loss
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Phases of Chemotherapy
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Remission Induction:
Goal: complete absence of leukemic
cells as evidenced by <5% blast cells
in bone marrow.
ALL
ANLL
Corticosteroids:
primarily
PREDNISONE
Vincristine
Doxyrubicin or
Daunomycin
L-Asparaginase
Others
Cytosine
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Phases of Chemotherapy (cont’d)
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Intensification or Consolidation therapy
Goal: to further decrease the # of
leukemic cells
Consists of pulses of chemotherapy
L-asparaginase
High-dose Methotrexate
Intermittent dose of Methotrexate &
Cytarabine
Methotrexate & MP
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Phases of Chemotherapy (cont’d)
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CNS PROPHYLAXIS:|
Goal: Treatment is directed at those
anatomic areas that are protected to some
degree from systemic chemotherapy
Triple Intrathecal Administration:
1. Methotrexate– used in all 3 phases of Tx
2. Cytarabine
3. Hydrocortisone
Cranial irradiation– now reserved for high
risk and those with CNS involvement
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Phases of Chemotherapy (cont’d)
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MAINTENANCE phase
Goal is to preserve remission by
preventing the reappearance of
leukemic cells. Child is usually on
chemotherapy for 2.5 – 3 years.
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ALL
ANLL
6-Mercaptopurine-daily
Methotrexate--IM
Ara-C
6 Thioguanine
Prednisone-monthly
6-Mercaptopurine
(MP)
Vincristine-monthly
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Phases of Chemotherapy (cont’d)
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REINDUCTION FOLLOWING RELAPSE
Goal: get child back in remission.
Each relapse gives a poorer prognosis
Testes are a common site of relapse d/t
resistance to chemotherapy
ALL
Prednisone
Vincristine
Other combinations
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Bone Marrow Transplantation(BMT)
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For ALL, BMT is usually only
indicated if chemotherapy is
UNSUCCESSFUL
For ANLL, BMT may be
considered with first
remission because of poorer
prognosis
See handout in syllabus on
process of preparation and
receiving BMT
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Nursing Care
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(see careplan pp.1470-1472)
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Prepare family for procedures–
painful diagnostic tests &
chemo
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Provide emotional support
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Recognize side effects of
drugs
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Nursing Care (cont’d)
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Monitor for infections, bleeding,
mucosal ulcerations, pain
* especially note need for careful oral
care in all patients receiving
chemotherapy
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Prepare child in an ageappropriate fashion for all
procedures.
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Osteogenic Sarcoma
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Etiology-- OS is the most frequently encountered bone
cancer in children.
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peak incidence between 10-25 years
Primary tumor sites:
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metaphysis(wider part of the shaft of long bones by the
epiphyseal growth plate) of long bones, especially of the
lower extremities;
> 1/2 occur in the femur
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. Medical Management
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- still controversial
**Surgery-- Traditionally, radical surgical resection or
amputation has been recommended.
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Amputation ~ 3” above the proximal tumor margin or above
the joint proximal to the involved bone.
For some pts., limb salvage procedures may be
indicated. This involves tumor resection and prosthetic
replacement of the involved bone.
Chemotherapy-- such drugs as high dose Methotrexate,
adriamycin, bleomycin, actinomycinD, ifosfamide,
cyclophosphamide, and cisplatin may be used alone or
in combination before and after surgery.
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Nursing Considerations:
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Support the family during the dx and the decision about tx.
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BE HONEST with the child about the dx and tx. Nurses do
not usually inform families of dx, but should be available for
clarification, reinforcement and emotional support.
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Offer only as much information as the child can absorb at a
given time. Allow for questions, and follow-up.
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Nursing Considerations (continued)
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Care for a child with a prosthesis is similar to any person,
except that compliance and understanding may take a
little longer.
Phantom limb pain-- common after amputation may be
manifested as itching, pain, tingling, burning, and/or
cramping in the area of the amputated leg. Acknowledge
the sensations as real.
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Amitriptyline (Elavil) may be used to  pain.
Support through referral to national organization as
Candlelighters Childhood Cancer Foundation would be
helpful to families
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Ewing Sarcoma
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is another bone tumor but it arises from
the bone marrow rather than the osseous
tissue (as in osteogenic sarcoma).
Treatment is more commonly intensive
irradiation of the bone and combined
chemotherapy.
Amputation is NOT routinely
recommended.
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Brain Tumors
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Infratentorial—Posterior 1/3
of the brain, primarily in the
cerebellum or brainstem.
Supratentorial—less
frequent, located in the
anterior 2/3 of the brain,
mainly the cerebrum.
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Etiology--cause is often unknown
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the most common solid tumors that occur in children and
are 2nd only to leukemias as a form of cancer. May be
benign or malignant.
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Infratentorial-- 30% of tumors occur in the posterior third
of the brain, primarily in the cerebellum or brainstem. Sx
are from  ICP.
Supratentorial-- < frequent; located in the anterior 2/3 of
the brain, mainly the cerebrum.
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Types--
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The type of cell from which the tumor originates
helps to classify it histologically.
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Common names: medulloblastoma, cerebellar
astrocytoma, brainstem glioma, ependyomas.
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Astrocytoma, is the most common Glial brain
tumor in children
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Symptoms-- often R/T increased
intracranial pressure (ICP)
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Headache-- especially worse on arising
Vomiting-- unrelated to feeding
Neuromuscular changes-- incoordination or clumsiness,
+ Babinski sign after age two
Behavioral changes-- irritability,  appetite, fatigue, failure
to thrive, lethargy
Cranial nerve involvement-- most common: head tilt,
visual defects
Vital sign changes:  pulse and respirations,  BP,
widened pulse pressure, hypo or hyperthermia
Other: seizures, cranial enlargement or bulging fontanel at
rest (only in young children whose skull sutures have not
yet fused),
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Diagnosis-
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Thorough hx and attention to details is
essential.
MRI is most common diagnostic procedure to
determine the location and extent of the
tumor.
CT scan-- may also be used. Lumbar
puncture is NOT recommended due to risk of
brainstem herniation in light of  ICP.
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Treatment--all 3 of the following may or may
not be used depending on tumor type and size.
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Surgery-- total removal of tumor without neurological
damage is the goal.
Radiation-- used to tx most tumors and to shrink the
size of the tumor before attempting surgical removal.
Chemotherapy-- being used more frequently
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Nursing Considerations
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Assess for signs and sx-- establish a baseline of data for pre and
post operative evaluation.
Vital signs are assessed routinely along with a neurological
assessment, and head circumference in infants and young children.
Detail all sx as HA, N/V, etc.
Prepare child and family for Diagnostic Procedures
Teach in an age-appropriate manner about x-rays & MRI’s etc.
Clarify child’s understanding of what is a brain tumor and why tx is
necessary.
Avoid giving false reassurance to parents re: outcomes following
surgery. There are no guarantees. Be honest yet hopeful.
Teach about surgery-- shaving area of the head, dressing post-op,
need for frequent assessments, etc.
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Prevent post operative complications
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Assessment-- VS, neuro ‘s, watch for  temp secondary to
hypothalamus or brainstem involvement during surgery.
Positioning–
 For INFRATENTORIAL surgery, keep flat or on left or right
side. Pillows are placed beside child’s back not head to maintain
position.
 For SUPRATENTORIAL surgery, may have HOB  to promote
CSF drainage.
Fluid regulation-- monitor carefully I & O. For Infratentorial surgeries,
keep NPO at least 24 hrs or longer if child’s gag reflex is depressed
or he is comatose. For supratentorial surgeries, feedings may be
resumed as soon as the child is alert. If vomiting occurs, make NPO
to decrease risk of  ICP.
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Comfort measures-
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Headache may be severe secondary to
 ICP.
Maintain quiet environment; avoid any
jarring of the bed, and prevent anything
which might  ICP.
Ice bag to the head may be soothing.
Opioids may be used if monitored
closely.
Prevent constipation with stool
softeners/laxatives.
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Support child and family
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Be present at time of discussion of prognosis so that
clarification can be done later of any misconceptions of
what was said initially.
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Encourage verbalization of feelings re: guilt they may
feel, fears, etc.
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Collaborate together in telling the child. Honesty preop
will help in discussion post-op.
Prognosis
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Promote return to optimal functioning-- goal is
to return to “normal Life”.
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Need multidisciplinary approach with parents,
doctors/case managers, school nurse,
teachers to make transition smooth for the
child.
Need also to be open to discuss feelings
about death and dying if prognosis is poor.
Integrate hospice care if indicated.
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Wilm’s Tumor—Nephroblastoma,
a tumor that arises in the kidney
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INCIDENCE & ETIOLOGY:
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Most common malignancy of the kidney in
children and accounts for 5-6% of all childhood
cancer.
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Usually presents between 2-3 years of age.
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> prevalent in females than males.
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Etiology is often unknown.
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Pathophysiology
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A fast-growing tumor of the kidney
that is usually encapsulated by a
thin membrane that can easily be
torn or broken.
2 Categories describe the histology:
 Favorable responsive to therapy
with good prognosis
 Unfavorable  less responsive to
therapy with poorer prognosis
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Metastasis can occur to lungs, liver,
brain, bones, or to the unaffected
kidney.
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Diagnosis
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Any abdominal mass needs a timely &
thorough work-up.
Rapidly growing tumors often migrate
to the point of least resistance and
may be found in the renal veins or
inferior vena cava.
Abdominal CT Scan or MRI will give a
clearer preoperative view of the
abdomen.
Diagnosis is confirmed at surgery
when a biopsy is performed.
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Nursing Alert
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A precaution is to limit manipulation of
the abdomen or liver in children with
Wilm’s Tumor that might cause spread of
malignant cells should the encapsulated
mass rupture.
A sign placed on the child’s crib or bed
that warns all health care providers to
avoid palpation of the abdomen, and
instructions to caregivers to use caution
when handling and bathing their child can
prevent trauma to the tumor.
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Treatment
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Surgical Resection—nephrectomy
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Chemotherapy
Dactinomycin (Actinomycin D)
 Vincristine
 Doxorubicin
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Radiation
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Today, only done with metastatic dz,
residual tumor after resection, and
recurrent tumors
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Nursing Care
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Support the family when the initial
diagnosis is made because surgical
treatment is usually quick followed
by chemotherapy.
Pain management post-op is
essential to care
Careful assessment of I and O to
ensure that there is adequate intake
with chemotherapy
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Nursing Care cont’d
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Careful management of nausea,
vomiting, & constipation 2ndary to
chemotherapy is critical as well.
Wound care and activity restrictions
should be reviewed.
Review side effects of radiation if
part of treatment: altered growth,
scoliosis, & possible secondary
malignancies
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Prognosis
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Continues to improve. Largely
dependent on histology and
staging
Overall 5 year survival rate is 90%
(online reference)
Early diagnosis and treatment is
essential to better outcome.
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
Be sure to review the Module on
Perceptions of Death and Dying in Children
and take the quiz on line in Reggienet.
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