This document summarizes key information from a presentation on early diagnosis of cancer in neonates and young infants. It discusses how cancer can present non-specifically in infants, with symptoms like lethargy and feeding difficulties. Several common childhood cancers are mentioned, including neuroblastoma, Wilms tumor, retinoblastoma, and leukemia. Challenges in diagnosing and treating neonatal cancer are outlined, such as the need for specialized pathology expertise and reduced chemotherapy doses. The presentation concludes with acknowledgements and a call for improved early diagnosis and shared care models for childhood cancer.

1. Early Diagnosis of Cancer
in Neonate and Young
Infant
Dr Avinash Thumallapalli,
Department of Paediatric Oncology
Kidwai Memorial Institute Of Oncology,
Bengaluru.
RBSK COMPREHENSIVE NEW BORN
SCEENING TRAINING PROGRAM: Screening
Visible Birth Defects at All Delivery Points.
[Date: 12/11/2018. Venue: Bangalore
Medical College and Research Institute,
Bengaluru].

2. Birth Defect-WHO Definition
• Birth defects can be defined as structural or functional abnormalities,
including metabolic disorders, which are present from birth.

3. Cancer-WHO
• Cancer is the uncontrolled growth and spread of cells. It can affect
almost any part of the body. The growths often invade surrounding
tissue and can metastasize to distant sites.

4. One Of The Twins.

5. Absence Of Wharton’s Jelly

6. Is Childhood Cancer a Public Health Problem?
• Around 4% Childhood Mortality Is Due to Cancer.
• 43% Children Die prior to Initiation of Treatment.
• Out of 2906 children diagnosed with malignancies between 2010 –
2014, a total of 134 were infants (4.6%)
• 77.7% had solid tumours while 22.3% had haematological
malignancies. The annual average of infantile malignancies was 27 per
year.
• Majority present in late infancy (64%) as compared to early infancy
(36%).

7. Childhood Cancers-Public Health Issue.
• Only 30% children presented at early stages while 70% presented
with advanced disease/metastatic disease.
• 72% of all tumors were diagnosed using fine needle aspiration
cytology as compared to 28% which required trucut/wedge/excision
biopsy.
• 28% children were enrolled for treatment and only 18% completed
treatment. Of these 80% achieved event free survival.
• Overall outcome in the world literature showed 75-80% survival for all
types of infantile tumors while our study had overall TFS of a meagre
15%.

8. INTRODUCTION
• Childhood cancer constitutes 4.5 – 5% of all cancers
in Developing countries and 1% in Developed
countries
• 12-14 per 100,000 children < 15 years of age develop
cancer
• 50,000 cases diagnosed annually in India
• 500 cases registered at KMIO annually
• Majority of paediatric cancers are curable with
protocol based and risk directed therapy

9. CHILDHOOD CANCERS:
PATTERN OF CHILDHOOD CANCERS
• Leukaemias – 30%
• Brain Tumors – 20%
• Lymphomas – 15%
• Neuroblastoma and Wilm’s – 10%
• Others – 25-30 %
• STS, Bone tumor, Retinoblastoma, GCT,
Retinoblastoma, Hepatoblastoma, PNET

10. CHILDHOOD CANCERS:HBCR:2013
0.2
1.7
3.1
3.1
4.3
4.8
5.7
6.9
11.9
13.8
44.7
0.0 10.0 20.0 30.0 40.0 50.0
Hepatic Tumor
Retinoblastoma
GCT
Neuroblastoma
Soft tissue
Renal Tumor
Bone Tumors
Oth.Malignant
Lymphoma
CNS
Leukaemia

11. CHILDHOOD CANCER: PBCR:2012
1.3
2.6
3.3
3.9
5.9
5.9
11.8
13.8
41.4
Retinoblastoma
Bone Tumors
Neuroblastoma
GCT
Soft tissue
Renal Tumor
CNS
Lymphoma
Leukaemia

12. PAEDIATRIC CANCERS
IMPROVEMENT IN SURVIVAL
• Understanding biology of the disease
• Diagnostic tool – Morphology,Cytochemistry
Karyotype, Phenotype,
Genotype
• Enrolling the patient to National trials
• Supportive care
• Trained personnel

13. CHILDHOOD CANCERS
5 YRS SURVIVAL %
Hodgkin’s and Wilm’s > 90
All other cancers 65 – 70
AML and Neuroblastoma (> 1 year) 25 – 30

14. NEONATAL CANCER
INTRODUCTION
• Incidence is relatively rare
• Different Clinical Presentations
• Response to therapy is differ
• Different clinical outcomes
• Challenges in treating these babies
• Some tumors regress spontaneously

15. NEONATAL CANCER
INTRODUCTION (Contd…)
• US Cancer Registry estimated prevalence is
36.5 /million
• UK Registry estimated 28/million live births
• Proportion of cases in Kidwai is around 1%

16. NEONATAL CANCER
Etiology:
• Unclear
• Genetic factors probably have a key role
• Acquired /Constitutional susceptibility during -
Prenatal, Intrauterine, Immediate Postnatal
environmental exposure

17. NEONATAL CANCER
Etiology (contd)
In Utrero Genetic susceptibility found in :
Eg: WT1- Familial Wilm’s Tumor
RB1 gene – Retinoblastoma
Down’s Syndrome – Teratoma
FAP – Hepatoblastoma
11q23 breakpoint – ALL
Favorable N-myc copies – Good prognosis Neuroblastoma
• Some babies have associated congenital abnormalities

18. NEONATAL CANCER
Clinical Features : Non Specific
• Lethargy
• Somnolence
• Irritability
• Feeding difficulties
• Vomiting
• Fever
• Hypothermia
• Failure to thrive

19. NEONATAL CANCER (%)
(Ref: NCI-SEER)
Type of Cancer Newborn
(<30 days)
Infants
( 1month – 12
months)
Leukemia 13 14
CNS 03 15
Neuroblastoma 54 27
Renal 13 11
Sarcomas 11 05
Hepatic 0 03
Teratoma 0 06
Retinoblastoma 0 13
Others 5.7 05

20. NEONATAL CANCER
Diagnosis
• Correct diagnosis requires the expertise
Pediatric Oncopathologist
• Cytochemical , ultrastructural, IHC for accurate
diagnosis
• Pitfalls in Diagnosis –
Pathologically malignant but have a benign
clinical course. (Infantile fibromatosis )

21. NEONATAL CANCER
Management- Multidisciplinary Approach -
Tertiary care setting
• Neonatologist
• Pediatric Oncosurgeon
• Pediatric Oncologist
• Anesthesiologist
• ICU Nurse
• Blood Banking
• Nutritionist

22. NEONATAL CANCER
Management - Surgery
Preoperative, operative, Postoperative period
focus on –
• Temperature regulation
• Blood volume
• Fluid and Electrolyte balance
• Cardiac, Pulmonary and Renal status
• Blood glucose
• Integrity of coagulation system
• Adequate venous access

23. NEONATAL CANCER
Radiotherapy
• RT must be used cautiously due to acute and
chronic side effects
• Organs vulnerable for toxicity – Brain, kidney,
Liver, Lungs, Musculoskeletal system
• Hence RT to be avoided in neonates

24. NEONATAL CANCER
Chemotherapy
• CT toxicity more in neonates
• All drug dosages to be reduced by 50%
• Calculate the drug dosage by weight rather than
surface area
• Needs pharmacokinetic monitoring

25. NEONATAL CANCER
Type of Cancer No. of patients
Teratoma 6
Wilm’s Tumor 4
Neuroblastoma 4
RMS 2
Retinoblastoma 2
Infantile fibrosarcoma 2
Kidwai Cancer Institute :
2010-2014 ( 5YRS )
N=20 (Solid Tumours)

26. Neonatal Leukemia
• There were 4 Infants with Haematopoietic Tumours, Juvenile
Myelomonocytic Leukemia (02). Acute Leukemia undifferentiated
(01), Acute Lymphoblastic Leukemia(01), and Acute Myeloid
Leukemia(01).

28. Differences between Paediatric and Adult
Cancers
Parameter Children Adult
Site Tissues Organs
Status at Diagnosis 80% Disseminated Local or Regional
Early Detection Usually Accidental Improves with education and
screening
Screening Difficult Adequate
Response Most Respond to Chemotherapy Lower response to Chemotherapy
Prevention Unlikely 80% Preventable

29. Tumours of Central Nervous System
These are solid tumors of the cranial cavity; they
are more frequent in early childhood, appearing
primarily from 5 to 10 years of age and declining
after puberty.
Irritability
Anorexia
Vomiting
Weight loss or poor weight gain
Regression in development
Increase in head circumference
Separation of sutures.
The anterior fontanelle may bulge or feel tense

30. Wilms Tumor
• This is a malignant neoplasm of the kidney cells, which compromises
one of the two kidneys, although it can also be bilateral. It is the most
common kidney cancer in young children, with greatest frequency
among 2 and 3 year-olds. It may be associated with congenital
malformations.
• The typical clinical manifestation is a palpable asymptomatic
abdominal mass, which may be detected by the parents or physician
during routine examination.

31. Neuroblastoma
• This is an extracranial malignant solid tumor of nerve tissue. It is most
frequently located in the adrenal glands, but may occur in any part of
the body, such as the neck, thorax, or spinal cord. It occurs most
frequently before 5 years of age; on average at 2 years of age.
• Tumors can grow in any part of the nervous system. Symptoms
depend on the mass effect of the tumor in the affected region, which
can be the head, neck, thorax, or paraspinal or lumbarsacral region.

32. Retinoblastoma
• This malignant neoplasm originates in the primitive cells of the retina.
It ranks 5th to 9th among child cancers, with its greatest incidence in
children under 3 years of age. It is more frequent in developing
countries, suggesting that it is due to exposure to infectious agents,
particularly adenovirus and human papillomavirus, and other factors
such as lack of vitamin A and folate in the diet.
• The most common sign is leukokoria (white eye
or cat’s eye) in one or both eyes. Leukokoria is
the absence of the normal red reflex of the retina
when illuminated with a light.

33. RB

34. RB

35. LCH

36. Soft Tissue Sarcomas
• The most frequent presentation is a painful or
painless mass. Clinical manifestations may vary
widely, depending on the tumor’s location. A
mechanical mass effect can occur.
• They may be aggressive, with rapid local growth,
and directly invades neighboring structures.
Its clinical presentation will depend on the
structures it affects.

37. Germ Cell Tumor
• This is a benign or malignant germ cell neoplasm,
which can grow in the ovaries or testes, or in
other sites, such as the sacrococcygeal region,
retroperitoneum, mediastinum, neck, and brain.

42. Acknowledgements
• Children and their Parents
• DHFW
• DHFW(ME)
• RBSK
• Director, KMIO
• Prof Dr L Appaji, KMIO
• HOD Paediatric Oncology, KMIO
• An Atlas Of Neonatology, Dr M L Kulkarni.

43. Thank You
Looking forward for an Early Diagnosis of
Childhood Cancer Module and a Shared Care
Model.