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Pediatric Malignancies

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Pediatric Malignancies Jan Bazner-Chandler CPNP,MSN, CNS, RN Pediatric Malignancies 1% of all cancers Involves tissues of: CNS, bone, muscle, endothelial tissue Grows ... – PowerPoint PPT presentation

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Title: Pediatric Malignancies


1
Pediatric Malignancies
  • Jan Bazner-Chandler
  • CPNP,MSN, CNS, RN

2
Pediatric Malignancies
  • 1 of all cancers
  • Involves tissues of
  • CNS, bone, muscle, endothelial tissue
  • Grows in a short period of time

3
Causes
  • Genetic alteration
  • Environmental influences
  • No know prevention
  • Metastasic disease seen in 80

4
Response to Treatment
  • Very responsive to chemotherapy
  • More than 60 cure rate

5
Classification of Tumors
  • Embryonal tumor arises from embryonic tissue
  • Lymphomas lymphatic tissue
  • Leukemias blood
  • Sarcoma seen in bone, cartilage, nerve and fat

6
Cardinal Signs of Cancer
  • Unusual mass or swelling
  • Unexplained paleness and loss of energy
  • Spontaneous bruising
  • Prolonged, unexplained fever
  • Headaches in morning
  • Sudden eye or vision changes
  • Excessive rapid weight loss.

7
Diagnostic Tests
  • X-ray
  • Skeletal survey
  • CT scan
  • Ultrasound
  • MRI
  • Bone marrow aspiration

8
Biopsy
  • Identify cell to determine type of treatment

9
Treatment Modalities
  • Determined by
  • Type of cancer
  • Location
  • Extent of disease

10
Surgery
  • The oldest form of cancer treatment
  • Surgery plays important role in initial
    diagnosis biopsy of primary tumor.
  • Excision of tumor when possible
  • Facilitating treatment insertion of catheters
    for long-term treatment

11
Radiation Therapy
  • The use of ionizing radiation to break apart
    bonds within a cell causing cell damage and
    death.
  • External beam therapy accounts for the majority
    of radiation treatments in children.
  • Problems radiation beams cannot distinguish
    between malignant cells and healthy cells.

12
Chemotherapy
  • Primary treatment modality used to cure many
    pediatric cancers.
  • Chemotherapy is the use of drugs to destroy
    cancer cells.
  • The destruction is accomplished by inhibiting
    cells within the body to divide, which eventually
    leads to cell death.

13
Chemotherapy
  • Can be given in addition to another form of
    therapy such as radiation or surgery.
  • Drugs may be administered before surgery to
    reduce size of tumor.
  • Adjuvant chemotherapy is used after surgery or
    radiation therapy to prevent relapse.

14
Chemotherapy
  • Combination chemotherapy is the use of more than
    one class of drug.
  • Administering different classes of chemo drugs
    ensures a greater chance of achieving complete
    cancer cell destruction and achieving remission.

15
Administration
  • Chemotherapy can be given by mouth, subcutaneous
    or intramuscular injections, intravenously, or
    intrathecally.
  • Oral route used if drug is well absorbed and non
    irritating to the GI tract
  • Sub-q or IM Slow systemic release
  • IV push, piggyback or intravenous infusion

16
Goals of Chemotherapy
  • Reducing the primary tumor size
  • Destroying cancer cells
  • Preventing metastases and microscopic spread of
    the disease

17
Chemotherapy Drugs
  • Alkylating drug attack DNA
  • Antimetabolites interfere with DNA production
  • Antitumor antibiotics interferes with DNA
    production
  • Plant alkaloids prevent cells from dividing
  • Steroid hormones slow growth of some cancers

18
Bone Marrow Transplant
  • HSCT Hematopoictic Stem Cell Transplant CHLA
    has one of the largest program.
  • The option of HSCT depends on the patients
    disease, disease status, and general physical
    condition.
  • Involves
  • Umbilical cord blood
  • Parents stem cells

19
Gene Therapy
  • Use of gene therapy in the treatment of childhood
    cancer is promising yet complex and still in
    early phases of clinical application.

20
Management of Cancer
  • Patient / family education
  • Begins at time of diagnosis
  • Continues through treatment phases
  • Maintained in post-survival years
  • Support if death of child
  • Emotional aspects of leukemia
  • http//leukemia.org/pages/413.html

21
Pain Management
  • Pain caused by disease
  • Pain with procedures and treatments
  • Pain associated with side effects of treatment

22
Pain Management
  • Pharmacologic
  • Non-Pharmacologic
  • Sedation or anesthetic medications
  • EMLA cream
  • Conscious sedation

23
(No Transcript)
24
Pain Control
  • http//pedspain.nursing.uiowa.edu/

25
Immunosuppression and Infection
  • Children with cancer become immune impaired from
    a number of causes
  • Lymphocyte production is altered
  • Splenic dysfunction can prevent maturation of
    blood cells and alteration is inflammatory
    response.
  • Cancer therapy can decrease immunoglobulin
    concentrations.

26
Neutropenia
  • Significant neutropenia can develop during
    chemotherapy creating an increased risk of
    infection in the child with cancer.
  • Neutropenia occurs when the absolute neutrophil
    count decreases below 500.

27
Treatment of Neutropenia
  • Granulocyte colony stimulating factor decreases
    the duration of neutropenia by stimulating the
    proliferation of the progenitor cells of the
    granulocytes, specifically the neutophils.
  • G-CSF 5mcg/kg/day given subcutaneous

28
Varicella
  • If an immunosuppressed child with no history of
    varicella infection or varicella immunization has
    direct contact with an individual with chickenpox
    or shingles, varicella zoster immune globulin
    should be administered.
  • Acyclovir IV is used in some cases.

29
Varicella Immunizations
  • Three months after chemotherapy
  • Off prednisone
  • Many will have already had the immunization as a
    toddler since it is now a required immunization.

30
Central Venous Access Devices
  • Two decades ago, CVAD were introduced as an
    integral part of the pediatric oncology patients
    treatment plan.
  • Used to deliver chemotherapy, blood components,
    antibiotics, fluids, TPN, medications and blood
    sampling.

31
CVAD Infection Prevention
  • Teach family to report signs of catheter
    infections fever, chills, swelling, pain,
    drainage, or erythema.
  • Aseptic technique for dressing changes and
    heparin flushing.
  • Avoid trauma to device
  • Observe for catheter occlusion

32
Chemotherapy Side Effect
  • Drugs affect not only the cancer cells but also
    healthy cells.
  • Cells most affected are rapidly growing cells
    such as hair follicles, reproductive system, bone
    marrow and gastrointestinal tract.

33
Management of Side Effects
34
Malnutrition
  • Occurs in 8 to 32 of the pediatric oncology
    population
  • Nutritional goals focus on maintaining normal
    growth and development as well as preventing
    nutritional deficiencies.

35
Nutrition Interventions
  • Initial nutritional assessment
  • History of childs eating habits, food allergies,
    use of nutritional supplements, base line weight
    and height measurements.
  • Enteral feedings at night preserve intestinal
    mucosa by keeping it functional

36
Nausea and Vomiting
  • Most common side effect of cancer treatment.
  • Chemotherapy-associated vomiting is a reflex
    controlled by chemoreceptor trigger zone that
    stimulates the vomiting center in the brain.
  • Tumor location
  • Radiation therapy
  • Anticipatory nausea

37
Interventions
  • Antiemetics such as Phenothiazines (Trilafon),
    (Phenergan)and (Thorazine) block dopamine
    receptors from stimulating the chemoreceptor
    trigger zones.
  • Serotonin-receptor antagonist such as Granisetron
    (Kytril) and Ondansetron (Zofran) are very
    effective. (gt3 years)
  • Antihistamines benadryl
  • Administer before chemotherapy

38
Mucositis
  • Progressive, inflammatory, ulcerative condition
    of the oral and gastric mucosa.
  • Occurs due to the interruption of cell renewal
    process of the epithelium leading the mucosal
    atrophy and ulceration
  • Thrombocytopenia or physical trauma may lead to
    bleeding and further mucosal damage.
  • Neutropenia and poor dental hygiene predisposes
    the oral mucosa to secondary infection.

39
Interventions
  • Baseline assessment including the oral cavity,
    teeth, and gingival mucosa.
  • History of dental exam and use of orthodontic
    appliances
  • Meticulous oral care
  • Mouth rinses
  • Monitor hydration status

40
Constipation
  • Assess normal bowel habits
  • Increase fiber and fluids in diet
  • Stool softeners / colace
  • Physical activity
  • Avoid digital manipulation

41
Diarrhea
  • Assess for signs of dehydration
  • Record stool patterns
  • IV fluids as needed
  • Low-residue or lactose-free diet
  • Good hand washing

42
Hair Loss
  • More important in the older child.
  • Most patients will experience hair loss within 10
    days of induction chemotherapy
  • Prepare patient for hair loss
  • Males shave hair
  • Females short hair style pick out wig

43
Psychosocial Support
  • Support groups
  • Open communication
  • Daily contact with oncology team
  • Trusting relationship with nurse

44
Growth and Development
  • Promote normal G D
  • Allow decision making
  • Establish daily routines
  • Play therapy
  • Friends
  • School attendance or tutor

45
Leukemia
  • Most common malignancy
  • 4 in 100,000
  • Increase in chromosome disorders
  • High survival rate

46
Leukemia
  • Unrestricted proliferation of immature WBCs in
    the blood forming tissues of the body.
  • The cells look different from normal cells and do
    not function properly.

47
Prognosis
  • Initial WBC most significant
  • The higher the count the poorer the outcomes
  • Greater than 100,000 WBC count poor outcome
  • Children under 2 years and older than 10
  • Girls do better than boys

48
Diagnosis
  • Peripheral blood smear
  • Bone marrow analysis
  • Lumbar puncture

49
Peripheral Blood Smear
Red circles or RBC large blue are WBC blue dots
are platelets
http//www.fghi.com/careers/html/body_smear.html

50
Bone Marrow
Normal
Acute Lymphoid Leukemia
http//alice.ucdavis.edu/imd/420a/dib/acute/index
.htm
51
Clinical Manifestations
  • Pallor and fever
  • Lethargy
  • Anorexia
  • Weight loss
  • Hemorrhage / petechiae
  • Hepatomegly / splenomegaly

52
3 Phase Treatment
  • Induction goal is to achieve remission last
    about a month
  • Consolidation most intensive phase of
    chemotherapy lasts 4 to 8 months
  • Maintenance last two to three years
  • If leukemia cells are detected in bone marrow
    process is started all over again.

53
Induction Therapy
  • Goal of therapy is to achieve remission
  • Leukemia cells are no longer found in the bone
    marrow samples, the normal cells return and blood
    counts become normal.
  • Drugs used L-asparaginase, vincristine and a
    steroid (dexamethasone), for high-risk children a
    fourth drug (daunorbucin) is often used

54
Consolidation Phase
  • Several drugs are used in combination to prevent
    remaining leukemia cells from developing
    resistance.
  • Drugs include methotrexate and 6-mercaptopurine,
    vincristine and prednisone

55
Maintenance
  • If leukemia continues to be in remission
    maintenance therapy can be started.
  • Two drugs vincristine and steroids over a brief
    period every 4 to 8 weeks.
  • Duration of total therapy 2 to 3 years.

56
CNS Therapy
  • CNS prophylaxis is initiated at diagnosis and is
    used to reduce the risk for CNS disease.
  • Preventive CNS is based on the premise that the
    CNS provides a sanctuary site for leukemic cells
    that are undetected at diagnosis and reside
    protected from the action of systemic therapy by
    the brain blood barrier.

57
Nursing Interventions
  • Assess for infection
  • Monitor blood values
  • I O / nutrition
  • Complications of chemotherapy
  • Good hand washing
  • Aseptic technique for blood draws

58
Leukemia Time Line
  • 1962 cure rate for pediatric cancer is 4 .
  • 1971 A combination of chemotherapy and cranial
    irradiation proves it can cure at least half of
    all children with ALL.
  • 1975 A new combination of chemo drugs helps
    patients with reccurrence of the disease.


59
Time Line
  • 1991 Long-term survival rate increases to 73
    with intensive induction therapy followed by two
    years of treatment with eight anti cancer drugs
    used on a rotating basis.

60
Time Line
  • 1997 Bone marrow transplants from unrelated,
    genetically matched donors are effective against
    many childhood leukemia's.
  • 1998 Study reveals the cure rate for All has
    increased from 73 to 80.

61
CNS Tumors
  • 2nd most common malignancy
  • 65 have 5 year survival rate
  • Most common tumors
  • Astrocytomas 50
  • Medulloblastomas 25
  • Brain stem gliomas 10

62
Clinical Manifestations
  • Classic signs and symptoms are indicative of
    increased intracranial pressure.
  • Pressure is due to tumor mass compressing vital
    structure, blockage of cerebrospinal fluid flow
    or tumor associated edema.
  • Gait changes / ataxia
  • Headache with or without vomiting
  • Blurred vision, or diplopia
  • Forceful vomiting upon rising in the morning or
    papilledema.

63
Management
  • Surgery if tumor accessible
  • Chemotherapy
  • Radiation Reserved for patient older that
    2-years of age
  • Survival rate based on location

64
Chemotherapy
  • After surgery to prevent tumor from coming back
  • Shrink tumor that cannot be operated on
  • Shrink tumor so it can be operated on

65
Chemotherapy
  • Blood brain barrier natural filter within the
    body that allows certain substances through from
    the blood to the brain tissues.
  • Drugs used are temozolamide, procarbazine or
    lomustine
  • Methotrexate is injected intra-thecal
  • Implantable wafers drug is fixed with gel wafer
    drug is slowly released into brain over 2 to 3
    weeks

66
Brain Tumors
Astrocytoma Large right frontal lobe neoplasm
with small area of necrosis
67
Hodgkin's Disease
  • 3rd most common malignancy
  • 15 to 30 years
  • Three times higher in males
  • Excellent cure rates

68
Clinical Manifestations
  • Night sweats
  • Weight loss
  • Malaise
  • Painless, firm nodes

69
Treatment
  • Radiation to nodes
  • Chemotherapy
  • Combination therapy for six months
  • Prednisone
  • Stem cell transplant

70
Long Term Side Effects
  • Infertility drugs can damage ovaries or
    testicles
  • Second cancers small risk for leukemia in future
  • Heart disease some drugs can cause heart
    problems or radiation to middle of chest
  • Lung damage pneumonitis from bleomycin

71
Neuroblastoma
  • Approximately 600 new cases a year.
  • Embryonic tumor
  • Average age of diagnosis is 2 years.
  • Poorest survival rate
  • 50 to 60 have metastases at time of diagnosis.

72
Clinical Manifestations
  • Depends on site of tumor
  • Diagnosis
  • CT scan
  • Bone scan
  • 95 secrete catecholamines in the urine.

73
Treatment
  • Determined by the stage of disease and age of
    child.
  • Children who have localized disease and complete
    response to treatment are more likely to achieve
    a disease free state and long-term survival.

74
Neuroblastoma
75
Wilms Tumor
  • Most common type of renal tumor in children
  • Approximately 460 new cases each year.
  • Children with hypospadius or cryptorchidism have
    a slightly higher incidence.
  • African American and Females at highest risk

76
Clinical Manifestations
  • Firm non-tender, painless mass in abdomen
  • Hematuria
  • Hypertension
  • Do not palpate the abdomen

77
CT Scan Wilms Tumor
http//www.uhrad.com/pedsarc/peds048.htm
78
Wilms Tumor
79
Treatment
  • Surgery
  • Nephrectomy
  • Prevent rupture of capsule
  • Sample for pathology
  • Chemotherapy and radiation are given based on the
    stage of the disease.

80
Osteogenic Sarcoma
  • Malignant tumor of bone
  • 400 new cases each year
  • Peak incidence is in the second decade of life,
    when adolescents are gaining vertical height
    rapidly.
  • Approximately 20 have metastases at diagnosis
  • High rate of metastasis to lungs

81
Diagnosis
82
Osteosarcoma Tumor
Femur has a large mass involving the metaphysis
of bone. Tumor has destroyed the cortex.
Andersons Pathology
83
Treatment
  • Limb salvage
  • Amputation
  • Chemotherapy

84
Limb Salvage
http//www.clevelandclinic.org/ortho/tumor/limbSal
vageLg.htm
85
Ewing Sarcoma
  • Tumor of flat bones
  • Pelvis, chest, vertebrae
  • Rare in children under 5 years
  • 75 diagnosed by age 20

86
Ewing Sarcoma
87
Ewing Sarcoma Tumor
Ewing Sarcoma at distal end of the tibia. tumor
extends into the soft tissue.
Andersons Pathology
88
Rhabdomyosarcoma
  • Most common soft bone tissue tumor
  • Head and neck 40
  • GU 20
  • Extremities 20
  • Trunk 15

89
Rhabdomyosarcoma
http//www.brisbio.ac.uk/ROADS/subject-listing/fac
e.html
90
Treatment
  • Surgical removal
  • Chemo based on tissue biopsy
  • Radiation

91
Retinoblastoma
  • Intraocular / Embryonic tumor
  • 1 in 16,000
  • family history
  • High incidence of malignancies

92
Retinoblastoma
Pupil reflex Cat Eyes
http//www.djo.harvard.edu/meei/PI/RB/RB.html
93
Retinoblastoma
http//homepage.idx.com.au/muznsam/
94
Retinoblastoma
95
Treatment
  • Surgical enucleation of eye
  • Genetic counseling
  • Follow-up care up to 18 Years
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