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 • Parent’s 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

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 patient’s 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 child’s 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. (>3 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 WBC’s 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 dotsare 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