Oncology

Question 1

At what age do you expect to see childhood cancers peak. And what kind?

Answer 1

0-4yrs

Most to least:

• Leukaemia
• Brain tumours
• Lymphoma
• Other

Question 2

What cancer is ass with the following syndromes?

• Down’s
• Fanconi
• Neurofibromatosis

Answer 2

Downs = Leukaemia

Fanconi = Adult type cancers incl mouth, anal, vulval & leukaemia

Neurofibromatosis = Neurofibromas, sarcoma & leukaemia

Question 3

How do we classify childhood cancers?

Answer 3

The International Classification of Childhood Cancers

It’s based on morphology unlike adult systems which use location

Question 4

Childhood cancers can present with lot’s of non-specific symptoms e.g. weight loss, lumps, tiredness, seizures, headache, vomiting, fever etc.
When would you refer and how quickly?

Answer 4

Same Day:

• Unexplained Petechiae
• Hepatosplenomegaly

48hrs:

• Repeat attenders with same problem but no diagnosis
• New neuro symptoms
• Abdo mass

2wks:

• Rest pain, back pain or unexplained lump
• Lymphadenopathy

Question 5

In general what are the tests, staging methods and treatment for childhood cancers?

Answer 5

Imaging e.g. US, MRI, CT, X-ray
Tumour Markers
Biopsy
Staging with scans and bone marrow biopsy

Question 6

Name 5 emergency presentations of a childhood cancer?

Answer 6

1) Sepsis or febrile neutropenia
2) Raised ICP
3) Spinal Cord Compression
4) Mediastinal syndromes
5) Tumour Lysis Syndrome

Question 7

Known cancer patient comes in with:

• Fever
• Rigors
• Drowsy
• Tachycardia & Tachypnoea
• Hypotensive

Answer 7

Sepsis

septic symptoms e.g. fever, rigors & drowsiness

+ shock symptoms e.g. tachy, hypotension, long cap refill, low UO & Metabolic acidosis

Question 8

First off what are the risk factors for sepsis in a cancer kid?

Answer 8

Neutropenia
Mucosal inflammation
Catheter
Chemo

Question 9

What organisms are likely to cause sepsis in a cancer kid?

Answer 9

Pseudomonas
E.coli
Pneumococcus
Enterococci
Staph
Fungi

Question 10

How do you handle sepsis in these kids?

Answer 10

Inititate sepsis 6:

• Fluids
• Abx
• O2
• UO
• Culture
• Inotropes

Transfer to PICU

Question 11

Kid with early morning headache & vomiting comes in, you notice a tense fontanelle and big head circumference?

Answer 11

Raised ICP (in this case from cancer)

Later they can get:

• Constant headaches
• Papillodema
• Diplopia
• Loss of upgaze
• Neck stiffness
• fits
• Low GCS
• Cushing’s Triad

Question 12

If you see a kid with raised ICP how would you handle it?

Answer 12

Get an emergency CT (screen) & MRI (to confirm)

Give Dexamethasone (reduces cerebral oedema & raises CSF flow)

Neurosurgery e.g. Ventriculostomy or EVD

Question 13

What tumours are likely to cause spinal cord compression in a kid and how would that present?

Answer 13

Ewing’s Sarcoma or MEdulloblastoma

Causes:
Weakness > Pain > Sensory impairment > sphincter disturbance

Question 14

What do you do if you suspect spinal cord compression?

Answer 14

Urgent MRI

Followed by dexamethasone (then normal cancer treatment)

Outcome is related to degree of impairment rather than rapidity of treatment but still urgent!

Question 15

What is SVS or SMS?

Answer 15

Superior Vena Cava/Mediastinal Syndrome

SVS is when a mediastinal mass (mostly lymphoma) compresses important structures:

• Facial/neck/upper thoracic swelling
• Cyanosis
• Distended Veins
• Generally unwell
• Anxious
• Low GCS

If it also affects the airways causing SOB, tachypnoea, cough, wheeze, stridor or orthopnoea it becomes SMS

Question 16

How would you handle a kid presenting with SVS or SMS?

Answer 16

Do a CXR/CT if possible to confirm and an Echo

Keep them upright

Do urgent Biopsy, FBC, pleural aspirate & Germ cell tumour (GCT) markers

Get them on Steroids –> Chemo/RT
If thrombosis occurs use thrombolysis

Question 17

First off define Tumour Lysis Syndrome?

Answer 17

Rapid death of tumour cell (usually due to chemo) –> Release of intracellular contents e.g. K & PO4 –> Metabolic derangement & renal failure

Question 18

So how might Tumour Lysis Syndrome present?

Answer 18

Kid on chemo or other cancer therapy:

• High K
• high urate, urea & creatinine
• High Phosphate
• Hypocalcaemia

Question 19

How do you manage tumour lysis syndrome?

Answer 19

ECG monitoring (K) + electrolyte + UO

Hyperhydrate!

Rasburicase or Allopurinol for Uric acid

RRT e.g. Dialysis

No potassium & protect with Ca Gluconate,
Remove potassium with Ca Resonium, Salbutamol & insulin

Question 20

What is Cushing’s train?

Answer 20

• Bradycardia
• Systolic hypertension
• Decreased respiration