Monday, March 9, 2009

Pediatric Nursing: pediatric malignancies/cancers

Pediatric Malignancies

1% of all cancers

Involves tissues of:

CNS, bone, muscle, endothelial tissue

Grows in a short period of time


Genetic alteration

Environmental influences

No know prevention

Metastasic disease seen in 80%

Response to Treatment

Very responsive to chemotherapy

More than 60% cure rate

Classification of Tumors

Embryonal tumor arises from embryonic tissue

Lymphomas = lymphatic tissue

Leukemias = blood

Sarcoma = seen in bone, cartilage, nerve and fat

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.

Diagnostic Tests


Skeletal survey

CT scan



Bone marrow aspiration


Identify cell to determine type of treatment

Treatment Modalities

Determined by:

Type of cancer


Extent of disease


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

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

Problems: radiation beams cannot distinguish between malignant cells and
healthy cells.


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.

Can be given in addition to another form of therapy such as radiation or

Drugs may be administered before surgery to reduce size of tumor.

Adjuvant chemotherapy is used after surgery or radiation therapy to prevent

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.


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

Goals of Chemotherapy

Reducing the primary tumor size

Destroying cancer cells

Preventing metastases and microscopic spread of the disease

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

Bone Marrow Transplant

HSCT: Hematopoictic Stem Cell Transplant: CHLA has one of the largest

The option of HSCT depends on the patients disease, disease status, and
general physical condition.


Umbilical cord blood

Parent’s stem cells

Gene Therapy

Use of gene therapy in the treatment of childhood cancer is promising yet
complex and still in early phases of clinical application.

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

Pain Management

Pain caused by disease

Pain with procedures and treatments

Pain associated with side effects of treatment

Pain Management



Sedation or anesthetic medications

EMLA cream

Conscious sedation

Pain Control

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.


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.

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


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.

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.

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.

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

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.

Management of Side Effects


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.

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

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


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


Progressive, inflammatory, ulcerative condition of the oral and gastric

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.


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


Assess normal bowel habits

Increase fiber and fluids in diet

Stool softeners / colace

Physical activity

Avoid digital manipulation


Assess for signs of dehydration

Record stool patterns

IV fluids as needed

Low-residue or lactose-free diet

Good hand washing

Hair Loss

More important in the older child.

Most patients will experience hair loss within 10 days of induction

Prepare patient for hair loss

Males: shave hair

Females: short hair style – pick out wig

Psychosocial Support

Support groups

Open communication

Daily contact with oncology team

Trusting relationship with nurse

Growth and Development

Promote normal G & D

Allow decision making

Establish daily routines

Play therapy


School attendance or tutor


Most common malignancy

4 in 100,000

Increase in chromosome disorders

High survival rate


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.


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


Peripheral blood smear

Bone marrow analysis

Lumbar puncture

Peripheral Blood Smear

Bone Marrow

Clinical Manifestations

Pallor and fever



Weight loss

Hemorrhage / petechiae

Hepatomegly / splenomegaly

3 Phase Treatment

Induction: goal is to achieve remission last about a month

Consolidation: most intensive phase of chemotherapy lasts 4 to 8 months

Maintenance: last two to three years

If leukemia cells are detected in bone marrow process is started all over

Induction Therapy

Goal of therapy is to achieve remission

Leukemia cells are no longer found in the bone marrow samples, the normal
cells return and blood counts become normal.

Drugs used: L-asparaginase, vincristine and a steroid (dexamethasone), for
high-risk children a fourth drug (daunorbucin) is often used

Consolidation Phase

Several drugs are used in combination to prevent remaining leukemia cells
from developing resistance.

Drugs include: methotrexate and 6-mercaptopurine, vincristine and


If leukemia continues to be in remission maintenance therapy can be

Two drugs: vincristine and steroids over a brief period every 4 to 8 weeks.

Duration of total therapy 2 to 3 years.

CNS Therapy

CNS prophylaxis is initiated at diagnosis and is used to reduce the risk
for CNS disease.

Preventive CNS is based on the premise that the CNS provides a sanctuary
site for leukemic cells that are undetected at diagnosis and reside protected
from the action of systemic therapy by the brain blood barrier.

Nursing Interventions

Assess for infection

Monitor blood values

I & O / nutrition

Complications of chemotherapy

Good hand washing

Aseptic technique for blood draws

Leukemia Time Line

1962 cure rate for pediatric cancer is 4 %.

1971 – A combination of chemotherapy and cranial irradiation proves it can
cure at least half of all children with ALL.

1975 – A new combination of chemo drugs helps patients with reccurrence of
the disease.

Time Line

1991 Long-term survival rate increases to 73% with intensive induction
therapy followed by two years of treatment with eight anti cancer drugs used
on a rotating basis.

1997 – Bone marrow transplants from unrelated, genetically matched donors
are effective against many childhood leukemia's.

1998 – Study reveals the cure rate for All has increased from 73% to 80%.

CNS Tumors

2nd most common malignancy

65% have 5 year survival rate

Most common tumors:

Astrocytomas 50%

Medulloblastomas 25%

Brain stem gliomas 10%

Clinical Manifestations

Classic signs and symptoms are indicative of increased intracranial

Pressure is due to tumor mass compressing vital structure, blockage of
cerebrospinal fluid flow or tumor associated edema.

Gait changes / ataxia

Headache with or without vomiting

Blurred vision, or diplopia

Forceful vomiting upon rising in the morning or papilledema.


Surgery if tumor accessible


Radiation = Reserved for patient older that 2-years of age

Survival rate based on location


After surgery to prevent tumor from coming back

Shrink tumor that cannot be operated on

Shrink tumor so it can be operated on

Blood brain barrier – natural filter within the body that allows certain
substances through from the blood to the brain tissues.

Drugs used are: temozolamide, procarbazine or lomustine

Methotrexate is injected intra-thecal

Implantable wafers: drug is fixed with gel wafer – drug is slowly released
into brain over 2 to 3 weeks

Brain Tumors

Hodgkin's Disease

3rd most common malignancy

15 to 30 years

Three times higher in males

Excellent cure rates

Clinical Manifestations

Night sweats

Weight loss


Painless, firm nodes


Radiation to nodes


Combination therapy for six months


Stem cell transplant

Long Term Side Effects

Infertility: drugs can damage ovaries or testicles

Second cancers: small risk for leukemia in future

Heart disease: some drugs can cause heart problems or radiation to middle
of chest

Lung damage: pneumonitis from bleomycin


Approximately 600 new cases a year.

Embryonic tumor

Average age of diagnosis is 2 years.

Poorest survival rate

50 to 60% have metastases at time of diagnosis.

Clinical Manifestations

Depends on site of tumor


CT scan

Bone scan

95% secrete catecholamines in the urine.


Determined by the stage of disease and age of child.

Children who have localized disease and complete response to treatment are
more likely to achieve a disease free state and long-term survival.


Wilm’s Tumor

Most common type of renal tumor in children

Approximately 460 new cases each year.

Children with hypospadius or cryptorchidism have a slightly higher

African American and Females at highest risk

Clinical Manifestations

Firm non-tender, painless mass in abdomen



Do not palpate the abdomen

CT Scan Wilm’s Tumor

Wilm’s Tumor




Prevent rupture of capsule

Sample for pathology

Chemotherapy and radiation are given based on the stage of the disease.

Osteogenic Sarcoma

Malignant tumor of bone

400 new cases each year

Peak incidence is in the second decade of life, when adolescents are
gaining vertical height rapidly.

Approximately 20% have metastases at diagnosis

High rate of metastasis to lungs


Osteosarcoma Tumor


Limb salvage



Limb Salvage

Ewing Sarcoma

Tumor of flat bones

Pelvis, chest, vertebrae

Rare in children under 5 years

75% diagnosed by age 20

Ewing Sarcoma Tumor


Most common soft bone tissue tumor

Head and neck 40%

GU 20%

Extremities 20%

Trunk 15%



Surgical removal

Chemo based on tissue biopsy



Intraocular / Embryonic tumor

1 in 16,000

+ family history

High incidence of malignancies



Surgical enucleation of eye

Genetic counseling

Follow-up care up to 18 Years