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Oncology Flashcards

1
Q

Syndrome associated with Wilms tumour

A
  • WAGR syndrome 30%, WT1 deletion- Wilms tumour; aniridia; genitourinary abnormalities; retardation
  • Denys-Drash syndrome 90%, WT1 missense mutation - pseudohermaphroditism; mesangial renal sclerosis, Wilms tumour.
  • Fanconi Anaemia (20%)
  • Beckwith-Wiedemann syndrome 5%, 11p15 Hemihypertrophy Cryptorchidism Hypospadias
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2
Q

VOD

A
  • Obstruction of small veins in the liver as a complication of high-dose myeloablative chemotherapy given before a bone marrow transplant ; also rarely seen in Wilms
  • Due to injury to hepatic venule, dilation of sinusoids and hepatocyte necrosis, sclerosis, collagen deposition -> obliteration and necrosis, fibrous tissue replacement of normal liver
  • Triad of: weight gain, painful RUQ hepatomegaly, jaundice
  • Onset within 30 days of SCT, occurs in 10-60%
  • Ascites and hyperbilirubinaemia In the early stages the classic diagnostic triad (see below) is often not present. Relative platelet refractoriness with a mild elevation of hepatic enzymes may be the only signs. This may worsen or settle but the risk of development of SOS with a subsequent course of treatment if there has been prior SOS is ~ 75%.

Clinical features

The classic clinical criteria (Jones’ criteria) are:

  • jaundice Br > 34 mmol/L and two of:
  • painful hepatomegaly
  • weight gain > 5% above baseline
  • ascites.

Other features include: - raised ALT and AST - refractoriness to platelet transfusions - usually occurs within 30 days of transplant or within a week of receiving more conventionally-dosed chemotherapy - liver failure and coagulopathy - hepatorenal syndrome - fractional excretion of sodium falls sharply just before the onset of overt SOS and explains the rapid weight gain. - disproportionate thrombocytopenia may indicate “low-grade” SOS and risk of portal hypertension.

Image with doppler USS or CT

  • Can treat with defibrotide (anti-thrombus, anti-inflamm). High mortality rates when associated with multiorgan failure - UDCA reduces hepatic complications
  • Supportive care
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3
Q

Poor prognostic signs in ALL

A

Presenting WCC>50 Age <2 and >10 years age Boys do worsel than girls Chromosomal abnormalities - t(4:11) - MLL rearrangements and - t(9:22) BCR-ABL Philadelphia (Rx TKI Imatinib) Hypodiploidy <44 CNS disease Poor response to induction chemo with minimal residual disease Relapse

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4
Q

Good prognosis ALL

A

Hyperdiploid >50 Trisomy 4, 10 ETV6-RUNX1 t(12;21) translocation - 99% cure rate Presenting WCC <50 Age 2-10

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5
Q

Philadelphia Chromosome

A

t(9:22) ; fusion of BCR and ABL1 creates novel tyrosine kinase which results in unregulated cell proliferation. TKI Imatinib added to intensive chemo Relapse free survival improving, currently >70% Associated with CML and rarely ALL Poor prognosis

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6
Q

Blinatumomab mechanism action

A

BiTE molecule (bispecific T cell engager). Binds B cell (CD19) at one end and T cell(CD3) on the other. Enables patients T cells to recognise malignant B cells. Used in B cell ALL Can lead to cytokine release syndrome (similar to MAS) and neurotoxicity

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7
Q

Infant ALL

A

2% ALL occurs, <1years

Poor prognosis ; High relapse rate ; High toxicity

Associated with MLL rearrangements in 80%

Clincal: Leukaemia cutis ; pulmonary involvement Usually negative for CD10 (unlike older kids)

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8
Q

Reed Sternberg cell is pathognomonic of ..

A

Hodgkins lymphoma

Twin nuclei and nucleoli look like owls eyes

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9
Q

APML

A

Subtype of AML t (15;17) PML-RAR alpha ;

This protein inhibits differentiation of the myeloid progenitor beyond the promyelocyte stage.

The differentiation agents all trans retinoic acid (ATRA) and Arsenic induce differentiation of the leukaemic promyelocytic clone by binding to the abnormal fusion protein thus releasing the differentiation block.

Presents with DIC Treatment with ATRA which is active form of Vit A (risk of differentiation syndrome in 5-20%

  • worse with leucocytosis >10
  • present with fever, weight gain, pulmonary infiltrates, oedema - Rx Dex) and arsenic

Good prognosis

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10
Q

Auer Rods seen in

A

AML

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11
Q

Clinical features in AML

A

2nd most common leukaemia Chloromas (Extramedullary blasts) (t8:21)

Gum hypertrophy

Subcutaneous nodules(blueberry muffin in infants), lymphadenopathy

HSM

Cytopenias, leucopenia/leucocytosis

Systemic symptoms

Rx Cytarabine based chemo for 6mo Incidence increases with age Overall survival 60-70%

Poor prognosis - MLL (11q23), FLT3-ATD , Monosomy 7 Favourable - t(8:21) and t(15:17)

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12
Q

Associations with JMML

A

NF1 Noonans Presents children <2

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13
Q

Bone cancer associated with Osteolytic lesion and onion skinning on Xray

A

Ewings sarcoma

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14
Q

Bone cancer associated with sunburst pattern on Xray

A

Osteosarcoma

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15
Q

Differences between Ewings and Osteosarcoma

A

Both occur 2nd decade of life most commonly

Osteosarcoma more common in adolescents Ewings more common <10

Osteosarcoma

  • Associated with Hereditary retinoblastoma (RB1 gene mutation) and Li Fraumenia (p53mutation)
  • Site Metaphysis of long bone (femur, tibia) - usually rapidly growing bones (prox tibia, distal femur, humerus) 80% in extremities ;
  • Xray: Sclerotic destruction, sunburst pattern, medullary and cortisol destruction of bone (moth eaten appearance), Codmans triangle (periosteal reaction that occurs when bone lesions grow so aggressively they lift the periosteum off the bone and do not allow the periosteum to lay down new bone)
  • Cell: Spindle cell producing osteoid Rx Need surgical resection for survival adj chemo (MAP), surgery 10/11week, chemo If recurrence Ifos/etop MAP chemo ++ emetogenic (MTX cisplat Doxo) Radioresistant

Poor prognosis if poor response chemo 5yr OS 70% mets in 15-20% ; 2yr EFS 40%

Ewings - Cell: Small round cell undifferentiated tumours of neural crest origin. More common in white people

  • More systemic symptoms (fever, weight loss, anaemia, elevated ESR).
  • median age presentation 15yrs but can present from infancy - Site: Diaphysis of long bone Axial and extremities (long bone, pelvic, chest wall)
  • Xray: Onion skinning (successive layers of periosteal development) ; Osteolytic lesion, Sharpey fibres (perpendicular osseous reaction - hairs on end) Translocation involving Ewings gene on Ch22 (t11:22 most common)

25% present with mets - lung, bone, BM

Rx Neoadj chemo VDC (vinc/doxo/cyclo) +/ie (irinotecan, etop) IE 14-17weeks, surgery, +/-RT 2nd line Irinotecan/temozolamide 80% respond chemo ( VDC IE, interval compression which is chemo every 2 weeks) Radiosensitive 5 yr EFS 70% ; mets <30% Both mets to lungs/bone Need biopsy ;

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16
Q

Langerhans cell histiocytosis

A

Bone: Lytic lesions Skin - seborrheic dermatitis CNS: DI, Cerebllar, facial nerve palsies Multiorgan: Lungs, LN, HSM Birbeck granules on EM CD1a, CD207 and S100

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17
Q

Ddx lytic bone lesion

A

Osteosarcoma Ewings LCH Bone cyst Lymphoma

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18
Q

Post chemo leukaemia

A

mostly AML - Alkylating agents - cyclophosphamide - Topoisomerase II - Etoposide

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19
Q

Hodgkins

A

More Common in teenager (most common malignancy 15-19) - 2 peaks 15-34 and >50 Lymphadenopathy (above diaphragm in 97%) Anterior mediastinal mass in 50-60% Risk of SVC obstruction B symptoms (fever, weight loss >10% body weight in 6mo, night sweats) Pain worse after alcohol, pruritus, anorexia Ann Arbor staging Need PET for staging Reed stern pathognomonic Chemo ABVD

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20
Q

NHL

A

usually HG and aggressive in Paeds 4 types 1. Lymphblastic lymphoma (90% T, 10%B) - Similar ALL but <25% blasts in marrow - Extranodal disease ; mediastinal mass 2. Burkitts (mature B ; t(8:14) 3. DLBL 4. Anaplastic (70% T, 20% B, 10%mixed) Clinical SVC obstruction Spinal cord compression TLS LN ; Abdominal mass (burkitt) St JUDGE staging Burkitt - sporadic abdominal) ; Endemic (head and neck ; EBV related jaw tumors). Rapidly growing tumours t(8:14) c-myc oncogene. Present intussusception / abdo obstruction High risk TLS Chemo CHOP /- Rituximab (anti-CD20)

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21
Q

Superior mediastinal syndrome

A
  • SVC obstruction - facial plethora, oedema, collaterals chest wall - Airway obstruction / Stridor / SOB - Horner’s syndrome - T cell leukaemia, lymphoma, GCT - Tx: Avoid GA/lying flat, MDT involvement steroids to shrink tumour/swelling may need anticoagulation (risk thromboembolism)
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22
Q

Tumor Lysis syndrome

A

Metabolic derangements caused by sudden release of intracellular products into blood steam due to rapid cell death

High phosphate (renal impair)

High uric acid (Renal F)

High potassium (arrhythmia)

Low calcium (bound to phosphate) - tetany, laryngospasm, long QT ; avoid calcium replacement as CaPo4 complex can worsen renal impairment

Occurs 3 days prior to up to 7 days after treatment

Peak risk 24-48hours after treatment

Higher risk with tumors that have high tumor burden - fast growing (Burkitts) or ALL with high presenting WCC High uric acid/LDH pre treatment

  • higher risk Patients with pre-existing renal impair higher risk

Rx

Hyperhydration

Allopurinol (xanthine oxidase inhibitor)

  • halts production of uric acid
  • Risk BM suppression with Azathioprine/6MP due to elevated 6 TGN (lowers MMP - lower hepatotoxicity)
  • High 6TGN - BM suppression, High 6MMP - hepatotoxicity

Rasburicase (used in high risk patients)

  • Recombinant Urate oxidase - transforms uric acid into excretable product Allantoin
  • CI in G6PD deficiency
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23
Q

How does rasburicase work?

A

Urate oxidase converts uric acid to Allantoin which can be excreted in urine CI in G6PD

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24
Q

Describe risks of hyperleukocytosis

A
  • WCC>100 (or >50 in AML). More frequent AML, higher mortality - Leukostasis in brain and lungs, like pulm oedema - DIC - Tumour lysis syndrome - Tx: hyperhydration, rasburicase may need leukapheresis manage DIC avoid transfusion (inc viscosity)
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25
Q

Differentials of mediastinal masses - ant, middle, post

A
  • Anterior: lymphoma, germ cell tumour - Middle: lymph nodes, TB, fungal, osteosarcoma, lymphoma/leukaemia (T cell) ; foregut duplication cysts - Posterior (neurogenic): neuroblastoma (<10), neurofibroma, schwannoma - 80% of mediastinal masses are malignant 10% in ant superior mediastinum compress SVC/airway
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26
Q

Tumors causing spinal cord compression Symptoms and treatment of spinal cord compression (3-5% of children at diagnosis)

A

Neuroblastoma Mets brain tumour Primary spinal tumour Ewings and Osteosarcoma Rhabdomyosarcoma Lymphoma / Leukaemia (Chloromas) - Local or radicular pain >80% - Motor weakness, sensory loss, incontinence (caudal equina) - Paraplegia/quadriplegia can progress rapidly - Emergency MRI, surgery/radio/chemo +/- dexamethasone Better outcome if treatment started within 10 days onset symptoms

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27
Q

Anaphylaxis most commonly with which chemotherapies?

A
  • L’Asparaginase/PEG asparaginase - Etoposide - Carboplatin - Amifostine - Platelet transfusions + newer moncolonal antibodies cause allergic reactions - Premedications given to reduce risk
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28
Q

Drugs that are high risk if extravasation occurs?

A

Doxorubicin, dactinomyin, danorubicin, vinblastine, vincristine Rx Attack new syringe, aspirate as much as possible, involve plastics

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29
Q

Febrile neutropenic Sepsis in AML on HD Cytarabine

A

Alpha haemolytic strep (strep mitis/strep pleuridans) Always treat these patients with tazocin + vancomycin

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30
Q

Drugs associated with mucositis?

A

Methotrexate, doxorubicin Mx Hyperhydration Leucovorin (folinic acid) rescue with HD MTX Oral hygiene Antifungals if high risk GCSF Mouth wash, pain relief Gut rest and IVN for typhilits Immune suppression for GVHD

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31
Q

Risk of cardiomyopathy with which cancer treatment ?

A

Doxorubicin (anthracyclines) + thoracic radiation - worse with puberty, pregnancy, high intensity exercise - Give dexrazoxane (iron chelator) prior to anthracycline in high risk patients

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32
Q

Febrile Neutropenia

A

>38 ̊C on 2 occasions or >38.5 ̊C on one occasion AND ANC of <0.5 x 109/L, or expected neutropenia from recent chemo • Urgent review because: – Chemotherapy causes decreased number and function of immune cells – Radiation complication – Surgeries – Breakdown of mucocutaneous barriers – Foreign bodies (CVL, grafts etc.) – They can decompensate very quickly Most common culprits are staph epi, streps, gram negative rods. But most rapidly lethal are gram negatives (E. Coli, Pseudomonas, Kliebsiella) – Microbiological diagnosis only made in 10-30% • Antibiotics should be started within the first hour – Tazocin (Piperacillin/Tazobactam) monotherapy – HD araC exposure/AML/BMT–add Vancomycin – Known ESBL–add Amikacin – If shocked–add Amikacin and Vancomycin – Avoid Amikacin if cisplatin exposure – If shocked, but cisplatin exposure or risk of renal damage–use Meropenem – If low risk–consider Ceftriaxone as outpatient

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33
Q

Antiemetics in oncology and mechanism

A
  • Ondansetron (5HT3 receptor antagonist) - can prolong QT
  • Dexamethasone (half Aprep if using)
  • Aprepitant (NK1 Antagonist) CI with IFOS, risk encephalopathy, dose reduce with steroids (toxicity) SE EPSE, long QT, NMS
  • Scopaderm patch (Hysoscine) ; Anticholinergic, CI with epilepsy and ileus. Use with metoclopramide
  • Dopamine antagonists - Metoclopramide/ Domperidone ; Prokinetic, risk EPSE ; acts on CTZ at floor 4th ventricle
  • Cyclizine (antihistamine) acts on Vestibular centre
  • Loraz (benzo) - anticipatory nausea

Refractory nausea

Olanzapine (antipsychotic)

Nozinan (Levomepromazine)

  • phenothiazine, broad spectrum antiemetic

Delayed emesis (24hrs-7days post chemo) is most common with cisplatin but also seen with high dose cyclophosphamide, doxorubicin, carboplatin and Ifosfomide. It is more likely when these drugs are used in combination.

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34
Q

Mucous membrane inflammation oncology

A

• Can involve the whole of the alimentary tract from mouth to anus • Chemo: – MTX related mucositis • Infection: – Candida / Herpes causing stomatitis / esophagitis • Neutropenia: – Typhlitis / neutropenic colitis • GVHD of tongue / gut

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35
Q

Hypertension in Oncology

A

Solid tumours - Wilms - Neuroblastoma - Brain tumour ALL (steroid SE) Post BMT (SE Ciclosporin)

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36
Q

Endocrine complications post cancer treatment

A

GH deficiency (most commonly affected by radiation - causes linear growth failure) Precocious puberty Thyroid problems Gonadal failure( Primary - high FSH/LH ; central - low/normal FSH/LH) - 50% males infertile - 30% women need oestrogen replacement, check AMH 12 months post Rx, Ovarian US for follicle count - Can use Zoladex (GNRH analogue) to suppress menstruation and limit gonadotrophin effects of treatment Bone disease - Osteoporosis, Rickets Obesity, Metabolic syndrome, insulin resistance Nearly 1/2 patients will have 1+ of above

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37
Q

Secondary malignancy

A

2% above average RF Radiation (Sarcoma, BMT, Hodgkins) ETOP / alkylating agents (Cyclophos/IFOS) - risk AML and sarcomas Genetic (Fanconi, Li Fraumenia, Retinoblasoma(Rb1) Hodgkin (mantle irradiation): breast (30-40% risk by age 50) and thyroid cancer Early off therapy (2-3 years) secondary AML Late (>5-10 years) post RT - 2-5% V. Late (>10yrs post treament ) - >10% eg risk breast ca post Hodgkins RT

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38
Q

Risk of high frequency hearing loss with which chemo?

A

Cisplatin (up to 70%), worse if had gentamicin, amikacin, frusemide treatment. 30% require hearing aids.

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39
Q

Klinefelters have an increased risk of?

A

Mediastinal germ cell tumour Breast cancer

40
Q

What are types of small round blue cell tumours?

A
  • Medulloblastoma - Neuroblastoma - Ewings - Wilms - Hepatoblastoma - Retinoblastoma
41
Q

Describe transfusion-related GvHD

A
  • Is a result of donor T lymphocytes directed against recipient tissue antigens. - Fever, rash, diarrhoea, LFT derangement and pancytopenia. - It has a very poor prognosis and is almost universally fatal - Prevent by using irradiated blood.
42
Q

Prognostic factors in neuroblastoma?

A

Good prognostic factors: Age <1 Hyperdiploidy Whole chromosome gains Poor prognostic factors: Amplification of the N-myc proto-oncogene Segmental chromosome abnormalities

43
Q

CNS manifestations of Tuberous Sclerosis

A
  • Supependymal giant cell astrocytoma (5-15%) - benign, slow growing, wall lateral ventricles - Cerebral cortical tubers (90-100%), associated with seizures - Subependymal hamartomatous nodules - Everolimus is the standard of care for unresectable lesions
44
Q

Posterior fossa syndrome

A
  • Delayed neuro changes after tumour resection - Cerebellar mutism, irritability, difficulty verbalising, emotional lability, nystagmus - 20% incidence after resection medulloblastoma - Mutism resolves ~1m, other neuro symptoms persist
45
Q

Which malignancies can metastasise to bone marrow?

A

Ewing’s, alveolar rhabdomyosarcoma, neuroblastoma

46
Q

Familial adenomatous polyposis (FAP)

A

AD cancer predispostion syndrome caused by germline mutations in the tumour suppressor gene APC. Inc risk bowel cancer and hepatoblastoma

47
Q

Cancer predisposition: Trisomy 21

A
  • ALL (inc 20x) ; T21 poor prognostic in ALL - Acute megakaryoblastic leukaemia (inc 500x) (AML > ALL in first 3 years life) ; AML good prognostic in T21 - Transient myeloproliferative disease (peripheral blasts, usually in first 3months life, most resolve) - 20-30% of these develop AML within 3 years life (mean 18months) T21 ++sensitive chemo, need to dose reduce MTX
48
Q

Cancer predisposition: Li-Fraumeni

A
  • Mutation in TP 53 gene, tumour suppressor gene - AD, FHx early-onset cancers - Soft tissue sarcoma, osteosarcoma, breast cancer, leukaemia, brain cancers, adrencortical
49
Q

Bloom syndrome

A

AR mutation BLM gene Associated Leukaemia, lymphoma, CNS tumors

50
Q

Ataxia telangiectasia associated malignancies

A

Leukaemia, lymphoma, CNS Mutation ATM tumor suppressor gene, AR

51
Q

Cancer predisposition: Beckwith-Wiedemann

A
  • 85% sporadic, mutation in 11p15.5 causing over-reactivity of IGF2 gene - From abnormal methylation or uniparental disomy - 10-20% develop malignancy - hepatoblastoma, neuroblastoma, Wilm’s, rhabdomyosarcoma, adrenocortical tumour Of the tumours in BWS, -43% are Wilms Tumour -20% hepatoblastoma and -7% adrenal cell carcinoma. - Abdo USS 3-monthly until age 8, AFP every 6 weeks until age 4 - After 10 years, the risk approaches the baseline risk of cancer in the general population.
52
Q

Gorlin Goltz syndrome

A

Multiple basal cell ca ; medulloblastoma AD mutation PTCH gene

53
Q

Von Hippel Lindau

A

AD mutation

VHL gene

Haemangioblastoma cerebellum and retina Phaeochromocytoma

Renal ca

54
Q

MEN 1 (werner) cancers..

A

Parathyroid Pancreatic islet Pituitary

55
Q

Men 2A (Sipple)

A

Medullary ca thyroid Hyperparathyroidism Phaeochromocytoma AD mutation RET proto-oncogene

56
Q

Relapse ALL

A

Late (>18mo off treatment) Early (>18mo since diagnosis, <6mo off treatment), 50% survival Very early (<18mo since diagnosis), poor prog 20-30% survival T cell ALL relapse has poor prognosis, <30% survival

57
Q

Cancer predisposition: neurofibromatosis 1

A
  • Mutation of NF-1 on Ch17, unable to produce neurofibromin - AD, variable expression - Neurofibroma, schwannoma, optic glioma, astrocytoma, pheochromocytoma, malignant tumour from plexiform neurofibroma
58
Q

Name the cancer predisposition syndromes

A
  • Familial retinoblastoma - germline RB1 mutation - Li-Fraumeni - mutation in tumour suppressor TP53 - Neurofibromatosis 1 - mutation of NF-1 gene on Ch 17 - Beckwith-Wiedemann - mutation in 11p15.5 - Trisomy 21
59
Q

Where are malignant germ cell tumours located?

A

Gonadal (30%) or extra-gonadal (70%) - sacrococcygeal, retroperitoneal, mediastinum, neck, pineal region

60
Q

Describe malignant germ cell tumours

A
  • Gonadal 30%, extra-gonadal 70%
  • Range from undifferentiated embryonal carcinoma to mature teratoma (pure teratoma has no metastatic potential)
  • Gonadal: testicular swelling, pelvic pain, ovarian torsion, abnormal or precocious puberty
  • Inc risk with undescended testes
  • Ix: AFP and b-HCG
  • Can metastasise to lungs, liver lymph nodes
  • Tx depends on type/location. Chemo is cisplatin and carboplatin
61
Q

Describe Wilm’s tumour (nephroblastoma)

A
  • 90% of all renal tumours - Predisposed by nephrogenic rest (foetal tissue persisting into infancy) - Abdo mass (75%), haematuria, constipation, pain, HTN - Metastasises to lungs and IVC tumour thrombus - Low risk - surgery+observe. Other risk - surgery + chemo +/- radiotherapy - Overall survival >90% for favourable disease
62
Q

Wilms (nephroblastoma)

A

Embryonal tumour ; Small round blue cells Most common malignant renal tumour of childhood 6% of paediatric tumours From infancy to 5 years. Very unlikely past then. -Rarely dx <6months -Best characterised gene is Wt1 deletion on 11p13 METS to LUNGS 95% unilateral 5% bilateral (at same time OR contralateral later in life) 90+ survival (unless anaplastic) Can be syndromic or non syndromic If known risk q3MONTHLY USS until age 8 If bilateral at same time -more aggressive chemo. Try to spare nephrons with surgery. If not remove –> dialysis 1-2 years –> transplant 20 years ESRF risk: 1% unilateral 12% bilateral Sx: Unilateral large mass (75% abdo mass only) Abdo pain Fever Painless gross haematuria HTN in 25% (increased renin from tumour) Complications: Bleed into tumour (with rapid enlargement) Anaemia Thrombus –> 5-10% can extend into IVC Acquired vWF deficiency METS to lung, IVC thrombus via renal vein IX: XR, USS, CT, MRI USS is good to look at cystic vs solid, and differentiate from adrenal tumours DDX: Mesoblastic nephroma (<3 months, solid tumour, mostly benign) Clear cell tumour (look for bone mets) Rhabdoid tumour kidney (look for brain mets; poor prognosis, rare; often haematuria presenting complaint) Prognostic factors: Age (<2 =better), stage, tumour weight, loss of heterozygosity at 1p and 16q (poorer prognosis), anaplasia Rx: Surgery and chemo Low risk- actinomycin- D and vincristine High risk: Actinomycin D, Vinc, Doxorubicin Late effects: 2nd malignancy cardiac toxicity pulmonary disease renal failure

63
Q

Rhabdomyosarcoma

A

Most common soft tissue malignancy in children

-Small round blue cells

3 types:

  1. Embryonal (60%)
    - NO translocations, intermediate prognosis. Include botyroid variant(bunch grapes).

Tumors resemble skeletal muscle

  1. Alveolar 25-40% (translocations 1;13 or 2;13) and are most often in trunk and extremities and have poor prognosis.

PAX-FOXO1 fusion associated poor prognosis

  1. Pleomorphic (adult type, rare) -chemosensitive -3.5% of childhood cancers - Can occur anywhere but usually head and neck (including face, nasopharynx, midle ear, sinuses etc) -more likely alveolar in older children
    - Can disseminate early + LUNG METS -Alveolar METS everywhere incl BONE MARROW
    - Associated with neurofibromatosis and Li-Fraumeni syndrome

Location

Head and neck 25% ; Orbit 9% GU tract 24% ; Extremities 19%

Sx: -Mass (may be painful) -Secondary sx from pressing on structures (anywhere from nose bleeds to cranial nerve palsies). Can often present with similar to common childhood conditions - If in extremities usually noticed after trauma and mistaken for haematoma -Can get vaginal rhabdo (grape like mass bulging through vaginal orifice)

Ix: CT and MRI Staging - bone scan, chest CT, BMA, biopsy

RX: 1.pre-operative chemo (VAC VI) 2. resection

  1. post -op chemo (vinc, cyclophosphamide)
  2. +/- irradiation depending on stage and site

Survival: Embryonal - 40-90%, still curable if mets

Alveolar 0-60% incurable if mets

Risk factors: Older = bad Histology and staging (mets and site) Fusion protein (PAX FOXO1 poor prog)

Late effects: -Impaired bone growth from radiation - second malignancy -Infertility from CYCLOPHOSPHAMIDE

64
Q

Retinoblastoma

A

Embryonal tumour

  • most common intra-ocular cancer in childhood
  • 4% malignancies (10% malignancy <1 year age)
  • Most cases <5 years old, median age 2; M=F

60% unilateral (10-15% germline RB1 mutation)

40% bilateral (germline RB1 mutation)

  • Hereditary and sporadic
  • Hereditary associated with younger age and bilateral retinoblastoma
  • Loss of function of RB1 gene on chromosome 13
  • Small round blue cell tumour with rosette formation
  • Generally presents with leukocoria or strabismus
  • Advancing disease results in orbital inflammation, redness and pupillary distortion - pain if glaucoma present

Can MET to CSF and spinal cord

AT RISK of trilateral tumour (pineal ) tumour which can occur at the same time or any time after (presents with HEADACHES AND VI NERVE PALSY

DDX: Other causes of leukocoria –> ROP, coats disease, cataract, persistent hyperplastic primary vitreous IX:

Dx made based on ophthalmological findings (under GA) as imaging is not diagnostic and pathology not required

Orbital USS / Brain MRI Staging: MRI brain and spine, LP +/- BM trephine (can mets to BM)

Rx: Focal chemo (etoposide, vincristine, carboplatin) If too large then enucleation of the eye If bilateral - focal chemo to reduce size + focal laser photocoagulation or cryotherapy +/-irradiation (significant deformity + increased risk of 2ndary tumour) If poor prognosis for vision or tumour in anterior segment - enucleation

Prognosis - good >95% Continue routine examination of eyes until age 7 If spread outside orbit, prognosis is poor

Those with RB1(tumour suppression gene) mutation increased risk of secondary tumours, esp if exposed to radiation (Osteosarcoma, breast ca, soft tissue sarcoma)

Late effects: Usually related to Rtx

  • cataracts -poor orbital growth deformities
  • lacrimal dysfunction - late retinal vascular injury

Trilateral disease - bilateral retinoblastoma and pineal tumour (palsy of upward gaze - Parinaud) and hydrocephalus

65
Q

Neuroblastoma

A

Tumor originates in primordial neural crest tissue

Most comon extra cranial solid tumour

  • 7% childhood malignancies ; 15% child cancer deaths
  • median age dx 22 months with 90% dx by 5 year old
  • Can occur at any site of sympathetic nervous tissue. about 50% adrenals, the rest along sympathetic ganglion
  • mets more likely if >1 year old -mets lymph nodes, long bones, skull, bone marrow, liver and skin
  • lung and brain mets are RARE
  • Associated with neural crest disorders such as hirschsprungs, NF1 and central hypoventilation syndrome -Associated with Beckwith wiedemann syndrome or isolated hemihypertrophy
  • Family Hx in 1-2% (PHOX2B gene mutation and germline ALK mutations)

3 types of risk

  1. High risk and malignant and aggressive (local/mets) -MYCM AMPLIFICATION -70% survival -HIGH dose chemo 13-18 months –> causes aplastic anaemia so need autologous stem cell rescue + surgery + radiation +/- MIBG radioactive isotope, chimeric (immune therapy), retinoic acid
  2. Intermediate risk local or metastatic <18 month -95% survuval -2-8 cycles mod chemo +surgery -No transplant, no chimeric, rarely radiation
  3. Low risk, localised and STAY that way -97-99% survival -small ones in babies usualy resolve spontaneously -larger ones cured with resection

Sx: Can present with syndrome (see slide) Great mimicker so can be non-specific and hard to dx -metastatic disease can present with systemic sx, bony pain, cytopenia, proptosis, periorbital ecchymoses(raccoon eyes),. -localised disease can present as asymptomatic or mass-related sx such as spinal cord compression, bowel obstruction and SVC syndrome

Dx: -Imaging - CT, MRI - Tumour markers such as catecholamine metabolites (HVA and VMA) in urine is elevated in 95% cases and helps to confirm dx -biopsy gold standard but dx can be made if small round blue cells in bone marrow and urine catecholamines are high

  • Staging - CT chest and abdomen, bone scan and at least 2x BMA and trephine for staging
  • MIBG scan (picks up cells with norepinephrine transport protein ; need iodine before and after scan as can be taken up by thyroid and cause damage)

Neurobolastoma risk: -met vs local - easy to resect vs not -age (older = worse. cut off age 18 months) -histology - genetics = MYCN amplification and 11q missing are bad

Rx depends on stage Surgery Chemo Chimeric (Dinutuximab) - Anti GD2 via ADCC (antibody dependent cell cytotoxicity), glycoprotein expressed on neuroblastoma ; also seen on normal pain fibres ; SE: ++pain, HR need 6 cycles multi agent induction chemo, then tandem autologous transplant and RT and post consolidation immunotherapy

66
Q

Syndromes associated with neuroblastoma

A

HORNER SYNDROME - neuroblastoma originating in superior cervical ganglion -Unilateral ptosis, myosis, ahydrosis - Sx DO NOT resolve with tumour resection

OPSOCLONUS-MYOCLONUS-ATAXIA syndrome -paraneoplastic syndrome of autoimmune origin - myoclonic jerking and random eye movement +/-ataxia - usually associated with lower risk tumour - may not resolve with tumour removal - can be progressive

SWEATING and HTN - catecholamine release from tumour

NEUROCRISTOPATHY SYNDROME -when neuroblastoma associated with other neural crest syndrome such as hirschsprungs, and congenital hypoventilation syndrome

  • Germline mutation of PHOX2B

KERNER-MORRISON SYNDROME -tumour secreation of vasointestinal peptides causing intractable secretory diarrhoea -tumours generally biologically favourable

PEPPER SYNDROME - massive involvement of the liver with mets disease +/- respiratory involvement

HUTCHINSON SYNDROME - irritability and limp in young child associated with bony and bone marrow mets.

67
Q

Chimeric (Ch14.18) monoclonal antibody Dinutuximab

A

targets “GD2” which is present on healthy and unhealthy nerve cells -antibody dependent cellular cytotoxicity (ADCC) -attacks healthy nerves = ++pain. need morphine and ketamine -causes physiological instability, fever, oedema

68
Q

Hepatoblastoma

A

Most common liver malignancy of childhood <1% malignancies of childhood (liver tumours account for 1%, hepatoblastomas about 65% of this) -usually in children <3 years -Alterations in APc/beta-catenin pathway -Environment predisposition LBW <1000g (38 x relative risk) –> not high enough to screen for -15% have genetic predisposition –> BWS –> FAP –> Li-fraumeni, T18, NF-1, ataxia telangectasia, fanconi anaemia, TS Ix: AFP raised (non-specific as high in HCC and GCTs) –> but used for monitoring response Can also have raised BHCG Biopsy gold standard RX: 1. resection key to cure (as much as 85% is fine with regeneration in 3-4 months!) 2. chemo in most Cisplatin/carboplatin (also treats mets) + sodium thiosulpahte (protects against SNHL) vinc and doxorubicin 3. Transplant if unable to resect +/- post-transplant chemotherapy The ONLY CONTRAINDICATION to TRANSPLANT: persistence of viable extrahepatic disease after chemo Prognosis: ->90% with low staged with surgery and post chemo - 60% if unresectable tumour - 25% if pulmonary mets

69
Q

Germ cell tumours

A

-tumour that begins in cells that give rise to eggs or sperm -can occur almost anywhere in the body and can be malignant or benign -1/3 arise in gonads -2/3 are extragonadal as arise from aberrant migration and occur in the MIDLINE - appearance may mimic any cell in embryo (yolk) or extra embryonic (chorion) -types include teratoma (mature and immature) –> benign Germinoma embryonal carcinoma Yolk sack tumor (raised AFP) choriocarcinoma (raised BHCG) Primary sites: -Gonadal - testes 25% (adolescents), ovaries 10% (adolescents -CNS–> pineal (2/3), suprasellar (1/3), rare and aggressive ; Germinoma 60% CNS, Good outcome with RT -cervical –> rare, teratomas/infants - MEDIASTINAL –> 5% (adolescents) associated with KLINFELTERS - Retroperitoneal 10% infants/children - SACROCCOYGEAL 50% infants/children Sx: present as mass lesions If in CNS presents often as diabetes insipidus in adolescents. Or as precocious puberty or panhypopit RX: 1. Surgery 2. Cisplatin/carboplatin if cannot be resected +/-radiation (intracranial chemo +radiation as cannot resect

70
Q

Genetic conditions and predisposing to Medulloblastoma

A

GORLIN SYNDROME -AKA basal-cell nevus syndrome -3% will get MB -PTCH pathway mutation TURCOT’s SYNDROME -mismatch repair cancer syndrome (Lycnh, HNPCC) -Increased risk of CNS tumours and cororectal polyposis/cancer -high grade gliomas and MB in childhood/adolescence LI-FRAUMENI SYNDROME -TP53 -bimodal peak <10 years abd 20-40 years - ASTROCYTOMAS >> MB

71
Q

Medulloblastoma genetic subtypes

A

4 types -different histology and age onset 1. WNT activated -monosomy 6, classic histology -10% patients ; good prognosis -90% long term survival ; more common girls 2. SHH activated -PTCH pathway -lateral tumours - nodular desmoplastic - INFANTS have excellent prognosis -TP53 mutated tumour very poor prognosis 3. Non-WNT/non SHH -Group 3 –> MYC amplification, large cell ANAPLASTIC, poor outcome -Group 4 –> MYCN amplification, cassic or large cell anaplastic, intermediate outcome These guys are stratified into SJMB12 treatment and guides chemo + RTX

72
Q

Medulloblastoma

A

most common CNS tumour approx 20%

  • primitive neuroectodermal tumour ;
  • small blue round cell tumour (SBRCT), large cell(poorer prognosis(
  • peak age 3-9 years, M>F (65%males)
  • post fossa (cerebellum, usually arises from vermis)
  • Predilection for CNS dissemination - up to 1/3 metastatic disease at presentation (CSF, nodule seeding in brain or spine)

On MRI: - T1 scan enhancement -Cystic spaces seen on T2

Prognosis based on:

  • ability to resect (do better if <1.5cm2 residual tumour)
  • stage ( AR if localised only aka M0, HR if M1-M4 or Anaplastic or if residual tumour)
  • histology ( if extensive nodularity and young child can rx with chemo only and no have to use Rtx)
  • molecular markers
  • Age > 3 years (<3 years do worse can cannot irradiate brain and spine)

Ix: -repeat MRI of spine and CSF at least 10/7 after resection

Rx: 1. maximal tumour resection

  1. Rtx –> reduced dose and tumour bed boost if AR; high dose RTX if HR
  2. adjuvant during and after Rtx –> St Jude’s - Cisplatin, vincristine, cyclophosphamide - HD chemo is HR with autologous stem cell rescue (don’t need for AR)

Prognosis 5 years:

AR –> 75-80%

HR –> M1 about 60% –> M2/M3 about 40% –> SJMB-96 M1-M3 66%

73
Q

ATRT

A

Atypical Teratoid/Rhabdoid tumour - Deletion or mutation in INI1 gene (aka SMARCB1 gene) in tumour -Highly malignant -Usually occurs <2 years of age - about 15% children <3 years old with CNS -short hx, aggressive -occurs anywhere in brain and spine MRI: - Cystic and calcifications (subtle) Genetics: - can be germline mutation –> if so at risk fro renal and soft tissue tumours - GTR of tumour assoc with longer median survival (12.5 months vs 9.25 months) -chemo curative in small minority -early Rtx used in majority of survivors if >3 years old -unclear if Craniospinal irradiation necessar

74
Q

Ependymoma

A
  • originates from cells lining lateral ventricle or central canal of the spinal cord -composed of neoplastic ependymal cells - third most common CNS tumour (10%) - 90% intracranial with 70% in the post fossa Poor prognosis if: - <3 years old - Anaplastic - Disseminated disease - Infratentorial worse prog than supratentorial Not usually chemosensitive Surgery and RT mainstay of treatment
75
Q

Juvenile Pilocytic astrocytoma

A

AKA low grade gliomas -low grade tumours (WHO grade 1 and 2)

  • comprise the largest group of CNS tumours in children -most common is juvenile pilocytic astrocytoma –> 2/3 occur in POST FOSSA involving the cerebellum
  • Associated with NF1 (optic pathway gliomas) –> also respond better to chemo
  • Large and cystic
  • Cause pressure effects and visual impairment (if involving the optic pathway -indolent –> can be stable or regress
  • 3 places –> posterior fossa (cerebellum), supratentorial and (optic pathway),
  • Almost all tumours involving the OPTIC pathway are JUVENILE PILOCYTIC ASTROCYTOMA Only 5% LG glioma present in optic pathway but >70% OPG due to NF1

Histo: low to mod cellularity with ROSENTHAL FIBRES

Genetics: single pathway - (B) RAF pathway aberration –> MEK inhibitors disrupted

Rx:

  • usually just observe with interval examinations and periodic CNS imaging
  • surgery +/- chemo (if non-resectable) +/_ RTX if symptomatic exp if visual disturbances - chemo –> carboplatin, vinc, vinblastine
  • Targeted therapy with MEK inhibitors for single pathway disease Prognosis 85-90%
76
Q

High grade glioma

A

Locally infiltrative astrocytomas

2 kinds:

  1. Anaplastic astrocytoma (grade III)
  2. Glioblastoma multiforme (grade IV) BUT <10% leptomeningeal spread at time of dx

Genetics poorly understood: P53, high Ki67 (mitotic index)

Rx:

  1. surgery –> unlikely to get GTR
  2. Rtx + alkylating agents (TEMOZOLAMIDE)

Prognosis: < 2 years progression free <20%

Prognostic factors:

  • degree of resection - grade
  • P53 expression (+ve =good prognostic factor)
  • proliferation index (high Ki67 = bad)
  • younger <3 years better prognosis
77
Q

Diffuse brainstem pontine glioma

A

A common type of brainstem glioma - usually dx 5-10 years old - Grade II-IV BUT prognosis based on mutation landmark = Histone H3.3 NOT grade H3.3 gene mutations do worse - 80% have H3.3 gene mutation (histone = protein replication and formation) Sx: Classic triad - Cerebellar signs (ataxia, dysmetria, dysarthria) - Long tract signs (increased tone, hyper reflexia, clonus, +ve babinski, motor deficit) - isolated or multiple nerve palsies (uni or bilateral) Ix: MRI diagnosis (+clinical signs) - T2 hyperintense -T1 hypotense (usually) - >50% in PONS - Diffuse changes -BASILAR artery encasement in >50% -Biopsy NO effect of survival so only if clinical trial available and trained surgeons Prognosis: At 2 years, approx 20% with <10% chance of no disease progression

78
Q

Late effects of CNS tumour Rx

A

NEUROCOGNITIVE: -serial decrease in IQ <7 years –> as in declines relative to peers as not progressing in learning –> if at least 7 years old when IQ projection is -0.42 pts/year –> If less than 7 years old IQ projection is -4.82 pts/year (note in normal ppl IQ plateau’s about 16-20 years) - spatial learning difficulties -adaptive behaviour deficits -academic failure - Deficits worsen with time Psychological Endocrine/fertility- GH deficiency is most common followed by TSH and ACTH (and many others) Neurological Secondary cancers Ototoxicity Vision (life long damage)

79
Q

Chemotherapy drugs causing an increased risk of secondary malignancy?

A
  • Cyclophosphamide (alkalising agent) - Etoposide (topoisomerase II inhibitor) - Doxorubicin and danorubicin (anthracyclines, topoisomerase II inhibitors)
80
Q

Discuss parent/sibling relationship with HLA markers for HSCT

A
  • Parents are haploidentical matches to patient (i.e. patient shares 50% with Dad, 50% with Mum) - 1/4 chance of having a complete HLA matched sibling
81
Q

CNS tumours clinical

A

• Recurrent headaches am, nausea or vomiting without deficits, lethargy suggest ↑ICP • Sun setting eyes (superior colliculus control vertical eye movments) • Sudden onset of cranial nerve palsies III,VI,VII • Papilloedema • Irritability • Listlessness • Failure to thrive • Progressive macrocephaly • Older children more likely than infants to have localising neurological signs • Change in personality • Change in gait • “Learning Disabilities” in older children • Cranial nerve palsies • Deterioration of vision • Strabismus • Other Symptoms – Genetic predisposition syndromes – Family history

82
Q

Diagnostic work up brain tumour

A

Neuro‐Imaging – MRI Brain and spine (MRA/diffusion/Spectroscopy/fMRI/DTI) – low threshold for GA or sedation – anatomical details are key • Procedures – Surgical resection or biopsy (safe maximum resection) – LP for CSF cytology (10-14 days after procedure) • Laboratory Studies – May include α‐FP and β‐HCG – blood and CSF (marker GCT) – Pituitary hormones

83
Q

Deletion or mutation in the hSNF5 (INI1) gene associated with

A

Atypical Teratoid / Rhabdoid tumours (ATRT) • Biallelic inactivation of SMARCB1 in majority (previously INI1, SNF5, BAF47), INI loss in tumour. • Check germline mutation – at risk for renal and soft tissue tumours ; screen siblings/parents

84
Q

Cell cycle dependent chemotherapy

A

G0 resting phase

G1 preproliferative phase - L asparaginase

S phase (DNA replication) - cytarabine - antimetabolites - MTX, 6MP,

G2 phase - Etoposide (topoisomerase inhibitor) - Bleomycin

M phase (mitosis) - Vincristine, vinblastine (vinca alkaloids)

Non phase dependent drugs Anthracyclines Alkylating agents

85
Q

Radiation recall

A

a delayed effect that results from the interaction of certain chemotherapeutic agents (doxorubicin, daunorubicin, or actinomycin-D) with radiation. After radiation therapy, an erythematous rash in the previous radiation field develops. The rash is geographic, usually precisely following the outline of the radiation field. Many of these occur months after the radiation treatment

86
Q

Anterior mediastinal mass

A

5 Ts Teratoma (GCT), Thymoma, Thryoid mass T cell leukaemia Terrible lymphoma

87
Q

Alkylating agents

A

Interfere with DNA synthesis Cyclophosphamide, Ifosfamide, melphalan DNA alkylation causes cytotoxic effect Dose Limiting effect is myelosuppression SE cyclophosphamide - Haemorrhagic cystitis (prevent with Mesna) - Myelosuppression - N&V - Infertility - Alopecia - Neurotoxicity Ifos - renal issues - fanconi syndrome - haemophilia cysts (use mesna to prevent) Can get secondary malignancies Mesna acts as a detoxifying agent. It is given as an adjuvant therapy and binds to acrolein in the urine, which creates an inert thioether that is excreted.

88
Q

Side effects of cisplatin?

A

Cisplatin is platinum analogue Ototoxicity (irreversible High freq hearing loss) Nephrotoxicity (renal fanconi) Delayed nausea reversible sensory neuropathy

89
Q

Anthracyclines mechanism and SE

A

Doxorubicin, daunorubimcin Metabolised by liver, 75% biliary excretion Liver dysfunction needs dose reduction Use in ALL and solid tumours Cardiotoxicity - related cumulative dose, increased risk female Radiation recall Mucosisits, Myelosupp, N&V, alopecia Secondary malignancy (AML)

90
Q

Etoposide mechanism and SE

A

G2 phase inhibition of topoisomerase 2 Use solid tumors, AML, HL SE Myelosuppression N&V, mucositis, alopecia 2nd malignancy (AML)

91
Q

Methotrexate SE

A

inhibits dihydrofolate reductase (folic acid antagonist) Cell death from DNA interference (S phase) SE: Mucositis, myelosupp, renal toxicity, hepatitis, neuro SE (GBS like syndrome), pnuemonitis Intrathecal (CNS necrotising leukoencephalopathy) Can use folinic acid (Leucovorin) to reverse SE Interacts with cotrimoxazole

92
Q

Cytarabine (ARA C) SE

A

Pyrimidine analogue, Inhibits DNA polymerase (S phase) 90% excreted by kidney Myelosupp, mucositis, N+V Conjunctivitis (steroid eye drops) CNS - acute cerebellar syndrome

93
Q

Vinca alkaloids

A

Vincristine, vinblastine Binds to tubulin in M phase - inhibits mitosis (antimicrotubule agent) Peripheral neuropathy (Vinc>vinb) Jaw pain Extravasation - vesicant Constipation, alopecia SIADH Minimal myelosupp Vincristine is fatal if given IT

94
Q

Side effects of L-asparaginase?

A

Used in ALL, inhibits protein synthesis (G1) Anaphylaxis Hyperglycaemia Pancreatitis Coagulopathy / platelet dysfunction Encephalopathy

95
Q

6 mercaptopurine

A

inhibits purine synthesis (S phase) SE Myelosuppression (worsened by allopurinol ; increased 6TGN) Mucositis

96
Q

Chemo agents in cell phase cycle

A
97
Q

Risk factors for graft failure post BMT

A
  • HLA mismatch (also causes GVHD)
  • Low TNC dose from donor graft
  • Previous multiple transfusions (older child >10)
  • Infections
  • GVHD
  • Drugs(myelosupp - aciclovir, cotrimox, MTX)

Paeds (25 decks)

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