peds oncology ppt

White Blood Cells (WBC)
Formed in bone marrow and lymphatic tissue
Destroy foreign cells via
phagocytosis and antibody production

Neutrophils
fight bacteria

Eosinophils
fight parasites
responds to allergens
influences the inflammatory process

Basophils
contain histamine
activate the inflammatory response

Participate in inflammatory and immune reactions

Monocytes (macrophages)
First line of defense in inflammatory process
Phagocytize large cells & necrotic tissue
Important for chronic infections

Lymphocytes
Blast cells in bone marrow, spleen, thymus and other lymph glands and tissue
Responsible for immune protection

T-cells
Made in thymus
Cell mediated immunity (RT an antigen)

B cells
Humoral immunity
“memory” cells that produce antibodies to specific antigens

Natural killer cells
kill certain type of tumor cells and viruses

Cancer is the 2nd cause of death <15 years
Leukemia
malignant disease of bone marrow and lymph system
ALL
most common form of childhood cancer
Peak onset 3-5 years of age
80% of cases of acute leukemia in childhood
Etiology;
Genetic abnormalities
Philadelphia chromosome (↓ prognosis)
Trisomy 21 = 20 x ↑ Risk
Chernoble - Nuclear Radiation exposure
Alkylating agents or certain chemical agents
Virus trigger of oncogene

Abnormal, poorly differentiated blast cells
DNA mutation of an immature white blood cell
Causes the cell to multiply uncontrollably
Infiltrate bone marrow & ↑ vascular RE organs
Hepatomegaly
Splenomegaly
Lymphadenopathy
Malignant blast cells replace the functioning WBC’s in bone marrow causing:
Anemia (↓↓ RBCs)
Neutropenia (↓↓ WBCs)
Thrombocytopenia (↓↓ Plts)

1st sign: Infections that linger > 2 weeks (↓WBC)
Fever
Chills
Anorexia
Weight loss (↑ metabolic demands of CA cells)
Bone & joint pain (Marrow expansion)
Abdominal pain (Hepatosplenomegaly)
Pallor, fatigue, lethargy (↓ RBCs)
Ecchymosis, petechiae, GI bleeding (↓ Plts)
CNS = ↑ICP ( HA, Vomiting & Irritability)
Late stage RT
Brain protected by blood barrier.

Bone Marrow Aspiration @ iliac spine
>25% blast cells = + diagnosis
Lumbar puncture (LP)
√ any CNS involvement
PET, CT & MRI Scans

WBC <10,000/mm3

Age 1-10

Female

Early + response

No CNS involvement

WBC >50,000/mm3

Age <1 or >10

Male

Poor treatment response

CNS involvement

Anti-inflammatory
↓ and kill lymphoblastic cells (↓ WBC)

Prednisone - 40 mg/m2 PO QD
Dexamethasone – 2.5 -10mg/m2/day IM/IV
÷ q6-8H
Side Effects:
Hyperglycemia
Na & Fluid retention = wt gain, puffy moon face
Peptic ulcers, mood changes
Delayed growth pattern

↓ levels of amino acid (asparagine) →
↓↓ tumor growth

L-Asparaginase (Elspar) 10,000 u/m2/day IM 2x/week

Side Effects:
Allergic rxn = chills, fever & rash
Jaundice √ LFTs
Respiratory distress & ↓ BP
N & V, DM

Anti-neoplastic = Inhibits cell division

Vincristine (Oncovin) 1.5 mg/m2 IV
Side Effects
Peripheral neuropathy
severe constipation
↓ bowel innervation
Stomatitis, N & V,
Anemia
Thrombocytopenia

Interferes with cell growth

Cyclophosphamide (cytoxan, CTX) 60-250 mg/m2/day
Ifosfamide (Ifos) 1.2gm/m2/day
Cisplatin (Platinol) 30-70 mg/m2/day
Side Effects
Alopecia
Pulmonary fibrosis
Hemorrhagic cystitis
(caused by chemical irritation of drugs)
Leukopenia
Anorexia, N & V

Documented bacterial infections

Actinomycin D (dactinomysin, ACT-D) 2.5 mg/m2/wk
Bleomycin (Blenoxane) 10-20 U/m2/wk
Doxorubicin (Adriamycin) 20mg/m2/wk

Side Effects
Cardiotoxic!
Red urine (Not hematuria)
Alopecia
N & V and stomatitis

Inhibits folic acid reductase = inhibits DNA synthesis and cellular replication. Inhibits replication of neoplastic cells

Methotrexate (MTX, Amethopterin) 20mg/m2/week PO IV or Intrathecal
Mercaptopurine (6-MP) 75mg/m2/day IV
Cytarabine (Ara-C, Cytosar-U) 100-200mg/m2/day IV
5-Fluorouracil (5-FU) 7-12mg/kg IV

Side Effects
Leukopenia, chills/fever, vomiting
Red rash, Alopecia
↓ Folic Acid metabolism
Hyperurecemia

Inhibits production of uric acid.

CA cell destruction = ↑ uric acid levels
accumulates in tubules → renal calculi
Side Effects
↑ SGOT & SGPT = hepatotoxicity
Blocks metabolism of 6-MP = 6-MP toxicity
Need 1/3 -1/4 normal dose of 6-MP

Ifosamide detoxifying agent.
Binds to toxic metabolites.
Prevents hemorrhagic cystitis
Use with alkylating agents
Cytoxan, Ifos, Platinol

Prophylactic in high risk patients
Minimize CNS involvement
Side Effects after 7-10 days
GI

Side Effects after 7-10 days

GI
dysphagia, stomatitis, N & V, diarrhea

Skin
Erythema, desquamination, alopecia
Myleosuppression ↓ RBCs ↓ WBCs↓ Plts
Fatigue, Infection, Bruising/Bleeding

Pneumonitis
↑ RR ↑HR Dyspnea & dry cough

Used to correct specific deficiencies

PRBC
Epoetin (Epogen)/Procrit
↑ RBC in 2-6 weeks

Platelets

Granulocyte Colony Stimulating Factors-GCSF
Filgrastin (Neupogen)
↑Neutrophils (ANC)
Stimulate dev of new white blood cells 10-14 days
SE: Bone pain, fever, malaise & HA

Whole blood transfusions
Rarely used since ↑ risk of fluid overload

Replaces pt own bone marrow.
Need 500 cc -1 Liter
Takes 1-3 weeks for marrow to self produce
Autologous
uses own bone marrow if in remission
Allogenic (Donor)
√ Compatible = match 6 HLA antigens
Prevent Graft vs. Host Disease (GVHD)

1st give ↑↑ dose chemo and radiation (total body)
Rids body of CA cells
Suppresses immune system to prevent rejection

Strict reverse isolation

Neutropenic Precautions
No fresh flowers, fruit, veggies
Monitor visitors √ immunization status

Monitor s/s of infection
√ Temp, CBC, Activity
√ Absolute Neutrophil Count (ANC) <500
↑ risk for overwhelming infection
ANC = WBC times the % of neutrophils

Live vaccines are contraindicated.
No MMR or Varicella
Inactivated vaccines
Wait @ least 6 months after chemo for appropriate immune response
↑↑ predisposition to resistant organisms
Broad spectrum prophylactic antibiotics

↑↑ Hydration ↑ Protein

↑Caloric Intake

Bland , easily digestible diet

Encourage nutritious foods

Allow pt to choose
↑ Pt participation with meal planning

No acidic juices or spicy foods

Frequent cleansing
Magic Mouthwash (Malox/Benadryl/HO)
Cotton swabs not toothbrush for ↓ Plts
Stomatitis
Chloroseptic spray
Viscous Lidocaine

High risk for rectal ulcers from diarrhea
Keep area clean and dry & OTA
Turn & Position
Sheepskin or Air mattress
√ SE from meds & radiation
↑risk for skin breakdown & irritation

Small frequent feeding
↑ PO intake via ices, jello, favorite fluids
√ weight √ I and O’s

Antiemetics
Ondanesetron (Zofran) [Aloxy]
Blocks 5-HT3 site in brain
Dronabinol (Marinol)
THC synthetic active component of marijuana

↓ bowel innervation → constipation
Foot drop, tremors, jaw pain
Weakness & numbness of extremities
Maintain safe environment
Assist with ambulation
Sneakers, hand rails & walkers

Prepare child & family ( temp condition)
Allow kids to cut their own hair!
Obtain wig before hair is lost
Scarfs or hats

Re-growth 3-6months
Darker, thicker & curlier

Chemical irritation to the bladder
↑ Fluid intake (1.5 x daily amount)
↑ Voiding frequency

Medication
Mesna
↓ Urotoxicity of Ifos & Cisplatin

Evaluate non-verbal and verbal cues
Note cultural differences & accommodate needs

H2O beds

bean bag chairs

stuffed animals

↓ Sensory stimulation (lights, noise, activity)

Massages, rocking, guided imagery, distraction,
Humor!

Give ATC to maintain steady state
Give meds before pain is severe
Adhere to scheduled med time
Kids have ↑ BMR
Need more frequent dosing not ↑ dose
Tylenol [10-15 mg/kg/dose q 4-6 H]
Maximum 90 mg/kg/dose (hepatotoxic)
Tylenol with codeine [Codeine 0.5 -1 mg/kg/dose]
Tylenol No. 1 (Codeine 7.5 mg & Acetaminophen 300 mg)
Tylenol No. 2 (Codeine 15 mg & Acetaminophen 300mg)
Percocet [oxycodone 0.1 mg/kg/dose]
[Oxycodone 5 mg & Acetaminophen 325 mg]
Tylox
[Oxycodone 5 mg & Acetaminophen 500 mg]
Vicodin
[Hydrocodon 5mg & Acetaminophen 500 mg]

NSAIDS
Ibuprophen (Motrin) 40 mg/kg/day
SE: Skin rash, abdominal cramps, N, dizziness

Opioids
Hydromorphone (Dilaudid) 0.4 -1mg/kg q 4-6 H
Quick onset of action 15 minutes
Shorter duration than MSO4
↑ potency 1 mg Dilaudid = 4 mg MSO4
Morphine SO4 (Roxanol) 0.025 -2.6 mg/kg/H
SE: Sedation, ↓ RR ↓BP Constipation Flushed face
Methadone (Dolophine) 0.2 mg/kg q 6-8 H
Long ½ life 24 -36 H
SE: Confusion, Sedation, ↓BP Constipation

Emotional support
Guidance with honest answers
Education
Serious signs & symptoms, adverse drug effects
When to seek medical attention
Establish good plan for FU care
Encourage verbalizations or fears/ concerns
Reassure pt will be comfortable

Most common solid malignant tumor in kids
↑ risk < 2 years old.
75% before child is 5 years old.
Tumors begin as embryonic cells
Develop into the adrenal medulla and sympathetic nervous system (ganglia).
Majority a non-familial, sporadic pattern
Silent Tumor
70% Dx after metastasis
Poor Prognosis

Mediastinum (15%)
Compresses trachea & bronchi
Tracheal deviation
Persistent cough, Dyspnea & SOB
Stridor & Chest pain

Lymphadenopathy
Cervical, supraclavicular & groin
Neck/facial edema
↑ ↑ HA in AM & ↑ ↑ HC

Supraorbital ecchymosis (Raccoon eyes)
Infection

Systemic
Weight loss
RT Anorexia RT ↓↓ Bowel function
Irritability
Fatigue
Myoclonus ataxia syndrome
Anemia
Febrile, ↑ HR ↑ BP
Changes in urination, bowel elimination

CT: Chest, Abdomen & Pelvis

Bone Scan IVP Abdominal Sonogram

Bone Marrow aspiration and biopsy

CBC: √Anemia √Thrombocytopenia

24 H urine collection of VMA Vanillylmandelic Acid = ↑ DA & NE

Surgery if tumor is localized

Radiation
↓ size of tumor a & p surgery

Chemotherapy
Diffuse & advanced disease
Cytoxin, Vincristine & Cisplatin
3F8 immunotherapy

Common type of abdominal tumor
↑ Incidence with Hypospadias & Cryptorchidism
80% diagnosed at <5years
↑ risk @ 3 years
90% survival rate
↑ Cure rate with early diagnosis
Encapsulated Tumor
Arises from renal parenchyma
Rapidly growing tumor
Favors left kidney and usually unilateral
10% of cases have both kidneys involved

Non-tender mid-line abdominal mass
Flank pain
↑↑ BP
RT kidney & adrenal compression & Renin
Anemia RT Hematuria
Rare Mets → Lung & Bone

Abdomen & Chest
CT scan, X-Ray & Ultrasound
IVP
Renal function tests
CBC with differential
Bone scan

1st Place sign on wall:
DO NOT PALPATE ABDOMEN!

Radiation and chemo a & p surgery

Surgery
Radical Nephrectomy
whole kidney and adrenal
Large Y autopsy-like incision:
Examine entire abdominal cavity

Prepare family for scar
Prepare for chemo and radiation
Abdominal surgical care
I&O’s
Monitor bleeding
No contact sports
Watch for any kidney infections or
⇊ function

Arises from bone forming osteoblasts and bone digesting osteoclasts
Most common bone tumor in children
10 – 15 years, can go up to 25 years
Femur, tibia or shoulder near growth plate
↑ Frequency during growth spurt

Gradual onset
Insidious, intermittent local joint pain
Palpable mass – (Bone Biopsy)
Pain more intense with activity
Limp & change in gait, ↓ ROM
High serum alkaline PO4, and LDH
Pathological fractures
Starburst formation on x-ray

R/O Metastasis
Bone Scan, CT, MRI & Lung Scan

Surgery
Amputation 3” proximal to tumor or joint
Limb salvage

Chemotherapy
↑ Methotrexate, Adriamycin,
Cisplatin, Ifos

Exercise to strengthen upper arms

Prepare patient for extensive PT

Emotional support
allow pt to grieve for limb loss
Focus on what the pt can do

Support Group:
ACS-Osteo Support Group; Camping & youth directed activities
www.candlelighters.org

√ signs of hemorrhage q1H x 24 then q4H
Tourniquet at bedside (arterial bleed)
Venous oozing reinforce dressing
Pressure dressing
Mold and shape for prosthesis
Phantom limb pain
Stimulation of nerve endings
Burning, aching, tingling & cramping.
It is real!
Pain meds & Elavil

1st 24 H - Elevate stump with pillow
>24 H No pillow below knee
Position prone to prevent hip flexion
No external rotation or abduction

Place prosthesis immediately after surgery.
Fosters early function and adjustment

2nd most common malignant bone tumor
Highly invasive into bone marrow.
Infiltrates soft tissue around the bone
Pain with soft tissue mass
Sites:
Femur, tibia, fibula, ulnar, ribs and vertebrae
5 – 25 years of age (peaks @ age 10-20)
Prognosis depends on degree of infiltration

Chemotherapy
Shrinks tumor & control mets
VAC
Vincristine, Actinomycin & Cytoxan

Intensive Total Body Radiation
(6-8 weeks)

No Surgery – tumor is too invasive

Anticipatory guidance RT Therapy SE
Radiation burns
Erythema, blisters, pain
Hyperpigmentation
Loose clothing, protective cream,
Protect against sunlight
Avoid sudden changes in temp
No ice/heat packs

Malignancy of lymphatic system
Proliferation of T or B lymphocytes
Lymphoblastic Lymphoma 30%
75% Medialstinal mass, Pleural effusion Lymphadenopathy
Large B Cell Lymphoma 20%
Lymphadenopathy & Invades other tissues
Associated with Epstein Barr virus
Small,non-cleaved type 50%
Burkitts Lymphoma-90% (intrabdominal mass)

Generalized and very aggressive

↑ Incidence with age
Males 2x > females
↑ Incidence with AIDS

Acute onset & progression
Pain & swelling in chest or abdomen
Lymphadenopathy in neck, underarm or groin

Fever, malaise & Night Sweats

Mediastinal mass = SOB ↑ RR ↑ Cough

CNS = HA & vomiting (no nausea)

Superior Vena Cava Syndrome (SVCS)
Obstruction of SVC
Edema of face, neck & trunk

Bone Marrow Infiltration
Petechia, Bruising, Bleeding & Bone Pain

Biopsy from tumor site

Staging (I – IV)
Bone marrow & Lumbar puncture
CT: Chest, Abdomen & Pelvis
PET Scans (total body) ↑ activity & uptake
Gallium Scans- Cardiac

Tumor Lysis Syndrome (WBC > 50,000)
Release of purines from destroyed lymphoblasts
↑ Uric acid levels →Renal Failure
Therapy
IV NaHCO3 keep urine pH > 7-8
Allopurinol (Zyloprim) ↑ uric acid secretion

Chemotherapy
Multi Agent aggressive R-CHOP protocol
R= Retuxin (monoclonal AB therapy)
CHOP
Cytoxin, Adriamycin, Oncovin (Vincristin) & Prednisone

Radiation
20 - 40 treatments @ tumor site

Chemotherapy & Radiation SE
Aranesp, Procrit, PRBC Transfusions
Neupogen & Neutropenic Precautions
No fresh fruit or Vegetables
↓ Exposure to infections

Immunizations
Flu, PPCV, Gamma Globulins, Acyclovir
Leuprolide (Lupron) suppress ovaries