SEMINAR

SEMINAR ON
ON
PEDIATRIC
PEDIATRIC
ONCOLOGY
ONCOLOGY

PRESENTED BY:
Ms. Muhsinath. A. R
GUIDED BY:
Ms. Mala. V. S
INTRODUCTION:

• Cancer in children are

the emerging problem
in health care system
which is drastically
increasing in number
within a few years.
• Childhood cancer is
the second leading
cause of death in
children.
 DEFINITION OF
CANCER:
• The term “Neoplasm” comes from the
Greek word meaning “newly growth”
or “new formation”.
• A tumor is a swelling caused by any
number of conditions like
inflammation and trauma.
ETIOLOGIC FACTORS:
• The cause of cancer is not
known.
• Genetic alteration is
considered to be a major
cause. E.g.: retinoblastoma
• Inheritance e.g. wilm’s tumor,
retinoblastoma,
neuroblastoma
• Chromosome abnormalities
e.g. leukemia, lymphoma
• Immune deficiencies
 ETIOLOGIC FACTORS:
contd…
• Retro viruses
• Epstein Barr viruses e.g. Hodgkin
disease
Risk Factors:
• Ionizing radiations
• Drugs containing radio
isotopes and
immunosuppressive agents
e.g. diethylstilbestrol
• Intramuscular vit. K
supplementation at birth
e.g. leukemia
• Maternal diet e.g. prenatal
multivitamin use
 Prevention:
• Knowledge of the risk factors can prevent the
childhood cancers
• Health professionals have two major role
 Preventing adult type cancers by educating the
children and parents about the hazards of
known carcinogens
e.g. cigarettes, over exposure to sunlight
 Teach them about periodical testes and breast
self examination
 Prevention: contd…
Health professionals need to be
aware of the cardinal symptoms of
childhood cancer.
 Diagnostic Evaluation:
o Complete history:-
 History of present illness: onset of symptoms,
severity and duration, alleviating or potentiating
factors.
 History of previous illness: communicable diseases,
infections, previous hospitalizations or surgery,
exposure to blood products, immunization status.
 Family history: previous family members with
cancer, type, treatment and outcome
 Diagnostic Evaluation:
contd…
 Present health status of family members: history
of illness or disease in other family members
 Developmental: milestones obtained, recent
regression in any milestones
 Psychosocial: family concerns or problems
o Review of symptoms:
 Skin: history of bruising or bleeding, lesions or sores
( leukemia)
 Head, Eyes, Ears, Nose and Throat (HEENT): history of
infections, proptosis, pupil discoloration, eye muscle
weakness (neuroblastoma, retinoblastoma)
 Heart: h/o murmur or thrill, dyspnoea
 Lungs: h/o infection, cough, wheezing, shortness of
breath (lung metastasis, lymphoma)
 Abdomen: h/o abdominal swelling, pain, mass, change in
bowel or bladder patterns (wilm’s tumor, neuroblastoma,
lymphoma)
 Musculoskeletal: h/o weakness in extremities,
limited range of motion, tenderness or swelling,
joint pain (osteogenic sarcoma, primitive neuro
ectodermal tumor of the bone, rhabdomyosarcoma)
 Neurologic: altered consciousness, decreased
sensations, abnormal reflexes, abnormal cerebellar
functions ( brain tumor)
 Lymphatic: h/o enlarged lymph nodes, frequent
infections (leukemia, lymphoma)
 Hematologic: h/o bruising, nose bleeding or gum
bleeding, paleness, fatigue, blood or tarry colored
( leukemia)
o Physical examination:
 general: orientation, state of health
 Skin: petechiae or ecchymosis, lesions or sores, presence of
blood from gums or nose, color of skin
 HEENT: evidence of infection, proptosis, pupil discoloration,
extra ocular movements, limited peripheral vision,
nystagmus
 Heart: murmur, peripheral pulses
 Lungs: evidence of infection, rales and rhonchi, decreased
breath sounds
 Abdomen: hepatospleenomegaly, mass, decreased bowel
sounds, striae
 Neurologic: altered consciousness, decreased sensations,
abnormal reflexes, abnormal cerebellar functions, unstable
gait
 Lymphatic: enlarged lymph nodes
o Laboratory tests:
 Complete blood count (CBC) - a measurement of size, number,
and maturity of different blood cells in a specific volume of
blood. Abnormal cells may indicate cancer. Variation in the
normal number, size, and maturity of cells may indicate a
problem.
 spinal tap/lumbar puncture - a procedure to evaluate the fluid
around the spine and brain for pressure and/or infection, and to
detect any abnormal cells. A small amount of cerebral spinal
fluid (CSF) can be removed and sent for testing to determine if
there is an infection or other problem.
 blood tests - to evaluate electrolytes, liver function, kidney
function, presence of infection, tumor markers (chemicals
released by a tumor), and/or genetic testing. Genetic counseling
may be recommended to families that are found or suspected to
have an inherited predisposition to developing cancer, in order
to identify other family members who may be at increased risk.
o Imaging studies:
 Lymph angiogram (LAG) - an imaging study that can
detect cancer cells or abnormalities in the lymphatic
system and structures. It involves a dye being
injected into the lymph system.
 Ultrasound (Also called sonography.) - a diagnostic
imaging technique which uses high-frequency sound
waves and a computer to create images of blood
vessels, tissues, and organs. Ultrasounds are used to
view internal organs as they function, and to assess
blood flow through various vessels. Tumors in the
abdomen, liver, and kidneys can often be seen with an
ultrasound.
 bone scans - pictures or x-rays taken of the bone after a dye has
been injected that is absorbed by bone tissue. These scans are
used to detect tumors and bone abnormalities.
 x-rays - diagnostic tests which use invisible electromagnetic energy
beams to produce images of internal tissues, bones, and organs onto
film. X-rays may be taken of any part of the body to detect tumor
(or cancer) cells.
 computed tomography scan (Also called a CT or CAT scan.) - a
diagnostic imaging procedure that uses a combination of x-rays and
computer technology to produce cross-sectional images (often
called slices), both horizontally and vertically, of the body. A CT
scan shows detailed images of any part of the body, including the
bones, muscles, fat, and organs. CT scans are more detailed than
general x-rays.
 magnetic resonance imaging (MRI) - a diagnostic procedure that
uses a combination of large magnets, radiofrequencies, and a
computer to produce detailed images of organs and structures
within the body.
o Biopsy:
 biopsy of the tumor - a procedure in which a sample
of tissue is removed from the tumor and examined
under a microscope. Biopsies may be necessary for a
diagnosis, since there are different types of cancer.
 surgery - may be necessary to perform a biopsy,
remove tumors, remove entire organs affected by
disease, and to look for tumors that may not be
detected with diagnostic imaging.
 Modes of Therapy:
Surgery
Chemotherapy
Radiotherapy
Immunotherapy/Biologic Response
Modifiers
Bone marrow transplantation
 Cancer Care Team:
• primary care physicians
• pediatricians
• pathologists
• hematologists
• oncology specialists (medical oncologist, radiation
oncologist, surgical oncologist)
• surgeons (including surgical specialists such as
urologists, gynecologists, and neurosurgeons)
• nurses
• oncology nurse specialists
• oncology social workers
 Cancer Care Team:
contd…
• pharmacists
• pastoral care
• respiratory therapists
• physical therapists
• lab technicians
• child life therapists
• psychologists
• radiation technicians
• dietitians
 Surgery:
• The main aim of surgery besides obtaining a biopsy, is to
remove the all traces of tumor and restore normal body
functioning.
• It is successful when the tumor is encapsulated and
localized
• It may only a palliative when the cancer is regional
or advanced.
• Recent trend is the conservative surgical incision. e.g.
resection of the affected cells of the area rather
performing full excision and ectomy.
 Chemotherapy:
 Chemotherapy is the use of anticancer drugs to
treat cancerous cells.
 chemotherapy works by interfering with the cancer
cell's ability to grow or reproduce. Different groups
of drugs work in different ways to fight cancer
cells.
 Chemotherapy may be used alone for some types of
cancer or in combination with other treatments such
as radiation or surgery. Often, a combination of
chemotherapy drugs is used to fight a specific
cancer.
 Certain chemotherapy drugs may be given in a
specific order depending on the type of cancer it is
being used to treat.
 Administration of
chemotherapy
Chemotherapy can be given:
• as a pill to swallow.
• as an injection into the muscle or fat tissue.
• intravenously (directly to the bloodstream; also
called IV).
• topically (applied to the skin)
• directly into a body cavity
 Radiation Therapy:
 Radiation therapy (also called therapeutic radiology
or radiation oncology) uses special kinds of energy
waves or particles to fight cancer.
 Radiation therapy is used in several ways depending
on the type and location of the cancer. Certain levels
of radiation work to destroy cancer cells or prevent
cells from growing or reproducing. This treatment
may provide a cure for cancer, control the disease,
or help relieve its symptoms.
 Types of Radiation Therapy
External radiation (external beam
therapy)
With external radiation (external beam
therapy), radiation is administered by a large
machine that points the energy waves
directly at the tumor. The radiation therapist
controls the machine. Since radiation is used
to kill cancer cells, special shields may be
made to protect the tissue surrounding the
treatment area. Radiation treatments are
painless and usually last a few minutes.
 Internal radiation (brachytherapy, implant
radiation)
With internal radiation (brachytherapy, implant
radiation), a high dose of radiation is given inside the
body as close to the cancer as possible. The radiation
treatment may be swallowed, injected, or implanted
directly into the tumor. Some of the radioactive
implants are called “seeds” or “capsules”. Internal
radiation involves administering a higher dose of
radiation in a shorter time span when compared with
external radiation. Some internal radiation treatments
stay in the body temporarily; other internal
treatments stay in the body permanently, although the
radioactive substance loses its radiation within a short
period of time. In some cases, both internal and
external radiation therapies are used.
 Immunotherapy or Biologic
Response Modifiers;
 BRMs modify the relationship between the tumor
and host by therapeutically changing the hosts
biologic response to tumor cells.
 This have a direct anti tumor activity, or stimulate
the cell growth, reducing the hematologic toxicity
associated with chemotherapy.
 It involves use of monoclonal antibodies in the
diagnosis and treatment of the cancers.
 Bone Marrow Transplantation:
 Bone marrow transplantation (BMT) is a special
therapy for patients with cancer or other
diseases which affect the bone marrow.
 A bone marrow transplant involves taking cells
that are normally found in the bone marrow
(stem cells), filtering those cells, and giving
them back either to the patient they were taken
from or to another person.
 The goal of BMT is to transfuse healthy bone
marrow cells into a person after their own
unhealthy bone marrow has been eliminated.
 Need For Bone Marrow
Transplant:
A bone marrow transplant can be used to:
• replace diseased, non-functioning bone marrow with healthy
functioning bone marrow (for conditions such as leukemia,
aplastic anemia, and sickle cell anemia).
• replace the bone marrow and restore its normal function
after high doses of chemotherapy or radiation are given to
treat a malignancy. This process is often called "rescue"
(for diseases such as lymphoma, neuroblastoma, and breast
cancer).
• replace bone marrow with genetically healthy functioning
bone marrow to prevent further damage from a genetic
disease process (such as Hurler's syndrome, and
adrenoleukodystrophy disorder).
 Different Types of Bone
Marrow Transplants:
• Autologous bone marrow
transplant
The donor is the child him/herself.
Stem cells are taken from the child
either by bone marrow harvest or
apheresis (peripheral blood stem cells)
and then given back to the child after
intensive treatment. Often the term
"rescue" is used instead of "transplant."
Different Types of Bone Marrow Transplants:
CONTD…
• Allogenic bone marrow transplant
The donor shares the same genetic type as the child. Stem cells
are taken either by bone marrow harvest or apheresis (peripheral
blood stem cells) from a genetically-matched donor, usually a
brother or sister. Other donors for allogeneic bone marrow
transplants include:
– a parent - a haploid-identical match is when the donor is a
parent and the genetic match is at least half identical to the
recipient.
– an identical twin - a syngeneic transplant is an allogeneic
transplant from an identical twin. Identical twins are
considered a complete genetic match for a marrow transplant.
– unrelated bone marrow transplants (UBMT or MUD for
matched unrelated donor) - the genetically matched marrow or
stem cells are from an unrelated donor.
Different Types of Bone Marrow Transplants:
CONTD…
• Umbilical cord blood transplant
Stem cells are taken from an umbilical cord immediately after
delivery of an infant. These stem cells reproduce into mature,
functioning blood cells quicker and more effectively than do
stem cells taken from the bone marrow of another child or
adult. The stem cells are tested, typed, counted, and frozen
until they are ready to be transplanted. Because the stem cells
are "new," they are able to produce more blood cells from each
stem cell. Another advantage cord blood has is that the T-
lymphocytes (part of the immune system that causes graft-
versus-host disease) are not completely functional this early in
the stage of life. Recipients of cord blood transplants have a
decrease risk for severe graft-versus-host disease.
 The bone marrow transplant
team:
• physicians - physicians who specialize in oncology,
hematology, immunology, and bone marrow
transplantation.
• transplant nurse coordinator - a nurse who
organizes all aspects of care provided to your child
before and after the transplant. The nurse
coordinator will provide patient education and
coordinate the diagnostic testing and follow-up
care.
• social workers - professionals who will provide
support to the family
 The bone marrow transplant team:
contd…
• dietitians - professionals who will help your child meet his/her
nutritional needs before and after the transplant. They will work closely
with you and your family.
• physical therapists - professionals who will help your child become
strong and independent with movement and endurance after the
transplantation.
• pastoral care - chaplains who provide spiritual care and support.
• other team members - several other team members will evaluate the
child before transplantation and will provide follow-up care, as needed.
These include, but are not limited to, the following:
– pharmacists
– respiratory therapists
– lab technicians
– infectious disease specialists
– dermatologists
– gastroenterologists
– psychologists
– child life specialists
 Complications and Side
Effects of BMT:
 Infections
 low platelets and low red blood cells
 Thrombocytopenia (low platelets) and anemia (low
red blood cells),
 Pain related to mouth sores and gastrointestinal
(GI) irritation
 Diarrhea, nausea, and vomiting
 fluid overload
 Graft failure respiratory distress
 organ damage
 Graft-versus-host disease (GVHD)
 COMPLICATIONS OF THERAPY:
 Infections
 Hemorrhage
 Nausea and vomiting
 Altered nutrition
 Mucositis
 Neurologic problems
 Hemorrhagic cystitis
 Alopecia
 Steroid effects
 Pain
 Infection:
 A major concern for the child receiving treatment
for cancer is the risk for the development of
complications secondary to the treatment.
 Major complications include fever, bleeding, and
anemia.
 The child with fever who has an absolute neutrophil
count less than 500/cumm is at risk for
overwhelming infection, malaise, dehydration,
seizure, invasion of organisms producing secondary
infection.
 The child with fever is evaluated for potential sites
of infection such as from a needle puncture, mucosal
ulcers, minor abrasion or skin tears etc
 Hemorrhage:
 Hemorrhage is the leading cause of death in
children with cancer.
 But it can be prevented or controlled with
judicious administration of platelet concentrates
or platelet rich plasma.
 Severe spontaneous internal hemorrhage varies but
usually doesn’t occur until the platelet count is
10,000/cumm or less.
 Infection increases the chances of bleeding and
bleeding sites become more easily infected, special
care must be taken to avoid performing skin
punctures whenever possible.
 Strict asepsis should be followed when any body
piercing procedures like venipunctures, IM injections
etc are performed.
 Observe for bleeding.
 Meticulous mouth care is needed.
 Hygiene of the rectum is essential.
 Frequent position changes and pressure reducing
water bed will reduce the risk of pressure ulcers.
 Platelet transfusions are used for those not
responding to the local treatments.
 Epistaxis and gingival bleeding will be common.
 The child should avoid activities that might cause
injury or bleeding such as cycle riding, skating,
climbing trees or playground equipments
 ANEMIA:
 Anemia may be profound due to the complete
replacement of the bone marrow by cancerous cells.
 Anemia may also be an effect of drug induced
myelosuppression causing delayed erythrocyte
production.
 Blood transfusion with packed red blood cells may
be necessary raise the hb%.
 Nausea and Vomiting:
 it may occur shortly after the administration of
several of the drugs and as a result of the cranial
or irradiation of the skull.
 5-hydroxytryptamine-3 receptors antagonists are
the antiemitics of choice used to manage nausea
and vomiting caused by chemotherapy and
radiotherapy.
 For mild to moderate vomiting phenothiazine type
of drug remains the mainstay of therapy.
 Metoclopramide is more effective drug in severe
vomiting
 Altered Nutrition:
 It is a very common complication of treatment.
 Continued nutritional assessment should be
performed through out the therapy.
 Regular evaluation of the child’s intake should be
recorded. The child’s height, weight and head
circumference must be measured routinely.
 Nutritional status is important to maintain because
it can contribute to reduced tolerance to
treatment, altered metabolism of chemotherapy
drugs, prolonged episodes of neutropenia and
increased risk for infection.
 Supportive nutrition include: oral supplements with
high protein and high calorie foods.
 Some ideas for adding calories and protein to
foods that child may eat for meals and
snacks:
• powdered milk (33 cal/Tbsp, 3 gm protein/tbsp):
– Add 2 to 4 Tbsp to 1 cup milk.
– Mix into puddings, potatoes, soups, ground meats,
vegetables, cooked cereal, milkshakes, yogurt, and pancake
batter.
• eggs (80 cal/egg, 7 gm protein/egg) or egg
substitute (Egg Beaters® 25 cal per 1/4 cup, 5 gm
protein per 1/4 cup):
– Add to casseroles, meat loaf, mashed potatoes, cooked
cereal, macaroni and cheese, and chicken or tuna salads.
– Add extra to french toast and pancake batter.
• Do not use raw eggs in uncooked items. Egg
substitutes may be used in uncooked items, such as
milkshakes or eggnog.
• butter or margarine (45 cal/tsp):
– Add to pudding, casseroles, sandwiches, vegetables, cooked
cereal, breads, and pasta.
• cheeses (100 cal/oz., 7 gm protein/oz.):
– Give as snacks, or in sandwiches.
– Add to casseroles, potatoes, vegetables, and soups.
• wheat germ (25 cal/Tbsp):
– Add 1 to 2 Tbsp to cereal.
– Mix into meat dishes, cookie batter, and casseroles.
• mayonnaise or salad dressing (45 cal/tsp):
– Use liberally on sandwiches, salads, as a dip for raw
vegetables or sauce on cooked vegetables.
• evaporated milk (25 cal/Tbsp, 1 gm protein/Tbsp):
• Use in place of whole milk in desserts, baked goods, meat dishes,
and cooked cereal.
• sour cream (26 cal/Tbsp):
– Add to potatoes, casseroles, and dips.
– Use in sauces and baked goods.
• sweetened condensed milk (60 cal/Tbsp, 1gm protein/Tbsp):
– Add to pies, puddings, and milkshakes.
– Mix 1 to 2 Tbsp with peanut butter and spread on toast.
• peanut butter (95 cal/Tbsp, 4 gm protein/Tbsp):
– Serve on toast, bagels, crackers, bananas, apples, and celery.
• Carnation® Instant Breakfast™ (130 cal/pkt, 7 gm protein/pkt):
– Add to milkshakes or milk.
• gravies (40 cal/Tbsp):
– Use liberally on mashed potatoes, rice, noodles, and meats.
 Mucositis:
 It is the most distressing side effects of several
drugs resulting in the GI ulcers anywhere along the
alimentary tract.
 Oral ulcers (stomatitis), are red eroded painful
areas in the mouth and/or pharynx.
 Similar can be occurred in the esophagus or rectum.
 Neurologic Problems:
 Vincristine, and to a lesser extent vinblastine can
cause various neurotoxic effects.
 Severe constipation, foot drops, weakness and
numbing of the extremities may cause difficulty in
walking or fine hand movements.
 Use of foot board to preserve the proper alignment
will helps the child.
 Jaw pain is another side effect.
 Analgesics may be necessary to relieve pain and
discomfort.
Alopecia:
 Alopecia, or hair loss, is a very common side effect
of most forms of chemotherapy.
 Hair loss occurs as a result of the chemotherapy
agents penetrating the hair follicle, causing the hair
shaft to break at the root.
 Hair is lost not only from the head, but eyebrows,
eyelashes, facial, and pubic hair is also lost.
 Depending on the age and sex of the child, this can
be a very distressing side effect of chemotherapy.
Younger children may not be bothered by hair loss,
but the school-age child and teenager may be
devastated.
 Hair usually begins to grow about six weeks after
completion of treatment. The hair may look different
when it returns. The color or texture may be
different than before treatment began.
 Minimize hair washing to every other day instead of
every day.
 Wash hair with a gentle moisturizing shampoo.
 Avoid harsh chemicals in the hair such as coloring
products.
 Avoid using curling irons, blow dryers, or curlers.
 You may want to consider a short hair cut before
chemotherapy begins, to minimize the shock of hair
loss.
 Have the child pick out several hats or scarves
before hair loss begins. He/she may even want to
start wearing these items before hair is lost so that
he/she is comfortable with them.
 If the child wants to wear a wig, have him/her pick
one out before treatment begins.
 Reassure the child that his/her hair will return
 Steroid effects:
 Increased appetite, sense of well being
 Alteration in body image
 Moon face
 Pediatric Oncologic
Emergencies:
HYPERLEUKOCYTOSIS
OBSTRUCTION
OVERWHELMING INFECTIONS
 COMMON CARCINOMAS IN
CHILDREN:
• LEUKEMIA
• LYMPHOMAS
• HODGKIN DISEASE
• RHABDOMYOSARCOMA
• BRAIN TUMORS
• HEPATOBLASTOMA
• NEUROBLASTOMA
• OSTEOSARCOMA
• BONE TUMORS
• RETINOBLASTOMA
• WILM’S TUMOR
• TESTICULAR TUMORS
LEUKEMIA:
DEFINITION:
 Leukemia is cancer of the blood and develops in
the bone marrow.
 In leukemia the bone marrow begins to make
white blood cells that do not mature correctly,
but continue to reproduce themselves.
 These abnormal cells reproduce very quickly and
do not function as healthy white blood cells to
help fight infection
 INCIDENCE:
 Leukemia is the most common form of cancer in childhood. It
affects approximately 3,800 children each year in the US,
accounting for about 30 percent of childhood cancers.
 TYPES:
 According to the American Cancer Society, acute lymphocytic
leukemia (ALL) is the type of leukemia that most commonly
affects children, most often between the ages of 2 and 3
years. ALL accounts for about 73 percent of leukemia cases
each year in the US.
 Acute myelogenous leukemia (AML) is the second most common
form of leukemia in children. AML generally occurs by the age
of 2 years, and is not often seen in older children until the
teenage years. AML is the most common type of acute leukemia
in adults. The chronic forms of leukemia are rarely seen in
children.
Causes of Leukemia:
 The majority of childhood leukemias are acquired
genetic diseases.
 An alteration or defect in the immune system may
increase the risk for developing leukemia.
 Factors such as exposure to certain viruses,
environmental factors, chemical exposures, and
various infections have been associated with damage
to the immune system.
 Symptoms of Leukemia:
 irregular bone marrow function
 Anemia
 bleeding and/or bruising
 Petechiae
 Thrombocytopenia
 bone and joint pain
 abdominal distress
 swollen lymph nodes
 difficulty breathing (dyspnoea)
Diagnosis of leukemia:
 bone marrow aspiration and/or biopsy
 complete blood count (CBC)
 additional blood tests
 computed tomography scan
 magnetic resonance imaging (MRI)
 X-ray
 ultrasound (Also called sonography.)
 lymph node biopsy
 spinal tap/lumbar puncture
 Treatment for leukemia:
 Treatment usually begins by addressing the
presenting symptoms such as anemia, bleeding,
and/or infection. In addition, treatment for leukemia
may include (alone or in combination) the following:
 chemotherapy
 intrathecal medications/chemotherapy (medications
are inserted through a needle into the spinal cord
into the area called the subarachnoid space)
 radiation therapy
 bone marrow transplantation or peripheral blood
stem cell transplantation
 biological therapy
 medications (to prevent or treat damage to other
systems of the body caused by leukemia
treatment)
 medications (for nausea and side effects of
treatment)
 blood transfusions (red blood cells, platelets)
 antibiotics (to prevent/treat infections)
 continuous follow-up care (to determine response
to treatment, detect recurrent disease, and
manage late effects of treatment)
stages of leukemia treatment:
• induction - a combination of chemotherapy and/or
radiation and medications given to stop the process
of abnormal cells being made in the bone marrow.
Remission is the goal in this stage of treatment.
Remission means the leukemia cells are no longer
being made. This phase may last approximately one
month and can be repeated if the goal is not
achieved.
• intensification or consolidation - continued
treatment even though leukemia cells may not be
visible. The leukemia cells may not be visible in a
blood test or bone marrow examination, but it is
possible that the cells are still present in the body.
• maintenance - the stage that maintains leukemia-
free bone marrow by continuing less intense
chemotherapy for a longer duration. This phase can
last months to several years. Regular visits to your
child's physician are required in order to determine
response to treatment, detect any recurrent
disease, and manage any side effects of the
treatment.
• relapse - may occur even with aggressive therapy.
Relapse is when the bone marrow begins making
abnormal cells again. Relapse can occur during any of
the stages of treatment, or may occur months or
years after treatment has ended.
LYMPHOMAS:
DEFINITION:
A group of neoplastic diseases that arise
from the lymphoid and hematopoietic
systems
Types:
Hodgkin disease
Non Hodgkin disease
 HODGKIN DISEASE:
 DEFINITION:
 Hodgkin's lymphoma is a type of cancer in the
lymphatic system. The lymphatic system is part of
the immune system and functions to fight disease
and infections.
 Hodgkin's lymphoma causes the cells in the
lymphatic system to abnormally reproduce,
eventually making the body less able to fight
infection and cause swelling in the lymph nodes.
Hodgkin's lymphoma cells can also spread
(metastasize) to other organs and tissue.
Causes of Hodgkin's disease:
 The specific cause of Hodgkin's disease is unknown
 genetic predisposition
Symptoms of Hodgkin's disease:
 painless swelling of the lymph nodes in neck,
underarm, groin, and chest
 difficulty breathing (dyspnoea) due to enlarged
nodes in the chest
 fever
 night sweats
 tiring easily (fatigue)
 weight loss/decreased appetite
 itching skin (pruritus)
 frequent viral infections (i.e., cold, flu, sinus
infection)
Diagnosis Hodgkin's disease:
• blood and urine tests
• x-rays of the chest
• computed tomography scan of the abdomen, chest,
and pelvis
• lymph angiogram (LAG)
 Stages of Hodgkin's disease:
• stage I - usually involves a single lymph node
region or structure.
• stage II - involves two or more lymph node
regions or structures on the same side of the
body.
• stage III - involves lymph node regions or
structures on both sides of the body and is
further classified depending on the organs
and areas involved.
• stage IV - involves the disease in other areas
(metastasis), in addition to the lymphatic
system involvement
 Treatment of Hodgkin's disease:
• chemotherapy
• radiation
• surgery
• bone marrow transplant
• supportive care (for pain, fever, infection,
and nausea/vomiting)
• continued follow-up care (to determine
response to treatment, detect recurrent
disease, and manage side effects of
treatment)
Wilm's tumor:
Definition:
 Wilm's tumor, also called nephroblastoma, is a
malignant (cancerous) tumor originating in the
cells of the kidney. It is the most common type
of renal (kidney) cancer and accounts for about
6 percent of all childhood cancers.
 Approximately 500 children in the US are
diagnosed with Wilm's tumor each year.
 The disease can occur at any age between
infancy and 15 years, but, in most cases, the
tumor is detected by the age of 3. This cancer
affects males and females equally.
 Causes of Wilm's tumor:
 genetic mutations
 WAGR syndrome - the acronym WAGR stands for
the four diseases present in WAGR syndrome,
including: Wilm's tumor, aniridia (absence of the iris,
the colored part of the eye), genitourinary
malformations, and mental retardation. This is
caused by loss or inactivation of a tumor suppressor
gene called WT1 on chromosome #11. Tumor
suppressor genes usually suppress the growth of
tumors and control cell growth. When altered, they
no longer control cell growth, and tumors may form.
 Denys-Drash syndrome - this syndrome is
characterized by kidney failure, genitourinary
malformations, and tumors of the gonads (ovaries or
testes). This is also caused by loss or inactivation of a
tumor suppressor gene called WT1 on chromosome #11.
Tumor suppressor genes usually suppress the growth of
tumors and control cell growth. When altered, they no
longer control cell growth, and tumors may form.
 Beckwith-Wiedemann syndrome - this syndrome is
characterized by large birth weight and a large liver,
spleen, and tongue; low blood sugar in neonatal period,
malformations around the ear, asymmetric growth of
the body, abdominal wall defects near the navel
(omphalocele), and tumors of the liver and adrenal
glands. This is thought to be caused by an overactive
copy of an oncogenes on chromosome #11, called IGF2.
Oncogenes control cell growth, but, if mutated,
uncontrolled cell growth may result.
 Symptoms of Wilm's tumor:
• a non-tender mass, or lump, felt or seen in the
abdomen
• swelling of the abdomen
• veins that appear distended or large across the
abdomen
• blood in the urine (hematuria)
• pain in the abdomen from pressure on other organs
near the tumor
• decreased appetite and weakness or tiredness
• fever
• high blood pressure (hypertension)
• If a tumor is suspected in the child's abdomen, it is
important not to apply pressure to this area. Careful
bathing and handling of the child is necessary
before and during any tumor evaluation. Rupture of
the tumor may lead to cancer cells spreading to
other tissues in the body.
Diagnosis of Wilm's tumor:
• abdominal ultrasound biopsy
• abdominal computed tomography scan (Also called a
CT or CAT scan.)
• blood and urine tests
• chest x-ray CT scans are more detailed than x-rays.
• magnetic resonance imaging (MRI)
• surgical removal of the tumor and kidney
(nephrectomy)
Treatment for Wilm's tumor:
• surgery (to remove all or part of the affected kidney
and any involved structures)
• biopsy of the tumor (if the tumor is too large or
involved in surrounding structures to be removed ; a
biopsy is also necessary for diagnosis and staging the
disease)
• chemotherapy (to shrink the remaining tumor, or to
treat metastasis and/or recurrent disease)
• radiation (to shrink the remaining tumor or to treat
metastasis and/or recurrent disease)
• medications (to control pain, hypertension, nausea,
and infections)
• blood pressure monitoring (essential when a kidney
tumor is present)
• continuous follow-up care
Osteogenic Sarcoma
 Definition:
 Also called osteosarcoma, osteogenic sarcoma is one
of the most common types of bone cancer in children.
 The disease usually occurs in the long bones, such as
the arms (humerus), legs (femur/tibia), and pelvis. It
rarely occurs in the jaw and fingers, but often occurs
at the ends of these bones near growth plates.
Osteosarcoma affects adolescents and young adults.
 This cancer occurs about 50 percent more frequently
in males than in females, possibly because of the
rapid growth rate at this age. Prior to adolescence,
the percentage of affected males and females is
equal.
Causes of osteogenic sarcoma:
 repeated trauma to an area may be a risk factor for
developing this type of cancer.
 Genetics
 hereditary abnormalities, including exostoses (bony
growths), retinoblastoma, Ollier's disease,
osteogenesis imperfecta, polyostotic fibrous
dysplasia, and Paget's disease, have an increased risk
for developing osteosarcoma.
 exposure to ionizing irradiation
Symptoms of Osteogenic Sarcoma:
 pain (sharp or dull) at the site of the tumor
 swelling and/or redness at the site of the tumor
 increased pain with activity or lifting
 Limping
 decreased movement of the affected limb
Diagnosis of Osteogenic Sarcoma:
 X-rays
 bone scans
 magnetic resonance imaging (MRI)
 computed tomography scan
 complete blood count (CBC) - a measurement of size,
number, and maturity of different blood cells in a
specific volume of blood.
 blood tests (including blood chemistries)
 biopsy of the tumor
Treatment for osteogenic sarcoma:
• surgery (i.e., biopsy, resections, bone/skin grafts,
limb salvage procedures, reconstructions)
• amputation
• chemotherapy
• radiation therapy
• resections of metastases (spreading of the tumor to
other locations)
• rehabilitation including physical and occupational
therapy and psychosocial adapting
• prosthesis fitting and training
• supportive care (for the side effects of treatment)
• antibiotics (to prevent and treat infections)
• continued follow-up care
 Neuroblastoma:
Definition:
 Neuroblastoma is a cancerous tumor that begins in
nerve tissue of infants and very young children.
 Neuroblastoma is rare in children older than 10
years of age
 The tumor usually begins in the tissues of the
adrenal gland found in the abdomen, but may also
begin in nerve tissue in the neck, chest, and/or
pelvis.
Causes Of Neuroblastoma:
 genetic abnormalities involving chromosome #1
 more common in children born with fetal hydantoin
syndrome, neurofibromatosis, and Beckwith-
Wiedemann syndrome
Symptoms of neuroblastoma:
 abdominal mass, either felt during an examination or
seen as swollen abdomen
 tumors in the face or head can cause swelling and
bruising of the area around the eyes and
uncontrolled eye movement
 compression of kidney or bladder by the tumor may
cause changes in urination
 bone marrow involvement may present as pain,
limping, paralysis, or weakness
 diarrhea may be present; diarrhea is caused by a
substance produced by the tumor (vasoactive
intestinal peptide, or VIP)
 fever
 high blood pressure and increased heart rate may
occur depending on location of tumor and the organs
the tumor compresses
Diagnosis of Neuroblastoma:
 blood tests - including a complete blood count, blood
chemistries, kidney and liver function tests, and a
urinalysis.
 computed tomography scan
 magnetic resonance imaging
 x-ray
 ultrasound
 bone scans
 spinal tap/lumbar puncture
Stages of neuroblastoma:
• stage 1 - involves a tumor that does not cross the
midline of the body, is completely resectable, and has
not spread to other areas of the body. The lymph
nodes on the same side of the body as the tumor do
not have cancer cells present.
• stage 2A - involves a tumor that does not cross the
midline of the body, but is not completely resectable.
This stage of tumor has not spread to other areas of
the body, and lymph nodes on the same side as the
tumor do not have tumor cells present.
• stage 2B - involves a tumor that may or may not be
completely resectable, has not spread to other areas
of the body, but lymph nodes on the same side of the
tumor have tumor cells present. Lymph nodes on the
opposite side of the tumor must be negative for
tumor cells in this stage of disease.
• stage 3 - involves a tumor that crosses the midline of
the body, is not completely resectable, and lymph
nodes are positive for tumor cells. This stage also
includes a tumor that does not cross the midline, but
the lymph nodes on the opposite side also contain
tumor cells.
• stage 4 - involves a tumor that has metastasized to
distant lymph nodes, bone marrow, liver, skin, and/or
other organs (except as defined in stage 4S).
• stage 4S - a child is younger than 12 months and has a
tumor that may have metastasized (spread) to liver,
skin, and/or bone marrow (includes minimal bone
marrow involvement; more extensive bone marrow
involvement should be classified as stage 4). The
tumor is on one side of the body and is localized. It
may have spread to the lymph nodes on the same side
of the body.
 Treatment for neuroblastoma:
 surgery (for tumor and/or metastatic resection, and
removal of lymph nodes involved)
 chemotherapy
 radiation therapy
 bone marrow transplant and peripheral blood stem
cell transplantation
 retinoid therapy
 supportive care (for the side effects of treatment)
 antibiotics (to prevent/treat infections)
 continuous follow-up care
 Rhabdomyosarcoma:
 Definition:
 Rhabdomyosarcoma is a cancerous tumor that
originates in the soft tissues of the body, including
the muscles, tendons, and connective tissues.
 The most common sites for this tumor to be found
include the head, neck, bladder, vagina, arms, legs,
and trunk.
 Rhabdomyosarcoma can also be found in places where
skeletal muscles are absent or very small, such as in
the prostate, middle ear, and bile duct system. The
cancer cells associated with this disease can spread
(metastasize) to other areas of the body.
 Rhabdomyosarcoma accounts for about 3 percent of
childhood cancers.
 In the US, about 350 children are diagnosed with
rhabdomyosarcoma each year. This disease affects
children between the ages of 2 to 20 years of age,
but can occur at any age.
 For unknown reasons, males are affected slightly
more often than females.
 Causes of rhabdomyosarcoma:
 chromosome abnormality
 common in children with neurofibromatosis
 Symptoms of rhabdomyosarcoma:
 a tumor or mass that can be seen or felt (may or may
not be painful)
 bleeding from the nose, vagina, rectum, or throat
(may occur if the location of the tumor is in these
areas)
 tingling, numbness, pain, and movement (may be
affected if the tumor compresses nerves in the
area)
 protrusion of the eye or a drooping eyelid (may
indicate a tumor behind the area)
Diagnosis of rhabdomyosarcoma:
 biopsy of the tumor - when a sample of tissue is
removed from the tumor and examined under a
microscope.
 blood and urine tests
 computed tomography scan
 magnetic resonance imaging
 x-ray
 ultrasound
 bone scans
 lumbar puncture/spinal tap
Stages of rhabdomyosarcoma:
 stage I - tumors involving the area near the eye, the
head, neck, and genitourinary tract (except the
prostate and bladder). The tumor is localized,
meaning the tumor has not spread to other areas of
the body.
 stage II - small, localized tumors less than 5 cm in
any site not in stage I. There are no tumor cells in
the surrounding lymph nodes.
 stage III - localized tumor at any site not included
in stage I that is smaller than 5 cm and has spread
to surrounding lymph nodes or is larger than 5 cm
and has not spread to surrounding lymph nodes.
 stage IV - disease that has spread to other areas of
the body at the time of diagnosis
Treatment for rhabdomyosarcoma:
 Surgery
 resection of tumor and/or metastases
 chemotherapy
 radiation therapy
 lumbar puncture (to administer medication and treat
cancer cells if found in this site)
 supportive care (for the side effects of treatment)
 antibiotics (to prevent/treat infections)
 bone marrow transplant or stem cell transplantation
 continuous follow-up care
 Retinoblastoma:
Definition:
 Retinoblastoma is a rare cancer of the retina (the
innermost layer of the eye, located at the back of
the eye, that receives light and images necessary
for vision).
 Causes Of Retinoblastoma:
 Mutations
 Genetic
 Inheritance

 Symptoms of retinoblastoma:
 leukocoria - a white light reflex that occurs at
certain angles when light is shown into the pupil.
 strabismus (Also called "wandering eye" or
"crossed-eyes.") - a misalignment of the eyes; when
one or both eyes do not appear to be "looking" in the
same direction.
 pain or redness around the eye(s).
 poor vision or change in child's vision
Diagnosis of retinoblastoma:
• complete eye examination
• fundoscopic examination
• computed tomography scan
• magnetic resonance imaging
• blood tests
• tests of the fluid surrounding the tumor
• genetic and/or DNA testing
Stages of retinoblastoma:
• group I - either one or more tumors that are
less than 4 disc diameters (DD) in size and
located at or behind the equator.*
• group II - either one or more tumors that
are 4 to 10 DD in size located at or behind
the equator.
• group III - any lesion in front of the
equator or any tumor(s) larger than 10 DD.
• group IV - multiple tumors with some or all
greater than 10 DD in size or any lesions
that extend beyond the back of the eye.
• group V - very large tumors involving more
than half of the retina and have spread to
other sites in the body.
 Treatment for retinoblastoma:
 surgery
 enucleation (removal of part or all of the eye or eyes
involved with the tumor)
 chemotherapy
 radiation therapy
 laser therapy  or photocoagulation
 thermal therapy 
 cryotherapy (uses a freezing process to destroy the
tumor)
 fitting and training for a prosthesis
 blind or decreased vision adaptation training
Brain Tumor:
Definition:
 Brain tumors, either malignant or benign, are tumors
that originate in the cells of the brain.
 A tumor is an abnormal growth of tissue.
Causes of brain tumors:
 radiation therapy
 chemical toxin
 alterations directly in the genes
 chromosome rearrangements
Symptoms of a brain tumor:
 increased intracranial pressure (ICP) - caused by
extra tissue or fluid in the brain. Pressure may
increase because one or more of the ventricles that
drain cerebrospinal fluid (CSF, the fluid that
surrounds the brain and spinal cord) has been
blocked, causing the fluid to be trapped in the brain.
Increased ICP can cause the following:
– headache
– vomiting (usually in the morning)
– nausea
– personality changes
– irritability
– drowsiness
– depression
– decreased cardiac and respiratory function and eventually
coma if not treated
 Symptoms vary depending upon which part of the brain
the tumor is found. Symptoms of brain tumors in the
cerebrum (front of brain) may include:
– seizures
– visual changes
– slurred speech
– paralysis or weakness on half of the body or face
– increased intracranial pressure (ICP)
– drowsiness and/or confusion
– personality changes/impaired judgement
– short-term memory loss
– gait disturbances
– communication problems
 Symptoms of brain tumors in the brainstem (middle
of brain) may include:
– seizures
– endocrine problems (diabetes and/or hormone regulation)
– visual changes or double vision
– headaches
– paralysis of nerves/muscles of the face, or half of the body
– respiratory changes
– increased intracranial pressure (ICP)
– clumsy, uncoordinated walk
– hearing loss
– personality changes
 Symptoms of brain tumors in the cerebellum
(back of brain) may include:
– increased intracranial pressure (ICP)
– vomiting (usually occurs in the morning without
nausea)
– headache
– uncoordinated muscle movements
– problems walking (ataxia)
 Diagnosis of brain tumor :
 neurological exam
 computed tomography scan
 magnetic resonance imaging
 x-ray
 bone scan
 Angiogram
 myelogram
 lumbar puncture/spinal tap
 positron emission tomography (PET) 
Treatment for brain tumors:
 Surgery
Surgery is usually the first step in the treatment of
brain tumors. The goal is to remove as much of the
tumor as possible while maintaining neurological
function. Surgery for a biopsy is also done to examine
the types of cells the tumor is made of for a
diagnosis. This is frequently done if the tumor is in an
area with sensitive structures around it that may be
injured during removal.
 Chemotherapy
 radiation therapy
 steroids (to treat and prevent swelling
especially in the brain)
 anti-seizure medication (to treat and
prevent seizures associated with intracranial
pressure)
 ventriculoperitoneal shunt (Also called a VP
shunt.)
A VP shunt may be placed in the head to drain
excess fluid from inside the brain. A VP shunt helps
control the pressure inside the brain.
 bone marrow transplantation
 supportive care (for the side effects of the
tumor or treatment)
 rehabilitation (to regain lost motor skills and
muscle strength; speech, physical, and
occupational therapists may be involved in
the healthcare team)
 antibiotics (to treat and prevent infections)
 continuous follow-up care
Hepatoblastoma:
Definition:
 Hepatoblastoma is a very rare cancerous tumor that
originates in the liver.
 This disease primarily affects children from infancy
to about 5 years of age. Most cases appear during
the first 18 months of life.
Causes of hepatoblastoma:
 genetic conditions
 exposure to hepatitis B infection at an early age
 biliary atresia
Symptoms of hepatoblastoma:
 a large abdominal mass, or swollen abdomen
 weight loss, decreased appetite
 abdominal pain
 vomiting
 jaundice (yellowing of the eyes and skin)
 fever
 itching skin
 anemia (pale skin and lips from decreased number of
red blood cells)
 back pain from compression of the tumor
Diagnosis of hepatoblastoma:
 biopsy
 complete blood count (CBC)
 liver and kidney functions, and genetic studies
 multiple imaging studies
Stages of childhood liver cancer:
• stage I - usually a tumor that can be completely
removed with surgery.
• stage II - usually a tumor that can mostly be
removed by surgery but very small amounts of the
cancer are left in the liver.
• stage III - usually a tumor that cannot be
completely removed and the cancer cells are found in
the lymph nodes.
• stage IV - cancer that has spread (metastasized) to
other parts of the body.
• recurrent - the disease has returned after it has
been treated. It may come back in the liver or in
another part of the body.
Treatment for hepatoblastoma:
 surgery (to remove tumor and part or all of the
liver)
 chemotherapy
 liver transplant
 supportive care (for the side effects of treatment)
 antibiotics (to prevent and treat infections)
 continuous follow-up care
Testicular Tumors:
Definition:
 Tumors of the testes which is malignant in
nature is called the testicular tumors.
Symptoms:
 Heaviness
 Painless swelling of the testes
 The affected testes hangs lower
Diagnosis:
 Biopsy
 CBC
 Scrotal examination
 CT Scan
 MRI
 Urine analysis
 FNAC
TREATMENT:
 Surgery
 Chemotherapy
 Radiotherapy
 Antibiotics
 Supportive care
 Continuous follow up care
 NURSE’S ROLE IN
PEDIATRIC ONCOLOGY
 Managing the pain with pharmacological non
pharmacological measures.
 Management of side effects of treatment.
 Maintaining the nutritional status of the child.
 Helping the child and family to cope with the
chemotherapy and radiation therapy.
 Educating the child and family about protecting the
child from sunlight, wind or cold.
 Minimizing the infection spread and sepsis.
 Improving the immunity by providing antibiotics.
 Helping the child to cope with bone marrow
transplantation.
 Educating regarding the follow up care.
 Making necessary meetings with those who survived
of cancer.
 Providing psychological support.
 Educating about the dental care, immunizations and
therapeutic regimen.
Nursing care plan of child
with cancer:
• Potential for injury r/t chemotherapeutic treatment
• Potential for infection r/t depressed body defenses
• Impaired nutritional status less than body
requirement r/t loss of appetite
• Pain r/t diagnosis, treatment and physiologic effect
of treatment
• Fear r/t diagnostic tests, procedures and treatment
 Nursing care plan of child
with cancer: contd….
• Body image disturbance r/t changes caused by
cancer and treatment
• Impaired family process r/t having a child with a
life threatening disease
• Potential for fluid volume deficit r/t nausea and
vomiting
• Impaired mucus membrane integrity r/t
chemotherapy side effects
• Impaired skin integrity r/t chemotherapy,
surgery, radiotherapy and immobility
 Nursing care plan of child
with cancer: contd….
• Impaired physical mobility r/t fatigue
• Activity intolerance r/t fatigue.
• Anticipatory grief r/t perceived potential loss of
a child.