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Peds Exam 3
Oncology/Childhood Cancers pt 2
| Question | Answer |
|---|---|
| sarcomas are | Malignancy in bone and soft tissue |
| bone tumors in adolescence generally occur in | 2nd decade of life |
| bone tumors in adolescence | Osteosarcoma Ewing sarcoma- bone and soft tissue |
| Soft tissue- younger children | Rhabdomyosarcoma |
| osteosarcoma occurs most commonly in | the long bones- distal femur, proximal tibia (near the knee), proximal humerus (near shoulder) AKA where bones are growing rapidly |
| osteosarcomas are associated with | pubertal growth spurt –peak 15 yrs. Boys >girls |
| osteosarcomas commonly metastasize to | the lungs which causes a lower prognosis |
| initial pain in sarcomas | dull and pain symptoms initially, so often mistaken for growing pains or injury so have advanced disease upon diagnosis |
| the initial dull pain progresses and | limits movement |
| what can happen with osteosarcomas | Swelling or lump around affected bone |
| risk for osteosarcoma | genetic conditions, radiation, rapid bone growth |
| prognosis for osteosarcoma | 60-70% |
| Ewing Sarcoma involves the | bone or soft tissue |
| Ewing sarcoma is most commonly in | femur, pelvis, ribs (diaphysis of bone) - long part of flat bones, not the ends |
| ewing sarcoma is classified as | localized or systemic |
| localized or systemic ewing sarcoma commonly metastasizes to | lungs, marrow, other bones |
| if ewing sarcoma does or does not metastasize, | 75% survival if no meta, decreased survival if metastasizes |
| ewing sarcoma is rare and typically affects | children between ages 10-20, a little younger than osteosarcoma Males> Females |
| ewing sarcoma causes | Intermittent pain progressively worsens Swelling/lump around site, (possibly warm to touch) Unexplained fracture Systemic symptoms |
| Systemic symptoms of ewing sarcoma | Unexplained fever Fatigue, weight loss – concern for metastasis Anemia |
| why are there systemic symptoms of ewing sarcoma | because of metastasizes |
| Diagnosis of bone tumors | Chest x-ray and chest CT, MRI primary site, PET or bone scans, bone marrow biopsy |
| treatment of bone tumors | Surgery - clean margin, optimum function Chemo Radiation for Ewing sarcoma, not osteosarcoma Stem cell rescue transplant for Ewing |
| Surgery - clean margin, optimum function for ewing | Treatment of choice limb-salvage surgery –prosthesis amputation possible - there are now limb surgeries which can take long to recover |
| chemotherapy for ewing | Pre-operative (neo-adjuvant) Post-operative- resume ASAP following wound healing |
| Radiation- for Ewing sarcoma, not osteosarcoma | Preoperative- shrinks tumor, makes surgery easier Post operative- kills remaining cancer cells Used if unable to operate |
| Rhabdomyosarcoma is highly | malignant due to metastasize to lungs |
| Rhabdomyosarcoma is a | Soft tissue tumor primarily, develops in skeletal muscle cells |
| Rhabdomyosarcoma is most common in | Head (especially orbit), neck, GU tract, or extremities |
| Risks for Rhabdomyosarcoma | High birth weight Genetic conditions |
| genetic conditions leading to higher risk for Rhabdomyosarcoma | Li-Fraumeni syndrome, Beckwith-Wiedemann syndrome, Neurofibromatosis type 1, Costello syndrome, Noonan syndrome |
| Diagnosis of Rhabdomyosarcoma | CT, MRI, biopsy - primary site CT of chest, bone scans, bone marrow biopsy, and LP to evaluate metastasis |
| Management of Rhabdomyosarcoma | Chemo, plus surgery and/or radiation |
| the younger the patient with Rhabdomyosarcoma, | the better the prognosis |
| Neuroblastoma is a | Peripheral nervous system tumor arising along the sympathetic chain (embryonic neural crest cells) |
| Neuroblastoma is most commonly in | adrenal glands- mass in abdomen, but also cervical, thoracic, and pelvic chains |
| Neuroblastoma is classified as | low, intermediate or high risk |
| Neuroblastoma best prognosis is | Under 12-18 months of age |
| Neuroblastoma Symptoms based on Location: spine | may stop crawling or walking or have weakness or paralysis |
| Neuroblastoma Symptoms based on Location: chest | may have trouble breathing |
| Neuroblastoma Symptoms based on Location: abdomen | they may have pain, enlarged belly, constipation, vomiting, diarrhea, difficulty urinating, high BP |
| Neuroblastoma Symptoms based on Location: metastasize to bone or other areas | may have black eyes, bone pain, bruises, fever, or paleness and may limp or stop crawling/walking, have unequal pupils |
| Diagnosis of Neuroblastoma | CT scan or MRI Chest x-ray, bone scan, skeletal survey Bone marrow aspiration and biopsy 24- hour urine collection: elevated catecholamine metabolites |
| Treatment of Neuroblastoma is dependent on | age and risk factors |
| Treatment of Neuroblastoma | Multi-modal therapy Low risk- observation, surgery Intermediate risk- surgery chemo High risk – surgery, chemo, high dose chemo with stem cell transplant rescue, immunotherapy, radiation |
| Low risk neuroblastoma prognosis | >95% |
| Intermediate risk neuroblastoma prognosis | >90% |
| High risk neuroblastoma prognosis | <60% |
| stem cell transplant for oncology | so they can get increased dose of radiation/chemo to fight because medication already cleared everything |
| Nephroblastoma (Wilms Tumor) is a | Primary malignant renal tumor |
| Nephroblastoma (Wilms Tumor) peak age | 2 - 3 years, parents will notice mass in abdomen during bath |
| small percentage of Nephroblastoma (Wilms Tumor) is associated with | congenital anomalies, familial predisposition |
| Nephroblastoma (Wilms Tumor) most commonly presents as | Asymptomatic abdominal mass: does not cross midline Hematuria Malaise Hypertension Fever |
| Treatment of Wilms Tumor | Surgery Chemo Radiation |
| Surgery for Wilms Tumor | resect tumor without rupturing capsule Kidney on affected side will be removed |
| What not to do with Wilms Tumor | DO NOT PALPATE- very thin and easily torn which will spread cancer cells |
| Chemo for Wilms tumor | intensity and duration dependent on stage |
| Radiation for Wilms tumor | reserved for stage III & IV patients |
| retinoblastoma (cancer in retina) is | Congenital, most common intraocular cancer in childhood- in retina |
| gene mutation in retinoblastoma | RB1 tumor suppressor gene Hereditary - autosomal dominant (often bilateral) Nonhereditary forms (advanced age- unilateral) |
| risks for retinoblastoma | < 3 yrs., family history |
| early signs and symptoms of retinoblastoma | leukocoria (white pupillary reflex- “cat’s eye reflex”), strabismus (eye misalignment) |
| late signs and symptoms of retinoblastoma | Pain, decreased visual acuity, orbital edema, redness of eye |
| Diagnosis of retinoblastoma | ultrasound, CT, MRI, ophthalmic exam |
| Treatment of retinoblastoma | brachytherapy, photocoagulation, cryotherapy (get rid of tumor but maintain vision) |
| if advanced retinoblastoma, | complete enucleation (eye removal) with prosthesis (3 wk till fitting and 6 wks till get it) |
| chemo for retinoblastoma if | spread outside eye, metastasis |
| prognosis of retinoblastoma | 90-95% if hasnt metastasized, and if has needs chemo |
| Enucleation of retinoblastoma | Prosthetic eye Protect vision in remaining eye |
| Retinoblastoma Nursing care | Follow up Genetic counseling - screening other children Increased lifetime other cancer risk- osteosarcoma Assess adaptation to possible vision loss |
| Genetic counseling for retinoblastomas | at birth, 1m and 3m and then every 4-6m until 7 yrs |
| Treatment Modalities for cancer | Surgery Chemotherapy Radiation Biologic Therapy Hematopoietic stem cell (bone marrow) transplantation (HSCT) *** treatment is typically multimodal |
| Treatment terms | Primary treatment- main treatment Neoadjuvant- given before primary treatment Adjuvant – given after primary treatment |
| Neoadjuvant- given before primary treatment | Reduces tumor size Kills cancers cells that have spread |
| Adjuvant – given after primary treatment | Destroys remaining cancer cells |
| what kind of treatment do children normally get | the trifecta - primary, neoadjuvant and adjuvant |
| Surgery for children | Seldom used alone Primary goal -diagnostic vs. therapeutic Definitive surgery may be delayed Specific to type of cancer |
| Primary goal -diagnostic vs. therapeutic | obtain biopsy document extent of disease |
| chemo kills | all cells not just cancer cells |
| overview of chemo | Antineoplastic agents Takes advantage - rapid rates of cellular division Given to cure, control cancer, or ease symptoms Primary treatment or adjuvant to surgery, radiation, or HSCT: Neoadjuvant – shrink tumor |
| Dose-limiting toxicities in chemo: myelosuppression | Neutropenia, thrombocytopenia, anemia |
| Dose-limiting toxicities in chemo: GI | n/v |
| Dose-limiting toxicities in chemo: integumentary | Stomatitis/mucositis |
| Dose-limiting toxicities in chemo: heart, liver, lungs | End-organ toxicities |
| Nursing Management for Patient on Chemotherapy pt 1 | Pre-treatment assessment Dose calculation & verification Safe handling & administration Monitoring for acute and delayed onset toxicities |
| Nursing Management for Patient on Chemotherapy pt 2 | Patient & family education: monitor temperatures, NO rectal temps, axillary best (especially with mouth sores) When to call the treatment team: first sign of fever |
| Myelosuppression | Decreased bone marrow activity Caused by chemotherapy, radiation, infiltration of marrow with cancer cells Nadir Support during Nadir |
| Decreased bone marrow activity with myelosuppression | WBCs- neutropenia RBCs - anemia Platelets -thrombocytopenia |
| Nadir | when blood counts are at their lowest timing and duration dependent on agent(s), dose, intensity |
| Support during nadir | reduce risk of life-threatening complications; neutropenia, anemia, and thrombocytopenia |
| when does Nadir occur | 7-10 days after chemo and counts must recover before next treatment |
| Prevention of infection due to neutropenia pt 1 | Handwashing, good mouth care, private room Precautions based on ANC – absolute neutrophil count Prophylaxis against Pneumocystis pneumonia- Trimethoprim-sulfamethoxazole (Bactrim) |
| Prevention of infection due to neutropenia pt 2 | Colony stimulating factors- G-CSF, Neupogen, Neulasta No flowers No fresh fruits and vegetables Avoid sick contacts |
| Management of infection due to neutropenia | Monitor for subtle signs/symptoms Fever may be only symptom – Call MD for all fevers 1.) Cultures- blood, urine, nasopharyngeal, stool for fever 2.) Initiate broad-spectrum antibiotics for fever during period of neutropenia |
| how long do you give BSA | until blood cultures allow to narrow down |
| when drawing cultures, | use first aspirate!!! never flush first incase line is infected |
| thrombocytopenia | Platelet transfusions as needed Bleeding risk Avoid skin puncture (even avoid BP cuff) Meticulous mouth care- prevent bleeding and mucositis (use soft toothbrush) Avoid rectal temperatures, suppositories Use acetaminophen for pain |
| anemia | PRBC transfusions as needed (plt only last 1-3 days) Not as severe as neutropenia May be delayed effect Regulate child’s activity – manage fatigue |
| an increased number of transfusions means | increased number of transfusion reactions |
| Nausea/Vomiting is the | most distressing side effects of cancer treatment |
| Nausea/Vomiting types | acute – during or immediately following chemo delayed – starting or persisting beyond 24 hrs. anticipatory – conditioned response when n/v poorly controlled with prior courses |
| Nausea/Vomiting goal | Prevention is goal – achievable for many children |
| Nausea/Vomiting Emetogenic potential | likelihood that specific agents will cause vomiting (low, moderate, high) - treatment for nausea before any chemo and continue at least 24 hrs after chemo |
| For agents with moderate or high potential, | administer anti-emetics before, during, and beyond chemotherapy regimen (time dependent on med) |
| Tailor approach based on | individual preferences, past experiences |
| important to do this during n/v | Keep patient well hydrated- may need to start IV fluids |
| radiation | Ionization causes single-strand or double-strand breaks in DNA |
| radiation causes | inability of cells to divide inability to repair DNA damage cell death |
| side effects of radiation | dependent on location and dose |
| goals for radiation | cure, long term control, and palliation |
| radiation can be used | alone or adjuvant therapy with surgery, chemotherapy or both |
| Radiation therapy Nursing Management | Assist with positioning child Monitor for side effects (acute or delayed) |
| Assist with positioning child for radiation | Reproducibility of treatment field essential |
| Monitor for side effects (acute or delayed) in radiation | Depends on area irradiated Myelosuppression- bone marrow Skin breakdown, alopecia- skin, head Nausea/ vomiting, anorexia, mucosal ulceration – GI tract, head Fatigue/post-radiation somnolence syndrome |
| late complications of radiation | diminished organ function, cognitive limitations, impaired growth, second cancers (osteosarcoma) |
| cognitive issues are | worse the younger the child Benefit vs Risk: Try to avoid brain radiation under 3-year-old |
| Hematopoietic Stem Cell Transplantation (HSCT) goal | rescue child after high dose of treatment to treat child after cancer exceed myelosuppressive threshold of standard cancer therapies |
| HSCT is | Maximum doses of chemo and/or radiation to maximize chance of killing cancer cells |
| HSCT has a profound risk of | toxicity, life-threatening complications, GVHD |
| types of HSCT | Autologous: own stem cells so won't reject but might not fight so increased risk of getting cancer back Allogeneic: match related donor, risk for rejection, devel graft vs host Syngeneic: identical twin Umbilical cord blood: have baby to get cord blood |
| Nursing Management for HSCT pt 1 | Coordinate administration of high-dose chemo and possible full body radiation Administer donor stem cells via IV infusion (blood transfusion) Implement positive isolation No dried, fresh flowers, potted plants |
| Nursing Management for HSCT pt 2 | Monitor for infection: fever Monitor for graft vs host disease (GVHD) Administer blood products as needed until engraftment Reposition patient |
| graft vs host disease (GVHD) symptoms | Diarrhea, maculopapular rash on hands, bottom of feet |
Created by:
leh195