INITIAL EVALUATION OF THE CHILD INITIAL EVALUATION OF THE CHILD WITH A SUSPECTED MALIGNANCYWITH A SUSPECTED MALIGNANCY

HEMATO - ONCOLOGY DIVISIONDEPARTEMENT OF CHILD HEALTH

MEDICAL SCHOOL UNIVERSITY OF SUMATERA UTARA

INTRODUCTIONINTRODUCTION

►► Each year Each year ±± 6500 children < 15 years : diagnosed 6500 children < 15 years : diagnosed with cancer in the USwith cancer in the USwith cancer in the US.with cancer in the US.

►► Cancer : the second leading caused death in Cancer : the second leading caused death in children.children.

►► > 65% of children diagnosed with cancer to now > 65% of children diagnosed with cancer to now to to be cured of their diseases.be cured of their diseases.

►► The diagnosis of cancer with a history & physical The diagnosis of cancer with a history & physical ►► The diagnosis of cancer with a history & physical The diagnosis of cancer with a history & physical examination.examination.

►► Environmental & genetics Environmental & genetics associated with the associated with the development of malignancydevelopment of malignancydevelopment of malignancy.development of malignancy.

►► Treatment : start after accurate diagnosis & Treatment : start after accurate diagnosis & staging.staging.

COMMON CHIEF COMPLAINTS GIVEN PARENTS THAT SUGGEST COMMON CHIEF COMPLAINTS GIVEN PARENTS THAT SUGGEST A PEDIATRIC CANCERA PEDIATRIC CANCER

Chief complaintChief complaint Suggested cancerSuggested cancer

Ch i d i f Ch i d i f L h ’ ll hi ti t iL h ’ ll hi ti t iChronic drainage from earChronic drainage from earRecurrent fever with bone painRecurrent fever with bone painMorning headache with vomitingMorning headache with vomitingL i k th t d ’ t d t tibi tiL i k th t d ’ t d t tibi ti

Langerhan’s cell histiocytosisLangerhan’s cell histiocytosisLeukemia,Ewings sarcoma, neuroblastomaLeukemia,Ewings sarcoma, neuroblastomaBrain tumorBrain tumorH d ki ’ H d ki ’ h d ki’ l h h d ki’ l h Lump in neck that does’nt respond to antibioticsLump in neck that does’nt respond to antibiotics

White dot in eyeWhite dot in eyeS ll f d kS ll f d k

Hodgkin’s or nonHodgkin’s or non--hodgki’s lymphoma, hodgki’s lymphoma, leukemialeukemiaRetinoblastomaRetinoblastomaNHL leukemiaNHL leukemiaSwollen face and neckSwollen face and neck

Mass in abdomenMass in abdomenPaleness & fatiguePaleness & fatigue

NHL, leukemiaNHL, leukemiaWilm’s tumor, neuroblastoma, hepatomaWilm’s tumor, neuroblastoma, hepatomaLeukemia, lymphomaLeukemia, lymphomaOsteosarcoma leukemiaOsteosarcoma leukemiaLimpingLimping

Bone painBone painBleeding from vaginaBleeding from vagina

Osteosarcoma, leukemiaOsteosarcoma, leukemiaLeukemia, Ewing sarcoma, neuroblastomaLeukemia, Ewing sarcoma, neuroblastomaRhabdomyosarcoma, Yolk sac tumorRhabdomyosarcoma, Yolk sac tumorHodgkin’s lymphomaHodgkin’s lymphomaWeight lossWeight loss

Mass in extremityMass in extremityHodgkin’s lymphomaHodgkin’s lymphomaRhabdomyosarcomaRhabdomyosarcoma

PRESENTING SIGNS & SYMPTOM OF SOME COMMON PEDIATRIC PRESENTING SIGNS & SYMPTOM OF SOME COMMON PEDIATRIC CANCERS & THEIR DIFF DIAGNOSISCANCERS & THEIR DIFF DIAGNOSISCANCERS & THEIR DIFF. DIAGNOSISCANCERS & THEIR DIFF. DIAGNOSIS

PRESENTING SIGNS PRESENTING SIGNS OR SYMPTOMSOR SYMPTOMS

COMMON DIAGNOSISI COMMON DIAGNOSISI (NONMALIGNAT CONDITIONS)(NONMALIGNAT CONDITIONS)

CANCERCANCER

Headache, morning Headache, morning Migraine, sinusitisMigraine, sinusitis Brain tumorBrain tumoreadac e, o geadac e, o gvomitingvomitingLymphadenopathyLymphadenopathyBone painBone pain

g a e, s us t sg a e, s us t sInfectionInfectionInfection, traumaInfection, traumaConstipation, kidnet cyst, full bladderConstipation, kidnet cyst, full bladder

a tu oa tu oLymphoma, leukemiaLymphoma, leukemiaBone tumor, leukemiaBone tumor, leukemiaWilm’s tumor, neuroblastomaWilm’s tumor, neuroblastoma

Abdominal massAbdominal massMediastinal massMediastinal massPancytopeniaPancytopenia

Constipation, kidnet cyst, full bladderConstipation, kidnet cyst, full bladderInfection, cystsInfection, cystsInfectionInfectionCoagulation disorders, platelet Coagulation disorders, platelet

Wilm s tumor, neuroblastomaWilm s tumor, neuroblastomaLymphomasLymphomasLeukemiaLeukemiaLeukemia, neuroblastomaLeukemia, neuroblastomay py p

BleedingBleedingBack painBack pain

Coagulation disorders, platelet Coagulation disorders, platelet disorders, ITPdisorders, ITPTraumaTrauma

Leukemia, neuroblastomaLeukemia, neuroblastomaLeukemia, lymphoma, CNS Leukemia, lymphoma, CNS tumor or extension of tumor or extension of abdominal tumor into spinal abdominal tumor into spinal cordcord

1. LEUKEMIA

► Incidence :4/100.000 children < 15 years,the peak incidence is 4/100.000 children 15 years,the peak incidence is between 2 & 5 yrs of age. ALL (75%) & AML (20 %) of the total number of cases leukemia leukemia.

► Clinical manifestation :Marrow invasion : Anemia,thrombocytopenia, leukopenia, neutropenia

Pallor , FatigueTachycardia fever bleedingTachycardia, fever, bleedingHepatosplenomegaliCNS : Morning headache, cranial n. VI palsy, vomiting, papilledemapapilledema

► Diagnostic studies :► Diagnostic studies :Complete blood count (CBC), differential, review peripheral blood smear.Bone marrow aspiration The presence of 25% or more blasts.Metabolic panel (liver function electrolyte renal Metabolic panel (liver function, electrolyte, renal function).Coagulation profileg pBlood culture if febrile.Chest radiograph : to evaluate the possible presence of

di i l mediastinal mass.

COMMON CLINICAL & LABORATORY FEATURES OF ALL AT COMMON CLINICAL & LABORATORY FEATURES OF ALL AT PRESENTATIONPRESENTATION

FindingsFindings Percentage of patientPercentage of patientFindingsFindings Percentage of patientPercentage of patientFeverFeverPallorPallorBleedingBleeding

606040405050gg

Bone painBone painLymphadenopathyLymphadenopathySplenomegalySplenomegaly

252550506060

HepatosplenomegalyHepatosplenomegalyWhite blood cell count (µl)White blood cell count (µl)

< 10.000< 10.00010 000 10 000 –– 49 00049 000

7070

5050303010.000 10.000 –– 49.00049.000

≥ 50.000≥ 50.000Hb (g/dl)Hb (g/dl)

7.07.0

30302020

40407.0 7.0 –– 11.011.0> 11.0> 11.0

Platelet (µl)Platelet (µl)

45451515

< 20.000< 20.00020.000 20.000 –– 99.00099.000≥ ≥ 100.000100.000

303045452525

2.RETINOBLASTOMA

► Incidence : 1/18,000 live birth in the United State.► The most common : < 2 years► The most common : < 2 years.► Bilateral : 20-30 % of patients.► The tumor from retina.

► Clinical manifeatation :A white pupilay reflex : leukocoria/ Cat’s eyes reflexA white pupilay reflex : leukocoria/ Cat s eyes reflex.StrabismusOrbital inflammation, hyphemaProptosisProptosisPain

LEUKOCORIA

3. LYMPHOMAS

► 10 – 12% of malignancies in children.► 60 % : Non-Hodgkin’s Lymphoma (NHL) of all lymphomas.► Clinical manifestation :

HODGKIN’S LYMPHOMAS► Incidence :

with a peak in 15 -34 years and 55 – 74 yearswith a peak in 15 34 years and 55 74 years.Slight male predominant.Rarely in children younger than 5 years.

Ch t i d b i l t f th l h ► Characterized by progressive enlargement of the lymph nodes with extension to contiguous nodes.

► Cellular immunodefficiency is present in >50%.d l d h 60% f h ► Mediastinal adenopathy : 60% of the cases.

HODGKIN’S LYMPHOMASE l t f th l h dEnlargement of the lymph nodes

HODGKIN’S LYMPHOMAHODGKIN’S LYMPHOMA

NON-HODGKIN’S LYMPHOMA

► 1.5 times as common of Hodgkin’s lymphomas.► The incidence in children increasea with age.► he nc dence n ch ldren ncreasea w th age.► Children with congenital or acquired dysfunction of

immune system : >>>► Mayor hystologic subtypes : large cwll, lymphoblastic,

undifferentiated.

► Clinical manifestation :NHLs can arise any where in the body , primarily in the L y y , p m ylymph nodes, Waldeyer ring, peyer patches, & bone marrow.N iti & bd i l di t ti i Nausea, vomiting, & abdominal distention, superior vena cava syndromes.

LIMFOMA NON HODGKINENLARGEMENT OF LYMPH NODES

4. NEUROBLASTOMA

► The most common solid tumor in childhood outside the CNS, 7% of all malignancies.

► The peak incidence :2 years of age.

Cl l f ► Clinical manifestation :It present as :

A tumor mass along symphathetic ganglia- A tumor mass along symphathetic ganglia.- An abdominal mass (70%).

Tumor can also be found : neck, thorax & pelvis.Tumor can also be found : neck, thorax & pelvis.The signs & symptoms depend on the site of the tumor, size & degree of spread.Hepatomegaly, anemia, a coagulopathy, bone pain.

Horner’s syndrome : contracted pupil, ptosis, enopthalmus, anhidrosis).Racoon eyes with periorbtal hemorrhage.

► Diagnostic evaluation :► Diagnostic evaluation :HistoryPhysical examinationPhysical examinationLaboratorium studies Diagnostic imaging : CT scang g gBiopsy

RACOON EYES

BONE MARROWBONE MARROW

5. NEFROBLASTOMA (WILMS TUMOR)

► It’s a tumor of the developing kidney.► The second retroperitoneal tumor in children.► Approximately : 6% of childhood malignancies.► O s in n hild n : 1 & 5 s► Occurs in young children : 1 & 5 years.

► Cinical manifestation :► Cinical manifestation :Abdominal massAbdominal pain, malise, hypertension, microscopic p , , yp , phematuria.Bleeding : Anemia, pallor, fatgue Th b l hThrombus, polycythemia.

WILMS TUMOR GLOMERULUS INWILMS TUMORWILMS TUMOR

6. RABDOMYOSARCOMA

► Incidence : 5 – 8% of childhood cancers.► It’s occur at virtually any anatomic site► It s occur at virtually any anatomic site.► Most often found : head & neck (40%), genitourinary

tract (20%), extremities (20%), trunk (10%).

► Clinical manifestation :lA mass that may or may not be painful.

Symptoms due to displacement or obstruction of normal structurenormal structure.Nasal congestion, epistaxis, mouth breathing, cranial nerve paralysis, blindess, headache, vomiting, trismus, etc.

RHABDOMYOSARCOMA

7. TERATOMA

► Germ cell neoplasma >> in the children.► Incidence : 4.2 cases permillion population per year.► In males : most common in white.

l l ► Male : female = 1:4

► Clinical manifestation :► Clinical manifestation :Present as masses, depends on location.AFP is elevatedAFP is elevated.

SACROCOCCYGEAL TERATOMA

8. OSTEOSARKOMA8 OS EOSARKOMA

► The high risk period : the adolescent growth spurt.g p g p► Patient : taller than their peers of similar age.► Etiology : unknown.

► Clinical manifestation :P i & lli Pain & swelling : >>>Initial complaints : sport injury & sprain.Limitation of motion joint effusion tenderness Limitation of motion, joint effusion, tenderness, warmth.

OSTEOSARKOMA

OSTEOSARCOMA

Swelling