Cancer

Question 1

Discuss factors that differentiate childhood cancer from adult cancer.

Answer 1

Pediatric cancers most often arise from primitive embryonal (mesodermal) and neuroectodermal tissues, resulting in leukemias, lymphomas, sarcomas, or central nervous system tumors.

Adult cancers arise from epithelial cells, causing cancer.

Question 2

Childhood Cancer

Answer 2

• usually affects the tissues
• histologic type: embryonal, leukemia, lymphoma
• sites: blood, lymph, bone, brain, kidney
• only small amount from enviroment
• unknown prevention
• usually incidental or accidental detection
  -latent period: short
• extent of disease: metastasis is often present at diagnosis
  Treatment: very responsive

Question 3

Adult Cancer

Answer 3

• usually in organ
• epithelial in origin
• great, lung, prostate, bowel, bladder
• environment: strong influence
• 80% preventable
• very early detection possible
• Latent period: can be very long
• metastasis is less often pressent
• treatment: less responsive

Question 4

Acute Lymphoblastic Leukemia

Answer 4

-most COMMON form of cancer in children, 85%
- most common in white children
- T celll, B cell, early pre-B cell, or pre-B cell
Overall cute: over 70*
-Prognosis is based on the WBC count at diagnosis, the type of cytogenetic factors and immunophenotype, the age at diagnosis, and the extent of extramedullary involvement. Generally, the higher the WBC count at diagnosis, the worse the prognosis. Children between 1 and 9 years of age and with a WBC count less than 50,000 at diagnosis have the best prognosis. When a child experiences a relapse, the prognosis becomes poorer. Complications include infection, hemorrhage, poor growth, and CNS, bone, or testicular involvement.

Question 5

Pathophysiology: ALL

Answer 5

• exact cause unknown; genetic factors and chromosome abnormalities pay role in its development
  ALL, abnormal lymphoblasts abound in the blood-forming tissues. The lymphoblasts are fragile and immature, lacking the infection-fighting capabilities of the normal WBC. The growth of lymphoblasts is excessive and the abnormal cells replace the normal cells in the bone marrow. The proliferating leukemic cells demonstrate massive metabolic needs, depriving normal body cells of needed nutrients and resulting in fatigue, weight loss or growth arrest, and muscle wasting. The bone marrow becomes unable to maintain normal levels of RBCs, WBCs, and platelets, so anemia, neutropenia, and thrombocytopenia result. As the bone marrow expands or the leukemic cells infiltrate the bone, joint and bone pain may occur. The leukemic cells may permeate the lymph nodes, causing diffuse lymphadenopathy, or the liver and spleen, resulting in hepatosplenomegaly. With spread to the CNS, vomiting, headache, seizures, coma, vision alterations, or cranial nerve palsies may occur

Question 6

adverse effects L ALL

Answer 6

changes in personality, headache, irritability, dizziness, persistent nausea, vomiting, seizures, lethargy, alter conscious, may indicate CNS infiltration. Immediately tell physician.

Question 7

Therapeutic Management: ALL

Answer 7

giving chemotherapy to eradicate the leukemic cells and restore normal bone marrow function. Treatment is divided into 3 stages. CNS prophylaxis is provided at each stage in order to prevent metastasis to the CNS (Craddock et al., 2018). The length of treatment and choice of medications are based on the child’s age, risk category, and subtype determined by bone marrow analysis. Table 24.7 discusses the stages of leukemia treatment. For relapsed or less responsive leukemia, HSCT may be necessary

Question 8

What is the purpose of Induction

Answer 8

Rapid induction of complete remission ; 3-4 weeks

Question 9

What are medications for induction?

Answer 9

Oral steroids, IV vincristine, IM L-asparaginase, daumycin (high risk)

Question 10

What is the purpose consolidation?

Answer 10

strengethen remisssion, reduce leukemic cell burden, varies

Question 11

what type of medication for consolidation?

Answer 11

High-dose methotrexate, 6-mercaptopurine; possibly cyclophosphamide, cytarabine, asparaginase, thioguanine, epipodophyllotoxins

Question 12

What is the maintenance stage?

Answer 12

Eliminate all residual leukemic cells ; 2-3 years

Question 13

What medications for Maintainene cancer?

Answer 13

Low dose: daily 6-mercaptopurine, weekly methotrexate, intermittent IV vincristine, and oral steroids

Question 14

What is CNS prophylaxis?

Answer 14

reduce risk of development of CNS disease ; given periodcally

Question 15

Medications for CNS prophylaxis?

Answer 15

Intrathecal chemotherapy; cranial radiation is used infrequently

Question 16

S/s of ALL

Answer 16

Fever (may be persistent or recurrent, with unknown cause) Recurrent infection Fatigue, malaise, or listlessness Pallor Unusual bleeding or bruising Abdominal pain Nausea or vomiting Bone pain Headach

Question 17

Nursing Alert** ALL

Answer 17

Have the child lie flat for 30 minutes after a lumbar puncture and increase fluid intake for 24 hours after the procedure to decrease incidence of headache

Question 18

Laboratory and Diagnostic Tests

Answer 18

CBC: abnormal findings include low hemoglobin and hematocrit, decreased RBC count, decreased platelet count, and elevated, normal, or decreased WBC count Peripheral blood smear may reveal blasts. Bone marrow aspiration: stained smear from bone marrow aspiration will show greater than 25% lymphoblasts. Bone marrow aspirate is also examined for immunophenotyping (lymphoid vs. myeloid, and level of cancer cell maturity) and cytogenetic analysis (determines abnormalities in chromosome number and structure). Immunophenotyping and cytogenetic analysis are used in the classification of the leukemia, which helps guide treatment. Lumbar puncture will reveal whether leukemic cells have infiltrated the CNS. Liver function tests and blood urea nitrogen (BUN) and creatinine levels determine liver and renal function, which, if abnormal, may preclude treatment with certain chemotherapeutic agents. Chest radiography may reveal pneumonia or a mediastinal mass.

Question 19

**

Answer 19

The child with leukemia undergoes frequent implantable port accesses for blood draws and chemotherapy, bone marrow aspirations for assessment of blood cell status, and lumbar punctures for laboratory studies and intrathecal medication administration. To decrease trauma produced by these repetitive painful procedures, utilize EMLA (eutectic mixture of local anesthetics) cream appropriately. Teach the child’s primary caregiver to apply the cream to the implantable port site 30 minutes to 1 hour prior to the child’s clinic appointment time. Apply EMLA cream to the posterior hip or lumbar spine, 1–3 hours prior to bone marrow aspiration or lumbar puncture.

Question 20

Alert

Answer 20

Blood products administered to children with any type of leukemia should be irradiated, cytomegalovirus (CMV) negative, and leukodepleted. This treatment of blood products before transfusion will decrease the amount of antibodies in the blood, an important factor in preventing GVHD should HSCT become necessary at a later date

Question 21

ALL: Reducing Pain Nursing Management

Answer 21

Children and teens with leukemia suffer pain related to the disease as well as the treatment. Chemotherapy drugs commonly used in leukemia may cause peripheral neuropathy and headache. Lumbar puncture and bone marrow aspiration, which are periodically performed throughout the course of treatment, also cause pain. The most common areas of pain are the head and neck, legs, and abdomen (probably from protracted vomiting with chemotherapy). Use distraction techniques, such as listening to music, watching TV, or playing games, to help take the child’s mind off the pain. Administer mild analgesics such as acetaminophen for acute episodes of pain. Using EMLA cream prior to venipuncture, port access, lumbar puncture, and bone marrow aspiration may decrease procedure-related pain events. In addition, applying heat or cold to the painful area is usually acceptable. Administer narcotic analgesics, as prescribed, for episodes of acute severe pain or for palliation of chronic pain.

Question 22

** ALL Alert

Answer 22

Administer medications as ordered using the least invasive method possible to avoid pain (intramuscular, subcutaneous, and rectal route should be avoided in the child with thrombocytopenia).

Question 23

** ALL Alert

Answer 23

Have the child lie flat for 30 minutes after a lumbar puncture and increase fluid intake for 24 hours after the procedure to decrease incidence of headache.

Question 24

Nursing Management: ALL

Answer 24

managing disease complications such as infection, pain, anemia, bleeding, and hyperuricemia and the many adverse effects related to treatment. Many children require blood product transfusion for the treatment of severe anemia or low platelet levels with active bleeding. Individualize nursing care based on the diagnoses, interventions, and outcomes presented in Nursing Process Overview section earlier in the chapter, depending on the child’s response to the disease and chemotherapy. Refer to the Nursing Process Overview section for further information related to managing the adverse effects of chemotherapy.

Question 25

Acute Myelogenous Leukemia

Answer 25

• second most common type; peaks during adolescent years.
  Affects the MYELOID cells precursors in the bone marrow resulting in fast growing cells
• survival is 50%

Question 26

Complications of AML

Answer 26

treatment resistance, infection, hemorrhage, and metastasis.
AML requires intense bone marrow suppression and prolonged hospitalization because AML is less responsive to treatment than ALL. Toxicity from treatment is more common in AML and is likely to be more serious than with ALL. Empiric broad-spectrum antibiotics and prophylactic platelet transfusions may be prescribed. After remission is achieved, children require intensive chemotherapy to prolong the duration of remission. HSCT is often required in children with AML

Question 27

** Alert AML

Answer 27

At the time of diagnosis, some children with AML present with a WBC count above 100,000 (hyperleukocytosis); this results in venous stasis and backup of blast cells in small vessels, causing hypoxia, hemorrhage, and lung or brain infarction. Hyperleukocytosis is a medical emergency. These children require leukapheresis to decrease hyperviscosity by quickly decreasing the number of circulating blasts

Question 28

Nursing Assessment: AML

Answer 28

Explore the health history for common signs and symptoms, including recurrent infections, fever, or fatigue. Explore the medical history for risk factors, such as Hispanic race, previous chemotherapy, and genetic abnormalities such as Down syndrome, Fanconi anemia, neurofibromatosis, Wiskott–Aldrich syndrome, and Diamond–Blackfan anemia. Perform a thorough physical examination. Note skin pallor and salmon-colored or blue-gray papular lesions. Palpate the skin for subcutaneous rubbery nodules. Palpate for lymphadenopathy. Note headache, visual disturbance, or signs of increased intracranial pressure, such as vomiting, which may indicate CNS involvement. Upon diagnosis of AML, the child’s WBC count is typically extremely elevated

Question 29

Nursing Management: AML

Answer 29

Nursing management of the child with AML is similar to that of the child with ALL. Nursing interventions focus on managing the adverse effects of treatment and preventing infection. Refer to the Nursing Process Overview section earlier in the chapter for appropriate interventions.

Question 30

Neuroblastoma

Answer 30

Neuroblastoma, a tumor that arises from embryonic neural crest cells, is the most common extracranial solid tumor in children (Russell & McLean, 2019). It most frequently occurs in the abdomen, mainly in the adrenal gland, but it may occur anywhere along the paravertebral sympathetic chain in the chest or retroperitoneum. When diagnosed past infancy or early toddlerhood, by the time of diagnosis, the neuroblastoma has usually already metastasized. Neuroblastoma is the second most frequently occurring solid tumor in children; 90% of cases are diagnosed before the age of 5 yearsMetastasis to the bone is a worse prognostic factor than metastasis to the skin, liver, or bone marrow. Children who relapse after initial treatment also tend to have a dismal prognosis. In addition to metastasis, complications may include nerve compression, resulting in neurologic deficits.

Question 31

Nursing Assessment: Neuroblastoma

Answer 31

Presenting signs and symptoms of neuroblastoma depend on the location of the primary tumor and the extent of metastasis. Often parents are the first to notice a swollen or asymmetric abdomen. Elicit the health history, Note neck or facial swelling, bruising above the eyes, or edema around the eyes (metastasis to skull bones). Inspect the skin for pallor or bruising (bone marrow metastasis) and document cough or difficulty breathing. Auscultate the lungs for wheezing. Palpate for lymphadenopathy, especially cervical. Palpate the abdomen, noting a firm, nontender mass. Palpate for and note hepatomegaly or splenomegaly if present.documenting bowel or bladder dysfunction, especially watery diarrhea, neurologic symptoms (brain metastasis), bone pain (bone metastasis), anorexia, vomiting, or weight loss.

Question 32

Diagnostic Test

Answer 32

CT scan or MRI to determine site of tumor and evidence of metastasis Chest radiograph, bone scan, and skeletal survey to identify metastasis Bone marrow aspiration and biopsy to determine metastasis to the bone marrow 24-hour urine collection for homovanillic acid (HVA) and vanillylmandelic acid (VMA); levels will be elevated.

Question 33

Nursing Management: Neuroblastoma

Answer 33

Postoperative nursing care depends on the site of tumor removal, which is most often the abdomen. Provide routine care after abdominal surgery. Refer to the Nursing Process Overview section earlier in the chapter for nursing care related to the effects of chemotherapy and radiation. Provide emotional support and possible referrals to help children and families cope with a potentially poor prognosis (due to the fact that the disease has often metastasized significantly by the time of diagnosis

Question 34

Atraumatic Care** Neuroblastoma

Answer 34

The child with cancer often undergoes a large number of painful procedures related to laboratory specimens and treatment protocols. To assist the child to cope with these procedures, provide distraction in the form of reading a favorite book or playing a favorite movie or musical selection.

Question 35

Ewing sarcoma

Answer 35

Ewing sarcoma is a highly malignant bone tumor. It is rarer than osteosarcoma, accounting for about 30% of childhood bone tumors (Craddock et al., 2018). It occurs most frequently in the pelvis or femur (Russell & McLean, 2019). About 25% of children demonstrate metastasis; the lungs, bone, and bone marrow are the most common sites (Craddock et al., 2018). The prognosis for Ewing sarcoma depends on the extent of metastasis.

Question 36

Ewing sarcoma Treatment

Answer 36

Radiation, chemotherapy, and surgical excision are usually used in combination. Treatment varies depending on the site of the primary tumor and the extent of metastasis at diagnosis. Myeloablative chemotherapy (which destroys the child’s marrow) may be used for metastatic disease, followed by a stem cell rescue transplant.

Question 37

Ewing sarcoma Nursing Management

Answer 37

Before treatment begins, discourage active play or weight bearing on the affected extremity to avoid pathologic fracture at the tumor site. Nursing management focuses on addressing the adverse effects of treatment (refer to the Nursing Process Overview section). Give honest and direct answers to teens with Ewing sarcoma who ask questions about their disease. These children will undergo intensive therapy and spend a great deal of time in the hospital. Depending on the age of the child, fantasy play, art or pet therapy, drama, writing, humor, and/or music may help the child to work through the psychological impact of this disease. Refer to the Nursing Process Overview section earlier in the chapter for additional interventions, which should be individualized depending on the child’s and family’s response to the disease process and treatment.

Question 38

Wilms Tumor

Answer 38

Wilms tumor is the most common renal tumor, the second most common abdominal solid tumor in children, and most commonly occurs between the ages of 2 and 5 years (Hackney et al., 2017). It usually affects only one kidney (Fig. 24.18). The etiology is unknown, but some cases occur via genetic inheritance. Associated anomalies may occur with Wilms tumor. Wilms tumor demonstrates rapid growth and is usually large at diagnosis. Metastasis occurs via direct extension or through the bloodstream. Wilms tumor most commonly metastasizes to the perirenal tissues, liver, diaphragm, lungs, abdominal muscles, and lymph nodes.

Question 39

Complications Wilms Tumor

Answer 39

metastasis or complications from radiation therapy such as liver or renal damage, female sterility, bowel obstruction, pneumonia, or scoliosis.

Question 40

Therapeutic Management: Wilms Turmor

Answer 40

Surgical removal of the tumor and affected kidney (nephrectomy) is the treatment of choice and also allows for accurate staging and assessment of tumor spread. Radiation or chemotherapy may be administered either before or after surgery.

Question 41

Physical Examination: Wilms Tumor

Answer 41

Measure blood pressure; hypertension occurs in 25% of children with Wilms tumor (Craddock et al., 2018). Inspect the abdomen for asymmetry or a visible mass. Observe for associated anomalies as noted above. Auscultate the lungs for adventitious breath sounds associated with tumor metastasis. Palpate for lymphadenopathy.

Question 42

Wilms Tumor Nursing Alert**

Answer 42

Avoid palpating the abdomen after the initial assessment preoperatively. Wilms tumor is highly vascular and soft, so excessive handling of the tumor may result in tumor seeding and metastasis.

Question 43

Labs/Diagnostic Testing

Answer 43

Renal or abdominal ultrasound to assess the tumor and the contralateral kidney
CT scan or MRI of the abdomen and chest to determine local spread to lymph nodes or adjacent organs, as well as any distant metastasis
CBC, BUN, and creatinine: usually within normal limits

Urinalysis: may reveal hematuria or leukocytes

24-hour urine collection for HVA and VMA to distinguish the tumor from neuroblastoma (levels will not be elevated with Wilms tumor

Question 44

Nursing Management Wilms Tumor

Answer 44

Postoperative care of the child with Wilms tumor resection is similar to that of children undergoing other abdominal surgery. Assessment of remaining kidney function is critical. The child may have adverse effects related to chemotherapy or radiation. Refer to the Nursing Process Overview section to individualize care for the child based on the child’s response to therapy.

Question 45

Nursing Alert** Wilms

Answer 45

To avoid injuring the remaining kidney, children with a single kidney should not play contact sports.

Question 46

Osteosarcoma

Answer 46

Osteosarcoma accounts for 60% of bone cancer in children, occurring most frequently in adolescents, males, and Whites (Craddock et al., 2018). It presumably arises from the embryonic mesenchymal tissue that forms the bones. The most common sites are in the long bones, particularly the proximal humerus, proximal tibia, and distal femur

Question 47

Complications: osteosarcoma

Answer 47

metastasis, particularly to the lungs and other bones, and recurrence of disease within 3 years, primarily affecting the lungs

Question 48

Treatment: Osteosarcoma

Answer 48

Surgical removal of the tumor is necessary. Chemotherapy is often administered before surgery to decrease the size of the tumor; it is usually administered after surgery to treat or prevent metastasis. Radiation is not helpful. The type of surgery performed depends on the tumor size, extent of disease outside of the bone, distant metastasis, and skeletal maturity. Radical amputation may be performed, but often teens undergo a limb-sparing procedure

Question 49

Labs?

Answer 49

CT scan or MRI to determine the extent of the lesion and to identify metastasis Bone scan to determine the extent of malignancy

Question 50

Assessment: Osteosarcoma

Answer 50

ascertaining when pain, limp, or limitation of motion was first noticed. Dull bone pain may be present for several months, eventually progressing to limp or gait changes. Inspect the affected limb for erythema and swelling. Palpate the affected area for warmth and tenderness and to determine the size of the soft tissue mass, if also present. As with other pediatric cancers, a thorough physical examination is warranted to detect other abnormalities that may indicate metastasis.

Question 51

Nursing Management: Osteosarcoma

Answer 51

The adolescent will generally be quite anxious about the possibility of amputation and even about the limb salvage procedure. Present preoperative teaching at the adolescent’s developmental level and ensure that he or she is included in planning treatment. Regardless of the type of surgery performed, provide routine orthopedic postoperative care. Educate the adolescent and parents on the care of the stump, if amputation is necessary, and ensure that the teen becomes competent in crutch walking. A prosthesis may be ordered. The adolescent will need time to adjust to these significant body image changes and may benefit from talking with another teen who has undergone a similar procedure. Support the teen in choosing clothing that may camouflage the prosthesis while still allowing the teen to appear fashionable. Provide emotional support, as the teen’s maturity level allows him or her to understand the severity of the disease. Peer support groups are often helpful, as teens value their peers’ opinions and enjoy being part of a group. Examples of comprehensive online support groups are