oncology peds

• Diagnostic evaluations

  • Complete history
  • Review of systems
  • Physical examination
  • Lab test (usually see pancytopenia)
  • Imaging studies
  • Biopsy
• Biotherapy 3 types

  • Stimulate immune system to act against cancer cells (immunotherapy or biologic response modifier therapy)
  • Antibodies or segments of genetic material to target and destroy cancer cells
  • Interfere with specific molecules involved in tumor growth and progression (targeted therapies)
• Stem cell transplant

  Really young cell that hasn't developed, restore stem cells following high dose chemotherapy or radiation and or replace dysfunctional bone marrow, if successful produce functioning nonmalignant blood cells
• Investigational drug trials

  • Phase 1= assess the maximum dose tolerated
  • Phase 2= assess tumors reaction to drug
  • Phase 3= looks at most effective routes/lengths of treatment/combination of drugs
• Cardinal symptoms of cancer

  • Unusual mass or swelling
  • Unexplained paleness and loss of energy
  • Sudden tendency to bruise
  • Persistent localized pain or limping
  • Prolonged unexplained fever or illness
  • Frequent headaches often with vomiting
  • Sudden eye or vision changes
• Leukemia

  Cancer of the blood forming tissues, unrestricted proliferation of immature white blood cells (bone marrow making too much underdeveloped white blood cells), cellular destruction from overgrowth of immature cells and competition of metabolic elements, primary consequences are anemia from decreased erythrocytes, infection from neutropenia and bleeding from decreased platelets
• Types of leukemia

  • ALL (acute lymphoblastic leukemia)= most common cancer in children, peak incident at 3-5 years
  • AML (acute myelogenous leukemia)= peak incident in adolescents like 10-15 years, at risk children with genetic disorders like down syndrome
• Effects of proliferation of immature white blood cells

  • Bone marrow dysfunction= anemia, infection, bleeding, bone/joint pain leading to hepatosplenomegaly/lymphadenopathy/fibrosis
  • Hyper metabolism= anorexia, weight loss, fatigue, cell growth, metabolic starvation, cell destruction, uric acid production, plugged renal tubules
  • CNS= Increased intracranial pressure, cranial nerve involvement
• Common presentation of leukemia

  • History of recent infection
  • Unexplained weight loss
  • Anorexia
  • Ecchymosis
  • Pallor
  • Joint pain
• Leukemia lab findings

  • Decrease red blood cells
  • Decrease platelets
  • Decrease neutrophils
  • Decrease hemoglobin
  • Increase or decrease or normal white blood cells
• Stages of leukemia treatment

  • Induction= immediately after diagnosis, last usually 4-5 weeks, determined by absence of signs & symptoms and <5% blast cells in bone marrow, CNS preventive give intrathecal meds, at risk for invasion of CNS by leukemic cells
  • Consolidation (intensification)= further decrease leukemic cells, periodically over 1st 6 months, keep patients in hospital huge risk for infection and bleeding
  • Delayed intensification= similar to induction and consolidation
  • Maintenance= goal preserve remission and further reduce leukemic cells
  • Off treatment
• Common medications for leukemia

  • Prednisone increases appetite
  • Leukovorin rescue drug for methotrexate
  • Vincristine bone marrow depression/neurotoxicity
  • L-asparaginase anaphylaxis
  • Methotrexate bone marrow depression
  • Zyloprim (allopurinol) excretes uric acid
  • Cyclophosphamide hemorrhagic cystitis
  • Cytarabine neurotoxic
  • Mercaptopurine immunosuppressive hepatotoxic
  • Granulocyte colony stimulating factor increases neutrophil count
• Nursing management for altered immunity

  • Monitor temperature frequently no rectal temps (potential for trauma to rectum which can cause severe sepsis)
  • Handwashing, strict aseptic technique procedures
  • Low bacteria diet
  • Environmental risk factors
  • Possible antibiotics
  • Increase frequency of mouth care
  • No suppositories
• Nursing management for neurotoxicity

  • Observe for constipation to flush out the meds
  • Observe for foot drop/weakness/numbing of extremities/jaw pain/post irradiation somnolence
• Lymphoma

  Neoplastic diseases arising from lymphoid and hematopoietic system
• Hodgkin's disease

  Peak incidence in adolescence rare before age 5, originates in lymphoid system primarily involves lymph nodes, metastasizes to non-nodal or extra-lymphatic sites, characterized by painless enlargement of lymph nodes commonly supraclavicular or cervical
• Hodgkin's diagnosis

  • Lymphangiogram
  • Biopsy node if possible
  • Staging laparotomy with or without splenectomy
  • Presence of reed Sternberg cells
• Hodgkin's treatment

  Radiation, chemotherapy, consider developmental issues of body image and reproduction, excellent prognosis in early stages
• Nursing care for Hodgkin's

  • Knowledge of adolescent needs
  • Skin care with radiation
  • Delayed secondary characteristics
  • Post op care
• Non-Hodgkin lymphoma

  Peak incidence 7-11 years, usually diffuse rather than nodular, cell type undifferentiated or poorly differentiated, dissemination occurs early more often and more rapidly, mediastinal involvement and invasion of meninges typically occurs
• Non-Hodgkin diagnosis

  • Surgical biopsy
  • Bone marrow aspirate
  • Radiologic studies
  • Lumbar puncture
  • Lack of reed Sternberg cells
• Non-Hodgkin treatment

  Irradiation, chemotherapy (induction, consolidation, maintenance), nursing care focuses on managing side effects of treatment
• Brain tumors

  Most common solid tumor in children, second most common cancer in children, majority are Infratentorial, cell malignancy may be less and issue than location of tumor, treatment surgery/radiation/chemotherapy
• Presenting signs and symptoms of brain tumors

  • Ataxia
  • Headache
  • Motor weakness
  • Vomiting
  • Visual defects
  • Cranial enlargement
  • Hormonal deficits
  • Vital sign changes
  • Papilla edema
  • Seizures
• Post-operative care for brain tumors

  • Altered neurological function
  • Monitor for increased intracranial pressure
  • Level of consciousness
  • Pupil checks
  • Head circumference
  • Positioning head elevated don't lay on side of operation
  • Seizure precautions
  • Fluid balance
• Neuroblastoma

  Originates from embryonic neural crest cells that normally become adrenal medulla and sympathetic nervous system, cancer of immature nerve cells, most tumors from adrenal gland or retroperitoneal sympathetic chain primarily within abdomen, other sites include head/neck/chest/pelvis, symptoms depend on site, adrenal catecholamine production increases blood pressure, often metastasized at diagnosis stage 3 or 4
• Neuroblastoma diagnosis

  • Scans
  • Liver/renal function
  • 24 hr urine for catecholamines
• Neuroblastoma treatment

  Surgically remove as much as possible, follow up chemotherapy, radiation, bone marrow transplant
• Neuroblastoma signs and symptoms

  • Aniridia (can't see pupil anymore)
  • Abdominal mass crosses midline/obstructive/compresses
  • Bone metastasis causes pain
  • Intracranial soft tissue
  • Mediastinal dyspnea and obstruction
  • Spinal cord paralysis
  • Pallor
  • Anemia
  • Weakness
  • Weight loss
• Nursing care for neuroblastoma

  • Post-operative care related to site
  • Monitor for hypertension
  • Parental support
  • Teaching about chemotherapy side effects
  • Prognosis 5 years after diagnosis and younger than 1 year 90% successful treatment, older child with advanced stage lesser chance for cure
• Wilms tumor (nephroblastoma)

  Tumor on kidneys, unilateral or bilateral, genetic component, compresses kidney renin production and hypertension, increasing abdominal circumference parents may discover this first, microscopic red blood cells in urine because kidney is damaged
• Wilms tumor presentation


  • Increase abdominal girth
  • Mass firm/nontender/confined to one side
  • Symptoms from pressure like hematuria/anemia/pallor
  • Fever/lethargy/weight loss
  • Metastasis to lungs with cough/shortness of breath/chest pain
  • Associated anomalies like genitourinary/hamartomas/eye defects
• Wilms tumor diagnosis

  • CT/MRI abdomen
  • Renal/liver function test
  • CBC/urinalysis
  • Cardiac evaluation like echocardiogram
  • Chest CT/MRI
• Wilms tumor treatment

  Surgical removal may pretreat with chemotherapy or radiation to shrink, large abdominal incision, follow up chemotherapy, good prognosis
• Nursing care for Wilms tumor

  • Protect tumor integrity, don't palpate the abdomen because it can rupture
  • Pre-operative vital signs
  • Monitor blood pressure
  • Post-operative abdominal care
  • Parent/family teaching
• Rhabdomyosarcoma

  Soft tissue sarcomas, originates from embryonic mesenchyme, soft tissue tumor of striated muscle, most common head/neck/eye
• Rhabdomyosarcoma presentation

  • Obstructive
  • Mass
  • Pain
• Rhabdomyosarcoma diagnosis

  • CT/MRI
  • Chest X-ray
  • Bone/liver scan
  • Biopsy
  • Kidney/liver function
• Rhabdomyosarcoma treatment

  Surgical resection, radiation, chemotherapy
• Bone tumors

  • Osteosarcoma= outside the bone, peak incident 10 years, most commonly found in long bones
  • Ewing sarcoma= grows inward and affects bone marrow, peak incident school age, most often found in bone marrow of long bones