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Cancers in Children

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Title: PowerPoint Presentation Author: Kennell, Lynn Last modified by: Kennell, Lynn Created Date: 1/1/1601 12:00:00 AM Document presentation format – PowerPoint PPT presentation

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Title: Cancers in Children


1
Cancers in Children
  • Lynn Kennell

2
Introduction
  • Focus on 4 Broad types of Cancer
  • LEUKEMIAS ALL, ANLL
  • BONE CANCERS OSTEOGENIC SARCOMA
  • BRAIN TUMORS INFRATENTORIAL
    SUPRATENTORIAL
  • WILMS TUMOR

3
Cardinal Signs Sx of Cancer in Children
  • OVERT SYMPTOMS
  • A mass
  • Purpura, pallor
  • Weight loss
  • Whitish reflex in the eye
  • Recurrent of persistent infection
  • Vomiting in the early morning
  • COVERT SYMPTOMS
  • Bone Pain
  • Headache
  • Persistent lymphadenopathy
  • Change in balance or gait
  • Change in personality
  • Fatigue
  • General malaise

4
Diagnosis
  • 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 tumorconclusive and determines type

5
Leukemias-2 types
  • Acute Lymphocytic Leukemia (ALL)
  • Acute Nonlymphocytic Leukemia (ANLL)

6
Cell Surface Immunologic Markers- --a form of
classification of cell morphology in the
diagnosis of leukemia
  • 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!

7
PATHOLOGY
  • Primary pathology decreased of functional
    WBCs but total of immature WBCs (blasts) is
    increased. See pathology flowsheet in syllabus.
  • Bone Marrow Depression
  • 1. Anemia d/t decreased RBCs
  • 2. Infection d/t decreased effectiveness of
    WBCs
  • 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

8
Pathology (contd)
  • 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

9
Pathology (contd)
  • EXTRA MEDULLARY INFILTRATION leads to the
    following ORGAN INVOLVEMENT
  • 1. Hepatomegaly 2. Splenomegaly
  • 3. Lymph Node Enlargement

10
Pathology (contd)
  • GENERALIZED HYPERMETABOLISM
  • Also known as cellular starvation 1. Muscle
    wasting 2. Fatigue 3. Anorexia 4. Weight
    loss

11
Phases of Chemotherapy
  • Remission Induction
  • Goal complete absence of leukemic cells as
    evidenced by lt5 blast cells in bone marrow.

ALL ANLL
Corticosteroids primarily PREDNISONE Doxyrubicin or Daunomycin
Vincristine Cytosine
L-Asparaginase Others
12
Phases of Chemotherapy (contd)
  • 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
13
Phases of Chemotherapy (contd)
  • 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

14
Phases of Chemotherapy (contd)
  • MAINTENANCE phase
  • Goal is to preserve remission by preventing the
    reappearance of leukemic cells. Child is usually
    on chemotherapy for 2.5 3 years.

ALL ANLL
6-Mercaptopurine-- daily Ara-C
Methotrexate--IM 6 Thioguanine
Prednisone-- monthly 6-Mercaptopurine (MP)
Vincristine--monthly
15
Phases of Chemotherapy (contd)
  • 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
16
Bone Marrow Transplantation(BMT)
  • 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

17
Nursing Care see careplan pp.1470-1472 (9th
ed.) pp. 1388-1390 (10th ed.)
  • Prepare family for procedures painful diagnostic
    tests chemo
  • Provide emotional support
  • Recognize side effects of drugs

18
Nursing Care (contd)
  • Monitor for infections, bleeding, mucosal
    ulcerations, pain especially note need for
    careful oral care in all patients receiving
    chemotherapy
  • Prepare child in an age-appropriate fashion for
    all procedures.

19
Osteogenic Sarcoma
  • Etiology-- OS is the most frequently encountered
    bone cancer in children.
  • peak incidence between 10-25 years
  • Primary tumor sites
  • metaphysis(wider part of the shaft of long bones
    by the epiphyseal growth plate) of long bones,
    especially of the lower extremities
  • gt 1/2 occur in the femur

20
. Medical Management-
  • - still controversial
  • Surgery-- Traditionally, radical surgical
    resection or amputation has been recommended.
  • 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.

21
Nursing Considerations
  • Support the family during the dx and the decision
    about tx.
  • 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.
  • Offer only as much information as the child can
    absorb at a given time. Allow for questions, and
    follow-up.

22
Nursing Considerations (continued)
  • 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.
  • Amitriptyline (Elavil) may be used to ? pain.
  • Support through referral to national organization
    as Candlelighters Childhood Cancer Foundation
    would be helpful to families

23
Ewing Sarcoma
  • 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.

24
Brain Tumors
  • InfratentorialPosterior 1/3 of the brain,
    primarily in the cerebellum or brainstem.
  • Supratentorialless frequent, located in the
    anterior 2/3 of the brain, mainly the cerebrum.

25
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26
Etiology--cause is often unknown
  • 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.
  • Infratentorial-- 30 of tumors occur in the
    posterior third of the brain, primarily in the
    cerebellum or brainstem. Sx are from ? ICP.
  • Supratentorial-- lt frequent located in the
    anterior 2/3 of the brain, mainly the cerebrum.

27
Types--
  • The type of cell from which the tumor originates
    helps to classify it histologically.
  • Common names medulloblastoma, cerebellar
    astrocytoma, brainstem glioma, ependyomas.
  • Astrocytoma, is the most common Glial brain tumor
    in children

28
Symptoms-- often R/T increased
intracranial pressure
(ICP)
  • 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),

29
Diagnosis--
  • 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.

30
Treatment--all 3 of the following may or may not
be used depending on tumor type and size.
  • 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

31
Nursing Considerations-
  • 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
    MRIs etc.
  • Clarify childs 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.

32
Prevent post operative complications
  • 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 childs
    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 childs 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.

33
Comfort measures--
  • 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.

34
Support child and family
  • Be present at time of discussion of prognosis so
    that clarification can be done later of any
    misconceptions of what was said initially.
  • Encourage verbalization of feelings re guilt
    they may feel, fears, etc.
  • Collaborate together in telling the child.
    Honesty preop will help in discussion post-op.
  • Prognosis

35
Promote return to optimal functioning-- goal is
to return to normal Life.
  • 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.

36
Wilms TumorNephroblastoma, a tumor that arises
in the kidney
  • INCIDENCE ETIOLOGY
  • Most common malignancy of the kidney in children
    and accounts for 5-6 of all childhood cancer.
  • Usually presents between 2-3 years of age.
  • gt prevalent in females than males.
  • Etiology is often unknown.

37
Pathophysiology
  • 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
  • Metastasis can occur to lungs, liver, brain,
    bones, or to the unaffected kidney.

38
Diagnosis
  • 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.

39
Nursing Alert
  • A precaution is to limit manipulation of the
    abdomen or liver in children with Wilms Tumor
    that might cause spread of malignant cells should
    the encapsulated mass rupture.
  • A sign placed on the childs 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.

40
Treatment
  • Surgical Resectionnephrectomy
  • Chemotherapy
  • Dactinomycin (Actinomycin D)
  • Vincristine
  • Doxorubicin
  • Radiation
  • Today, only done with metastatic dz, residual
    tumor after resection, and recurrent tumors

41
Nursing Care
  • 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

42
Nursing Care contd
  • 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

43
Prognosis
  • 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.

44
  • 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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