When to suspect cancer in pediatric age Prof. Safinaz El-Habashy Prof. of Pediatrics, Ain Shams University MD, MHPE, TQM
Objectives• To recognize conditions that mimic cancer.• To recognize symptoms suggestive of cancer.• To interpret results of initial work up.• To appreciate the importance of early referral of suspected cases.
Incidence of Childhood CancersLeukemia--------------------------- 30.2Central nervous system tumor-- 21.7Lymphoma------------------------- 10.9Neuroblastoma-------------------- 8.2Soft tissue sarcoma--------------- 7.0Renal tumor----------------------- 6.3Bone tumor------------------------ 4.7Others------------------------------ 11.0
Specific Signs and Symptoms Depend on•type of cancer•site(s) of disease• age of patient
What are the symptoms? Anemia Bleeding Bone tenderness Lymphadenopathy Hepatospleenomegaly Headaches Mass; Abdominal / Mediastinal Fever
Cancer in children may present as• A mass• Symptoms directly related to tumor• Non specific symptoms related to tumor or metastatic growth
Symptoms that may indicate the presence ofa malignancy in children•Unexplained paleness and fatigue•Loss of energy (limited time at play)•Persistent localized pain or swelling•Prolonged unexplained fever or illness,especially with bone pain•Frequent headaches, especially in the morning,often with vomiting•Sudden eye or vision changes•Lymphadenopathy
Symptoms that may indicate the presence ofa malignancy in children•Excessive rapid weight loss•Swelling of the face and neck•Cat’s eye reflex•Limping•Vaginal bleeding in a premenstrual child, orprolonged bleeding between or with periods,excessive bleeding during periods.
Signs and Symptoms of Childhood Cancers and Conditions That Can Mimic These CancersFever Leukemia, Infection lymphomaVomiting Abdominal mass, Infection, gastroesophageal brain tumor refluxConstipation Abdominal mass Poor dietCough Mediastinal mass Upper respiratory infection, reactive airway disease, pneumoniaBone or muscle Leukemia, bone Musculoskeletal injury, viral pain tumor, infection Neuroblastoma
Signs and Symptoms of Childhood Cancers and Conditions That Can Mimic These CancersHeadache Brain tumor Tension headache, migraine, infectionLymphadenopathy Leukemia, lymphoma, Lymphadenitis, systemic (>3 cm) metastatic disease infection, collagen vascular diseaseHematuria Wilms tumor Urinary tract infection, glomerulonephritisVoiding difficulty Rhabdomyosarcoma Congenital urinary tract abnormalities
Anemia Features suggestive of malignancyRapidly progressive anemia.Anemia requiring repeated blood / red cell transfusions.Anemia associated with bleeding, lymph- adenopathy, bone pains and lumps in the body.
When to do Bone Marrow Examination?Significant depression of one or more cell lines or abnormal blood counts in absence of infection/inflammation.Abnormal blood counts with unexplained lymphadenopathy or hepatospleenomegaly.Presence of atypical or blast cells in peripheral blood smears.* Both aspiration and trephine bone biopsies are recommended in cases of acute leukemia to determine morphology and marrow cellularity.
What guidelines sayTiny red spots or larger red areasAn urgent referral is always needed if a child has tiny red spots(petechiae) or larger areas where there has been abnormalbleeding into the skin (purpura).TirednessIf your child is tired and was previously healthy, an urgent referralis recommended if he or she also has swelling of the lymph nodes or enlargement of liver and spleen.
What guidelines sayPain in the bones• the pain is widespread or involves the back;• or it always occurs at the same place;• or your child needs to take pain killers to control it;• or the pain is preventing him or her from doing some things.
What guidelines saySwelling of the lymph glands: a lump is firm or hard, not tender, and more than 3cm(1 inch) across; or a lump is getting bigger; there are other signs of illness, such as a hightemperature or loss of weight; the swelling is in the armpit or in lymph nodes abovethe collar bone (unless there is an infection nearby thatcould be causing swelling of these lymph glands); swollen lymph glands are seen on an x-ray of thechest.
When to do fine needle aspiration cytology (FNAC)It is used for any mass lesion or enlarged lymph nodes. It could even be used safely for deep- seated masses/mediastinal nodes either by USG or CT scan. It must, however, be followed by a biopsy if results are inconclusive or reported as reactive hyperplasia.
What guidelines sayHeadachesReferral if the headaches are recent and have at leastone of these features:•getting more frequent or more severe•worse in the mornings, or wake your child up early inthe morning;•child is also being sick;•there are signs of nerve damage, such as a squint orloss of co-ordination;•child’s behaviour has changed or he or she is doingless well at school than usual.
What guidelines sayA lump in a soft tissueConsider referral for any lump if it has at least one ofthese features: it is growing steadily or rapidly; it ismore than 3cm (1 inch) across; it does not move whenexamined, or it is deep within the tissue; there areswollen lymph glands near the lump.Development of breasts or starting periods earlierthan usual
When to do excisional/ incisional biopsy?• When mass is localized to an organ e.g. adrenal gland or kidneys, with no evidence of metastatic disease. Total removal should be the aim.• When FNAC is inconclusive.
When and How to Evaluate Signs and Symptoms for CancerFeverVomiting Fever lasts > 14 days with CBC with differential no identifiable cause. Vomiting lasts > 7 days Abdominal and head with no identifiable cause. CT scans Vomiting is associated Head CT scanConstipation with headache during sleep. Constipation is prolonged Abdominal and (>1 month) and does not pelvic CT scans respond to conventionalCough measures. Chest radiograph Cough is prolonged (>2Bone or weeks) and has no muscle pain identifiable cause. Plain-film Pain is prolonged (>2 radiograph, bone weeks) and has no and CT scans, CBC identifiable cause.
When and How to Evaluate Signs and Symptoms for Cancer Headache occurs during Head CT scanHeadache sleep, is associated with neurologic signs and vomiting, or in the absence of a family history of migraine. Evaluate immediately if Abdominal U/SHematuria hematuria has no identifiable cause. Evaluate immediately if Abdominal U/SVoiding difficulty voiding difficulty has no identifiable cause.Lymphadenopathy Evaluate if CBC with (>3 cm) lymphadenopathy does differential, lactate not respond to a 7-day dehydrogenase course level of antibiotic.
Clinical and epidemiological clues Age and Cancer Infancy - Embryonal tumors, neuroblastoma, retinoblastoma and hepatoblastoma. Childhood: – Acute lymphatic leukemia and brain tumors.Adolescents: - Lymphomas, rhabomyosarcoma and Ewing’s tumor.
Clinical and epidemiological clues• Signs and symptoms according to 1 ry site and mets Pulmonary Abdominal Neurologic• Congenital anomalies
Do’s and don’ts for diagnosis of Pediatric Cancer• Do not administer steroids in a suspected case of JRA without doing a BM aspiration.• Do not start anti TB therapy/ antibiotics in patients with lymphadenopathy without a definite diagnosis.
Do’s and don’ts for diagnosis of Pediatric Cancer• Do a lymph node biopsy if FNAC is inconclusive and neoplasia is suspected.• Give a blood transfusion prior to a definite diagnosis only if Hb is <5gm/dl or if there are impending features of CCF.• Refer children suspected to have a neoplastic disease as early as possible.
Case PresentationA 15-year-old white female reports that she has had fever, weight loss, and night sweats for 3 months. On physical examination, she has painless swelling of the left cervical and supraclavicular lymph nodes. Her liver and spleen are not enlarged. The initial evaluation of the patient should include• A. bone marrow aspiration• B. abdominal CT• C. chest radiograph• D. head CT• E. erythrocyte sedimentation rate
Case PresentationThe chest radiograph of the patient described reveals mediastinal lymphadenopathy. The next appropriate diagnostic test is• A. abdominal CT• B. head CT• C. bone marrow biopsy• D. lymph node biopsy• E. thoracic CT
Case PresentationA mother states that her 14-month-old infants eye has a "cats eye" appearance. On routine office ophthalmoscopic examination, you have a hard time seeing the fundus but observe no gross abnormalities. The extraocular muscles and remaining head and neck and general physical findings are normal. You should• A. reassure the mother that nothing is wrong• B. obtain toxoplasmosis titers• C. culture for rubella• D. refer the patient to an infectious disease specialist• E. refer the patient to an ophthalmologist for examination under general anesthesia