Oncology Flashcards
What are contributors to CA
- chemicals (asbestos, benzene from petroleum products, radon)
- Radiation
- Viruses (EBV, HepB, HPV)
- Genetics
__ accelerate cell growth and division
Oncogenes
*When any of these genes are mutated, abnormal cells may be allowed to reproduce leading to unchecked growth of poorly differentiated cells, which is cancer.
____ detect abnormal cells and prompt cell suicide so the abnormal cell does not have the opportunity to replicate.
Tumor suppressor genes and DNA repair genes
*When any of these genes are mutated, abnormal cells may be allowed to reproduce leading to unchecked growth of poorly differentiated cells, which is cancer.
An excellent example of mutation in the ___ gene is the BRCA 1 and 2 genetic mutations implicated in breast and ovarian cancer in women, in which the gene is inactivated.
tumor suppressor
85% of pediatric cancer patients present with:
- Fever
- Bone pain/new onset limp
- Headache/morning vomiting
- Lump/mass
- Pupillary white reflex
*While cancer is a fearful diagnosis, and should be on the differential for those presentations
Describe the initial lab presentation of ALL
- have at least 2-3 cell lines down
2. lymphoblasts present in peripheral blood smear
Presentation of ALL
- fever (usually persistent or recurrent)
- infections
- easy bruising
- obvious petechial/purpuric rashes
- Bone pain
- new onset limp/joint pain
- easily fatigued
- Generalized LAD
- hepatosplenomegaly
PE findings of ALL
- generalized LAD including axillary, supra/infra-clavicular, inguinal
- hepatosplenomegaly (as lymphoblasts infiltrate the lymph node, spleen and liver)
It is thought that the time lag between onset of lymphoblasts in the bone marrow and patient onset of symptoms/clinic presentation is ___
not long- less than 1 month.
___ is the most common cancer in children and the most common blood cancer, much higher than ___
Acute lymphoblastic leukemia (ALL)
acute myelogenous or chronic myelogenous leukemia.
Describe the prognosis of ALL
- Outcomes for these kids are good, with between 80-95% being cured.
- Treatment is usually 2 years in length for girls, 3 years for boys due to the risk of testicular recurrence.
Describe the treatment of ALL
Treatment consists of chemotherapy, both inpatient and outpatient, and may progress to hematopoietic stem cell transplant for some children.
-Tx ~2yrs in girls and ~3yrs in boys due to risk of testicular recurrence
DDX of LAD
- localized or systemic infection (bacterial or viral)
- JIA
- a cyst
- Tumor (benign or malignant)
- Scalp laceration
- EBV
- HIV
- TB
- ALL
- hodgkin’s
A concerning history and exam of LAD
- persistent (>4-8 weeks) or progressive LAD
- size >2cm
- generalized
- non-tender
- firm, rubbery or rock-hard,
- several lymph nodes that appear to be connected together (matted), or
- fixed,
- LAD in unusual areas such as axillary, infra- or supraclavicular or inguinal.
*We often see so-called “shotty” LAD in pediatrics, which feels like small pea-size LAD in the cervical area, and these don’t raise much concern.
Overlying erythema on LAD suggests __
abscess or lymphadenitis
Labs for LAD
- CBC
- ESR (LT inflammation)
- EBV titers
- PPD
- LDH and
- uric acid
- CXR
- US of the node
___ are indicative of high cell turnover and a positive result would be indicative of malignancy
LDH and uric acid
Describe the break down of pediatric lymphomas
40% Hodgkin's 60% Non-Hodgkin's -<15% large cell lymphoma -20-40% lymphoblastic lymphoma -40-50% Burkitt's Lymphoma
Hodgkin’s lymphoma is associated, in both children and adults, with so-called “B-symptoms” of:
- weight loss
- fevers
- night sweats
Why is a PPD indicated in the work up of LAD?
active TB and B-symptoms are very similar (Wt. loss, fevers, night sweats)
Why do you need a CXR in the work up for LAD
- look for mediastinal masses which are common in lymphoma
The lymphoblastic lymphoma listed under non-Hodgkin’s lymphoma is the same pathology as ALL, except for:
a decreased percentage (or infiltration) of the bone marrow with lymphoblasts.
Treatment of pediatric lymphoma consists of
- chemotherapy
- radiation in select cases, and
- possible bone marrow transplant (BMT)
ANY abdominal mass in a child is ___ until proven otherwise.
a malignancy
*constipated children often have a sausage-shaped mass of stool in their LLQ, but this bears a repeat exam after treatment for their constipation.
DDX of a pediatric abdominal mass
- Hydronephrosis
- PKD
- Malignancy (Wilm’s tumor MC)
- Infectious splenomegaly
- Liver disease
- AV malformation
- neuroblastoma
- lymphoma
- germ cell tumor
- constipation
Wilm’s tumors are usually seen in __
young children (2-5y)
Tx of Wilm’s Tumors
- Surgical removal of tumor and kidney
- Chemo
- possibly radiation
___ is a tumor of undifferentiated sympathetic nervous tissue, which presents in various ways in young children
Neuroblastoma
What is the median age of a neuroblastoma
22 months
Because nervous tissue does need some time to differentiate, when neuroblastomas found in ___, they may spontaneously remit.
children <12m
Sites of neuroblastomas
- Adrenal gland, presenting as an abdominal mass (MC)
- Paraspinous
- Cervical regions
- Posterior mediastinum
- but metastases are common, so patients may present with bony metastasis,
- liver or
- lymph node involvement, or
- a subcutaneous nodule.
Neurblastomas may present with
- prolonged severe watery diarrhea or
2. catecholamine-induced hypertension due to the tumor consisting of sympathetic tissue.
Treatment of neuoblastomas
- Surgical resection
- Chemo
- Possible radiation or
- BMT
Malignant brain tumors usually occur in children ___, and ___% of children will have an abnormal neurologic exam at the time of presentation.
<9y/o
94%
Symptoms of brain tumors
- headache
- irritability or
- lethargy,
- a.m. vomiting,
- focal seizures,
- hemiparesis,
- ataxia,
- visual disturbances,
- gaze paralysis,
- unexplained changes in personality or school performance.
- papilledema
Concerning HA symptoms
- Age <3y/o
- A.M. HA
- HA awakening pt from sleep
- w/ AM vomiting
- change in quality, frequency, or pattern of HA
The average delay in diagnosis of brain tumor is ___, so be vigilant about including a neurologic exam in patients with H/A and/or vomiting, including a __
6 months
fundoscopic exam to look for papilledema
Most children __ can cooperate with a fundoscopic exam.
4y+
Tx of brain tumors
- Surgery
- Chemo
- Radiation
DDX of bone pain
- Growing pains
- Trauma
- Synovitis due to bacteria or inflammation
- Reactive arthritis
- rheumatological disease
- Cancer (leukemia, neuroblastoma, osteosarcoma, Ewing’s sarcoma)
Bone pain occurs in up to __% of patients with leukemia as the cancer cells infiltrate the bone marrow.
30%
concerning bone pain symptoms
- persistent or progressive
- occurring at night
- associated with swelling
- mass
- Decreased ROM
Labs for bone pain
- CBC
- ESR
- LDH
- plain film X-ray
- +/- It may become necessary to do a CT scan, MRI or bone scan.
How do osteosarcomas appear on Xrays
have a “sunburst” pattern on x-ray
*MC in long bone
Osteosarcomas are more common in the __ bones, with a peak incidence in ___
long
adolescents
Ewing’s sarcoma are more common in__, but more commonly effect the ___
adolescents
pelvis or shoulder.
How do Ewing’s Sarcoma appear on Xrays
They have an “onion peel” pattern on x-ray.
Tx of osteosarcoma or Ewing’s sarcoma
- Surgery
- +/- Amputation (limb salvage may be possible)
- Chemo
- Radiation
___ is a malignancy of skeletal muscle
Rhabdomyosarcoma
Describe the peak incidence of Rhabdomyosarcoma
bi-modal peak incidence in young children 2-5yrs and adolescents
Presenting sx of Rhabdomyosarcoma
- Mass- hard on palpation
* It can occur anywhere, although the most common site is head and neck.
Tx of Rhabdomyosarcoma
- Surgery
- Chemo
- Radiation
___ is a malignancy of embryonic retinal cells
Retinoblastoma
What is the peak incidence of Retinoblastoma
mean age at presentation is 23 months
Presenting sx of Retinoblastoma
- Leukocoria (MC)
Tx of Retinoblastoma
- These children need to be seen immediately by ophthalmology.
- enucleation of the eye, and
- may include chemotherapy and radiation.
new and established diagnoses may be accompanied by symptoms which are oncologic emergencies such as __
tumor lysis
Oncologic emergency sx of tumor lysis
- releases large amounts of potassium, phosphate and nucleic acids into general circulation which can result in
- renal damage,
- very high WBC (>50K) which can
- impede circulation, or
- the neurologic symptoms (SC compression, Increased ICP) due to concerns about further damage to the spinal cord or brain stem herniation.
For patients undergoing cancer treatment, they are immunocompromised during treatment and therefore __ or __ may be indicative of a SBI.
fever and/or neutropenia
If a febrile oncology patient (___) presents in primary care, it is important to have them evaluated in the ED or directly in the oncology clinic ASAP regardless of the source or suspected cause of their fever.
(> 101)
*They are susceptible to infections with fungus, bacteria and viruses and need a full septic workup including bacterial/fungal cultures of their chemotherapy port, and empiric broad spectrum antibiotics until cultures return
Describe the work up of a febrile oncology pt
- Full septic workup
- bacterial/fungal cultures of the chemo port
- empiric broad spectrum Abx until cultures return
- It is sometimes necessary to calculate an absolute neutrophil count which is WBC (in thousands) x (neutrophils + bands percentiles)
How do you calculate an absolute neutrophil count
WBC (in thousands) x (neutrophils + bands percentiles)
Neutropenia is defined as
ANC <500 or <1000 and falling.
Just a note that patients with neutropenia will not produce pus, in the event they have a wound infection, due to their ___
low numbers of WBCs.
What are new DX that demand immediate evaluation and initiation of treatment
- Tumor lysis
- Hyperleukocytosis
- Neuro sx: SC compression, increase ICP
- Fever and neutropenia
Growth can be affected in children treated with radiation for:
- ALL
- CNS tumors, and
- head and neck CA,
**so watch their growth curves
Late Effects of cranial radiation in children
- Learning problems,
- precocious or
- delayed puberty
- hypothyrodism
Chemotherapy can result in __ and __
pulmonary fibrosis and fertility issues.
Second malignancies can result from __ and __.
___ can result from various chemotherapy agents
- underlying genetic disorder,
- tissues in the field of previous radiation, and
AML can result from various chemotherapy agents.
