Pediatric Oncology Flashcards
(93 cards)
1
Q
pediatric oncology considerations?
A
◦ Children react differently to treatments
◦ Children heal more quickly
◦ Children are undergoing periods of rapid growth and
development
- Children will be active if they feel up to it
- Family-centered care is crucial
2
Q
Known risk factors (I dont think this is an objective)
A
◦ Exposure to ionizing radiation increases risk of childhood leukemia
◦ Solid organ transplant recipients – increased risk for non-Hodgkin lymphoma secondary to use of
immunosuppressants
◦ Cancer risk is increased in children with certain genetic syndromes (Down syndrome, Li Fraumeni syndrome)
◦ Accelerated fetal growth and higher birth weight associated with increased risk of acute lymphocytic leukemia, CNS tumors, NHL, rhabdomyosarcoma
3
Q
Carcinoma
A
◦ Malignant neoplasm of epithelial origin; accounts for 80-90% of all cancers
◦ Adenocarcinoma – develops in an organ or gland
◦ Squamous cell carcinoma – originates in the squamous epithelium
4
Q
sarcoma
A
◦ Originates in supportive and connective tissues – bone, tendon, cartilage, muscle, fat
5
Q
Myeloma
A
originates in the plasma cells of bone marrow
6
Q
leukemia
A
cancer of the bone marrow, considered “liquid cancer” or “blood cancer”
7
Q
lymphoma
A
develops in the glands and nodes of the lymphatic system
8
Q
general signs and symptoms
A
- Unusual mass or swelling
- Unexplained paleness or loss of energy
- Sudden increase in tendency to bruise or bleed
- Persistent, localized pain or limping
- Prolonged, unexplained fever or illness
- Frequent headaches, often with vomiting
- Sudden eye or vision changes Excessive, rapid weight loss
9
Q
when does leukemia occur?
A
- when defective, nonfunctional leukocytes are produced in large numbers
- Defective leukocytes migrate from the bone marrow into the bloodstream, displacing the healthy leukocytes
10
Q
common signs and symptoms of leukemia
A
◦ Lymphadenopathy, hepatosplenomegaly, fever, easy bleeding or bruising, night sweats, weight loss
11
Q
characterizations of leukemia
A
- acute or chronic
- lymphoid or myeloid
12
Q
what is the most common pediatric cancer?
A
acute lymphoblastic leukemia (ALL)
13
Q
characteristics of acute lymphoblastic leukemia
A
- Defined by rapid proliferation of immature, nonfunctional leukocytes
- If left untreated, death occurs quickly in these patients
- Survival is 90% with chemotherapy (sometimes for 2 to 3 years)
14
Q
neuromuscular and musculoskeletal complications of ALL
A
◦ Pain, paresthesia, muscle weakness, ROM deficits, impaired gross and fine motor performance, decreased energy expenditure, avascular necrosis, osteopenia, osteoporosis, learning disabilities
15
Q
acute myeloid leukemia
A
- Characterized by the presence of defective and nonfunctional granulocytes or monocytes
- AML compromises the body’s immune system
- Occurs most frequently in the 1st 2 years of life
- Survival is ~63% with chemotherapy
16
Q
lymphocytes include:
A
- B cells: synthesize antibodies
- T cells: activate phagocytes and inflammatory process
17
Q
where do lymphomas occur?
A
in lymphatic structures: lymph nodes, spleen, bone marrow, thymus, lymphatic structures in the brain, GI tract and liver
18
Q
common signs and symptoms of lymphomas
A
◦ Lymphadenopathy, fever and chills, night sweats, unexplained weight loss, persistent fatigue, anorexia,
pruritus
19
Q
definitive diagnosis of lymphoma
A
made by examining a biopsy of lymph tissue for the presence of abnormal tissue architecture and lymphocytes
20
Q
Non-Hodgkin’s Lymphoma
A
- Heterogeneous group of blood cancers that adversely affects both B and T lymphocytes
- Occurs more frequently in children over age 3
- Survival rate 87%
21
Q
signs and symptoms of non-hodgkins lymphoma
A
◦ Painless supraclavicular or cervical adenopathy, nonproductive cough, fatigue, anorexia and
pruritus
22
Q
risk factors for non-hodgkin’s lymphoma
A
◦ Medical conditions or treatments that result in immune suppression, inherited
immunodeficiency diseases, and HIV infection
23
Q
Hodgkin’s lymphoma
A
- Less common
- Identified by the presence of abnormal B lymphocytes called Reed Sternberg cells
- Incidence increases in adolescence; most common in 15- to 19-year-old age group
- Survival rate 97%
24
Q
common signs and symptoms of Hodgkin’s Lymphoma
A
◦ Painless lymphadenopathy (cervical,
supraclavicular, axially, inguinal), mediastinal mass, fatigue, weight loss, anorexia, fever, drenching night sweats, hepatic and/or splenic enlargement
25
Brain and CNS tumors
- Tumors are classified by the type of cell or tissue in which they originate OR by the tumor’s location within the CNS
- Benign tumors can cause significant adverse effects --> growth may cause compression of adjacent healthy functioning tissue
26
Brain and CNS Tumors signs and symptoms
◦ Dependent on tumor location, developmental stage of the child, and presence of increased intracranial pressure ◦ Headache; vomiting (especially in the AM); vision, speech and hearing changes; worsening balance; unsteady gait; unusual sleepiness; weakness
27
Astrocytoma
- Most common type of glioma - Arise in astrocytes (neural support cells)
- Can be found in the brain and spinal cord
28
look at the signs and symptoms of astrocytomas slide if you want to
but we did just have a whole test on that sooooooo
29
meduloblastomas
- Highly invasive embryonal tumor
- Rare in adults but common in children (under the age of 10)
- Typically arise in the cerebellum but can spread throughout the entire CNS via CSF
30
signs and symptoms of medulloblastomas
◦ Headache, vomiting, nausea, lethargy, dizziness, double vision, poor coordination, unsteady gait
◦ Can be related directly to the tumor or due to increased
intracranial pressure
31
Ependymomas
- Tumors that arise from the glial cells lining the ventricular system of the brain or the central canal of the spinal cord - Can range in severity from low to high grade
32
What do ependymomas do
- directly damages the brain tissue
- can disrupt normal flow of CSF resulting in increased ICP and further CNS damage
33
signs and symptoms of ependymomas
◦ Headaches, seizures, nausea and vomiting, pain or stiffness in the neck, loss of balance, difficulty walking, weakness in legs, blurry vision, back pain, changes in bowel and bladder,
confusion
◦ Tend to vary from child to child
34
Neuroblastoma
- Neuroendocrine tumors that arise from neuroblasts
- Most commonly arises in and around the adrenal glands --> Can also develop in the abdomen, chest, neck and near the spine
- Found throughout the developing sympathetic nervous system
- Most commonly affect children under the age of 5, but can occur later
35
signs and symptoms of neuroblastoma
◦ Mass under skin, proptosis, periorbital hyperpigmentation, back pain, fever, unexplained weight loss, bone pain
◦ Neuroblastoma in abdomen: abdominal pain, non-tender mass, changes in bowel habits ◦ Neuroblastoma in chest: wheezing, chest pain, changes to the eyes incl. ptosis and anisocoria
36
retinoblastoma
- Tumors that originate in the retina, can affect one or both eyes
◦ Arise when immature retinoblasts mature into
cancerous cells Most frequently diagnosed in children younger than 4 years of age, 40% arise from a heritable gene defect
37
Retinoblastoma
- Tumors that originate in the retina, can affect one or both eyes
◦ Arise when immature retinoblasts mature into
cancerous cells
- Most frequently diagnosed in children younger than 4 years of age, 40% arise from a heritable gene defect
38
signs and symptoms of retinoblastoma
◦ Pupil that appears red or white instead of black,
crossed eye, vision changes, enlarged pupil
39
Wilms Tumor/ Nephroblastoma
- Most common form of kidney cancer in children
- Most frequently diagnosed in children younger than 5 years old
- Tumors tend to be unilateral and large when diagnosed
40
signs and symptoms of Wilms Tumor/Nephroblastoma
◦ Asymptomatic, unilateral abdominal lump or mass,
blood in the urine, fever, diarrhea, urogenital infections, systemic symptoms including fever and malais
41
Osteosarcoma
- Tumors found in the bone that arise from inappropriate growth and development of immature bone cells
◦ Bone tissue is weaker than normal bone tissue and more
susceptible to fracture
◦ Typically affect the distal femur, proximal tibia or proximal humerus
42
Signs and symptoms of osteosarcoma
◦ Pathologic fracture = typically first presenting sign
◦ Long-term bone or joint pain that worsens at night; pain in
the lower femur or just inferior to knee in active youth, visible swelling (if osteosarcoma is large enough)
43
Treatment for Osteosarcoma
◦ Surgical excision of tumor; limb sparing
◦ Rotationplasty – in the event of an amputation
--> Use the foot/ankle as the knee joint in order to
assist with increasing functional mobility and
giving the child a functional, neurovascularly
intact knee joint
--> Greatly improves function and decreases energy
expenditure with a prosthesis
44
Ewing sarcoma
Malignant cancer found in both bone and soft tissue
◦ Typically begins in the long bones of the pelvis, legs or
arms, but can occur anywhere - Most common in adolescents and young adults
45
Signs and symptoms of Ewing sarcoma
◦ Pain and swelling near the affected area, bone pain
that worsens at night and with activity, fatigue, fever,
unintended weight loss, pathologic fracture
46
flow cart of Ewing sarcoma
When it arises in the soft tissue --> greater chance of metastatic spread --> reduces the chance of cure and survival
47
What is rhabdomyosarcoma
- Soft tissue sarcoma that arises from the mesenchymal cells destined to become striated muscle cells
- Tumors occur most frequently in head and neck region, urinary system, reproductive system, arms and legs
48
Signs and symptoms of rhabdomyosarcoma
◦ Head and neck: headache, bulging or swelling of eyes,
bleeding in the nose, throat or ears
◦ Urinary or reproductive system: difficulty urinating,
blood in urine, constipation, mass or bleeding from
rectum or vagina
◦ Arms and legs: swelling or lump, pain in affected area
49
what is cancer treatment dependent on
type of tumor present, location, and extent of disease
50
why is it important to understand disease severity and treatment protocols
◦ Allows PT to better anticipate adverse effects of treatment
◦ Enables PT to develop plans consistent with current and ANTICIPATED impairments and activity
limitation
51
Curative surgery
gross total resection
clear margins
52
palliative surgery
relieve pain, minimize symptoms, QoL
53
Implications for PT - need to understand
◦ Tumor location
◦ Impact to tissue – both healthy and cancerous
54
Implications for PT - knowledge of
◦ Surgical procedure --> aids in identifying impairments and possible impairments
◦ Presence of indwelling devices --> caution not to dislodge during PT treatment
55
Implications of PT - Anesthesia
◦ Pediatric patients may undergo anesthesia or light sedation for procedures, imaging studies and
radiation
◦ Following anesthesia, a child is at risk for falls --> consider this with scheduling your PT sessions
56
do we really have to learn radiation again
57
radiation implications for PT
fibrosis --> tissue injury
58
review chemo if you want
59
what is chemo most effective against
rapidly dividing cells
60
Bone Marrow, Stem Cell and Cord Blood Transplants
Healthy marrow or stem cells are infused into a patient’s blood stream
- Goal of transplant is engraftment
61
indications for Bone Marrow, Stem Cell and Cord Blood Transplants
◦ Patients with relapsed ALL and AML
◦ Patients with life-threatening disease
◦ Patients with neuroblastoma
◦ Some patients with brain tumors
62
pre-transplant conditioning
◦ High doses of chemo and/or radiation (Total body irradiation for some patients)
◦ Leaves patients severely myelo- and immune suppressed
63
post-transplant process
◦ Await engraftment
◦ Usually 12-17 days
◦ Patients are at higher risk of infection during this time b/c they are severely immunosuppressed
64
Side Effects of Bone Marrow and Stem Cell Transplant
Graft versus Host Disease (GVHD) Mucositis Nausea/vomiting Venous Occlusive Disorder Steroid induced myopathy Sterility Cardiac and pulmonary disease High risk of life threatening infection Secondary malignancies
65
theres a whole chart on impact of anticancer therapies on function
66
cancer rehabilitation across the continuum
diagnosis --> IP admission --> OP follow up --> re-admissions --> clinic visits --> end of treatment --> survivorship
67
lab values
- know the Childs values and adjust as necessary
68
2 most important ways to prevent infection spread
Cleaning all toys and mats prior to use and managing appropriate hand hygiene
69
limitations in cardiopulmonary system
– identified through observation
◦ Increased work of breathing, nasal flaring, changes in skin color during activity
◦ Decreased willingness to walk – need to use stroller or be carried
70
impairments in cardiopulmonary system
◦ Deconditioning
◦ Cancer-related fatigue
◦ Treatment related pulmonary complications
71
deconditioning assessment
◦ General cardiopulmonary tests and measures
◦ HR, O2 saturation, BP
◦ Standardized test:
◦ 6 minute walk test
◦ Timed Up and Go
◦ RPE
72
deconditioning intervention
◦ Aerobic
◦ Guidelines are the same as for typically developing children --> 60 minutes or more of physical activity per day at a moderate-to-vigorous
intensity
◦ Participation in sports and age-appropriate recreational
groups ◦ PE classes
73
assessment of cancer related fatigue
parent fatigue scale
childhood fatigue scale
fatigue scale - adolescent
74
intervention for cancer related fatigue
exercise
sleep hygiene
meditation
75
why do pulmonary complications occur
Due to radiation therapy to chest or total body irradiation; complication of bone marrow transplant
Common diagnoses: radiation pneumonitis, pulmonary fibrosis, lung graft versus host disease, bronchiolitis obliterans
76
assessment of pulmonary complications
◦ Chest wall measurements in various positions
◦ Posture
◦ Shoulder ROM
◦ Strength assessment specifically of core and proximal musculature
77
integument changes
- Bruising, pale complexion --> decreased platelets and RBC
◦ Poor wound healing, edema, open sores
78
common integument impairments associated with treatment
◦ Scar adhesion
◦ Graft versus Host Disease (GVHD)
◦ Radiation changes/burns
◦ Poor wound healing
79
graft versus host disease
- Occurs when the transplanted stem cells give rise to blood cells, which recognize tissue of the recipient as foreign and reject those tissues
- Antirejection drugs are given prophylactically during engraftment to prevent
- Allogenic transplant
80
Acute GVHD
◦ Rash, itchy skin, skin discoloration, dry mouth, mouth ulcers, diarrhea and weight loss, joint contracture, malabsorption
◦ Liver, skin and GI tract severely impaired
◦ Treated with high doses of glucocorticoids (side effects include infection, diabetes,
sleep disorders, osteoporosis, hyperglycemia and water retention)
81
chronic GVHD
◦ Occurs ~ 1 year or more post-transplant
◦ Presents similarly to acute
82
GVHD management
Skin injury prevention ROM Positioning Posture Mobility Joint play Flexibility
83
common MSK impairments
- steroid myopathy
- avascular necrosis
- post op ortho conditions
- bone instability
84
steroid myopathy
◦ Causes weakness to the proximal muscles of the upper and lower extremities
◦ S and S: symmetric, proximal muscle weakness, malaise, fatigue, absence of sensory complaints
85
Late effects of MSK system
Stunted growth Bone pain Joint stiffness Decreased bone density Gait alterations
86
When are neuromuscular symptoms notes in a child?
when they avoids movement of a particular body part, refuses to bear weight on an
extremity, does not respond due to not hearing, does not understand due to neurocognitive delay
87
Common neuromuscular impairments
◦ Chemotherapy Induced Peripheral Neuropathy
◦ Ataxia
◦ Spasticity
◦ Hemiplegia
88
Vincristine induced CIPN
can occur at any age, occur at within a week of receiving the 1st dose of vincristine or only after multiple doses have been administered
89
CIPN Assessment
◦ Ankle DF ROM
◦ Achilles reflex
◦ Sensation/vibration
◦ Foot positioning/alignment
◦ Gait
◦ Pediatric modified Total Neuropathy Score (peds-mTNS)
90
Pediatric modified Total Neuropathy Score (peds-mTNS)
◦ An assessment scale to measure CIPN in children with non-CNS cancers
◦ Assess sensory symptoms, functional symptoms, autonomic symptoms, light touch sensation, pin sensibility, vibration sensibility, strength
and deep tendon reflexes
◦ Most sensitive tool for assessing CIPN in peds
91
Treatment for CIPN
◦ Focus on fine motor dexterity, gait and balance stability, ongoing parent education
◦ Use of AFOs
◦ No treatment can cure or reverse nerve damage
92
Neurologic late effects
Neurocognitive impairments
◦ Lower IQ scores
◦ Poor attention/memory
◦ Poor eye hand coordination
◦ Behavioral problems Developmental delay
Pituitary issues
Seizures Headaches
93
bottom line
- Get to know your patient and their family – Build RAPPORT
- Understand the medical treatment and the organ systems impacted by the treatment, identify impairments and functional limitations, treat accordingly!
