Oncology: Intro to Pediatric Oncology Flashcards
1
Q
What is Cx?
A
“broad group of dis’s involving unregulated cell growth. In cx, cells divide and grow uncontrollably, forming malignant tumors, which may invade nearby parts of body.”
2
Q
Medical Interventions for Cx DEPENDS ON 3 THINGS:
A
- TYPE
- GRADE
- STAGE of Cx
3
Q
PRIMARY intervention used for MOST Cx
A
Chemotherapy
4
Q
Chemo MAY be combined w/ what other forms of Tx?
A
Radiation tx
Sx for tumor removal
5
Q
Chemo related terms
Adverse Effects—–
A
UNWANTED responses to Tx, may be immediate OR persistent
6
Q
Chemo related terms:
Persistent Effects—–
A
relate to late term or long term effects of Cx tx
7
Q
Chemo/Cx related Side effects/Adverse Effects
A
- Nausea/vom
- dizziness/vertigo
- PAIN
- Fatigue–Cx related fatigue**
- dyspnea
- anorexia
- coughing
- 2* malignancies**
-
Thrombocytopenia
- bed rest typ results from any of above
8
Q
PERSISTENT effects aka
A
LONG TERM EFFECTS
9
Q
PERSISTEN EFFECTS consist of:
7:
A
- 2* Cx’s
- organ damage
- Infertility
- chronic hepatitis
- Alterations in growth and development
- PEDS
-
impaired cognitive functioning
- CNS tumors
-
Toxicity
- MOST related to the medical mgmt of Primary Cx
10
Q
These 2 types of Cx acct for more than HALF of ALL CHILDHOOD CX
A
- Leukemias
- Cx of CNS
11
Q
1/3 Cx in children are…..
A
Leukemias
12
Q
MOST COMMON TYPE OF Leukemia in Children
A
Acute Lymphoblastic Leukemia
ALL
13
Q
Most common Solid tumors in children
A
- BRAIN TUMORS
- Gliomas
- Meduloblastomas
14
Q
Other LESS COMMON SOLID TUMORS in children
A
- Neuroblastomas
- Wilms tumor
- Sarcomas
15
Q
MOST COMMON TYPE OF PEDIATRIC Cx
A
ALL
Acute lymphoblastic leukemia
16
Q
ALL (most common pediatric cx)
Cancer of _____ and ______
A
Cx of blood and bone marrow
17
Q
Describe ALL
Cx of blood and bone marrow
A
- malignant proliferation of immature WBCs, beginning in bone marrow
- Leukemia cells crowd out Norm blood cells and cause:
-
Anemia
- reduced RBCs
-
Bruising
- reduced plts
-
INCd infection risk
- DECd norm WBCs
-
Anemia
18
Q
Possible Risk Factors/Causes for ALL
5:
A
- being exposed to X-rays before birth
- being exposed to radiation
- Past tx w/ chemo
- having certain changes in genes
-
Genetic cond’s
* Down syndrome
* Neurofibromatosis type 1 (NF1)
-
Genetic cond’s
19
Q
WARNING SIGNS OF ALL
A
- Persistent (long term) fever
- easy bruising or bleeding
-
Petechiae
-
flat, pinpoint, dark-red spots UNDER skin caused by bleeding
- rash-like, internal bleeding
-
flat, pinpoint, dark-red spots UNDER skin caused by bleeding
- Unexplained bone or jt pain
- Painless lumps in the neck, underarm, stomach, groin
- inflamed lymph nodes
- pain or feeling of fullness below ribs
- weak, tired, pale
- Loss of appetite
20
Q
Multitude of tests performed to Dx ALL
A
- Hx and physical
- CBC
- Blood chem studies
- Bone Marrow Aspiration/Biopsy
- Cytogenic analysis
21
Q
Prognostic Factors for ALL
# of WBCs in the blood @ Dx
A
LOWER #===POOR
22
Q
Prognostic factors ALL
A
- # Of WBCs in the blood @ Dx
- LOWER==POOR
- Whether there are certain changes in the chromosomes or genes of the lymphocytes w/ cx
- POOR
- whether the child has Down Syndrome
- POOR
- whether leukemia cells are found in the CSF
- POOR
- how quickly and how low the leukemia cell count drops AFTER initial Tx
- BETTER w/ FASTER drop rate
23
Q
Survival rate for ALL w/ medical intervention
A
~80%
24
Q
4 Modes of Tx used for ALL
A
- Chemo (but toxic)
- Radiation
- Stem cell transplasnt
- Targeted Therapy
25
Tx used for **ALL**
**5. what is Targeted Therapy?**
* tx that uses **drugs or other substances** to **ID and attack specific cx cells** w/out harming NORMAL CELLS
26
SIDE EFFECTS OF MEDICAL INTERVENTION
## Footnote
**Chemo agents often associated w/ \_\_\_\_\_\_\_\_\_\_**
Neuropathy
27
SIDE EFFECTS OF MEDICAL INTERVENTION
Chemo agents often associated w/ **Neuropathy**
**explain other SEs of Chemo**
* **Vincristine==** one of the drugs used
* toxic--\> **causes peripheral neuropathy**
* chemo successful in killing cancer
* chemo is toxic to body
* **Peripheral neuropathy common SE**
* ****so we will see **Foot drop**
28
SIDE EFFECTS OF MEDICAL INTERVENTION
Another Tx other than chemo...
**Methotrexate**
* helps to STOP GROWTH of cx cells
* may lead to **Roid rage** and mood difficulties
29
SHORT and LONG-TERM complications of **ALL/Medical Tx**
* PAIN
* parasthesias--\> **distal UE/LE**
* reduced DTRs
* mm cramps
* learning disabilities
* **miss school**
* AVN
* **Osteopenia/osteoporosis**
* **esp w/ long term steroid use**
* **HIGH Fx RISK\*\***
* Impaired gross and fine motor skills
* mm weakness
* DECd energy expenditure
30
Role of PT in **ALL**
## Footnote
**in general...**
* COMBAT 2\* effects of **bed rest**
* **cx fatigue**
* **chemo toxicity**
31
Role of PT in **ALL**
## Footnote
**Research shows children w/ ALL have deficits in MULTIPLE AREAS both DURING and AFTER tx**
**examples?**
* Cardiopulm fitness
* LOW activity lvl
* Strength
* ROM
* Motor skills
* Balance
32
Obesity affects _______ children w/ **ALL**
## Footnote
**\*long term steroid use**
**\*gain wt during medical tx and are unable to lose after tx is complete**
11-57%
33
Vincristine related neuropathies
may also require PT
34
BRAIN tumor common in children
Medulloblastoma
35
Medulloblastoma is a form of **brain tumor that arises WHERE?**
Posterior Fossa
* **approx 40% of all post fossa tumors**
* **\*\*80% of medulloblastomas arise in the region of the _4th ventricle_**
36
**Medulloblastoma warning signs**
**EARLY sx's are related to what?**
BLOCKAGE of **CSF** and **resultant _hydrocephalus_**
37
Medulloblastoma Warning Signs
## Footnote
**commonly present w/:**
* **relatively abrupt** onset of HA's
* vomiting
* lethargy
* Unsteadiness-- **truncal unsteadiness**
* some degree of **nystagmus**
* **Papilledema**
38
Medulloblastoma warning signs:
## Footnote
**INFANTS--presentation is variable**
* NONSPECIFIC lethargy
* psychomotor delays
* **loss of developmental milestones**
* feeding diff's
* **Bulging of the _anterior fontanel_** due to **INCd ICP AND abnormal eye mvmts**
* **Anterior fontanel** is hole in top of skull
* closes by 24mos
* early as 12mos
* **look for bulging here from Hydrocephalus**
39
Prognostic Factors for **Medulloblastoma**
* **Extent** of dis @ Dx
* LARGER tumor==poorer prognosis
* Age @ dx
* **\<3 NOT favorable**
* amt of **residual disease after definitive sx**
* **POOR prognosis if unable to resect all dis'd tissue**
* Tumor histopathology/tumor cell characteristics
* **Survival rates vary**
40
Medical tx's for **Medulloblastoma**
* Sx to resect tumor
* **total or partial resection performed IF SAFE TO DO SO**
* Additional tx's:
* **chemo + radiation**
* **compliment the Sx**
* ****shrink tumor and attack metastatic dis.
41
Post-op Presentation of **Medulloblastoma**
* SIGNIFICANT **neurological deficits** caused by **pre-op tumor related brain injury OR Sx-related brain injury**
42
Post-op Presentation of **Medulloblastoma**
**Cerebellar Mutism Syndrome aka Posterior Fossa Syndrome**
Sx's:
**Directly from trauma in brain--** Pre-op Hydrocephalus, Sx trauma
* delayed onset of speech
* Suprabulbar palsies
* Ataxia
* Hypotonia
* Emotional lability
43
Tx Considerations for Pts w/ Brain Tumors
* Tx pt as if they had sustained a **TBI**
* Assess stage of **Recovery (Ranchos Scale)**
* Lvl of **alertness**
* Higher cognitive functioning
* **Neuro impairments MAY be main focus**
44
Asssessing lvl of Recovery for **Medulloblastoma**
**TBI related**
**\*NOTE:** try to move them thru scale
see pics
45
SOLID Bone Tumor----
Osteosarcoma
46
What is an **Osteosarcoma aka Osteogenic sarcoma**
EXTREMELY **malignant tumor affecting BONE**
47
What is the **MAIN CHARACTERISTIC of Osteosarcoma?**
## Footnote
**MAIN:**
Presence of **Osteoid, or immature bone**
* **produced by malignant cells W/IN BONE**
48
Osteosarcoma can present as _____ or ______ Dx
PRIMARY
or
SECONDARY
49
**Primary** Osteosarcoma
## Footnote
**Tumor develops where?**
PRIMARY tumor develops in **Bone**
50
**Secondary** Osteosarcoma
## Footnote
**Tumor is FROM where**
* Tumor is **metastasis FROM ANOTHER SITE W/IN body**
51
Osteosarcoma is
RARE!!!
52
Out of all bone cx dx in children, osteosarcoma accts for \_\_\_\_\_\_\_\_
50% of them
53
When is Osteosarcoma dx most often?
Children + ado's w/ **peak incidence** durng **pubescent growth spurts**
54
Osteosarcoma more freq dx in \_\_\_\_\_
MALES
55
OSTEOSARCOMA most often occurs @\_\_\_\_\_\_\_
metaphyseal portion of **most actively growing bones**
## Footnote
**femur, tibia, prox humerus, pelvis**
56
Etiology of Osteosarcoma
* exposure to **ionizing radiation and chem factors**
* **genetic mutation**
* **Bone sarcomas may be induced by viruses**
* **\*possible genetic component**
57
Risk Factors for **Osteosarcoma**
\*genetic disorders
\*NO MODIFIABLE RISK FACTORS AT THIS TIME
58
**Osteosarcoma is known to originate from \_\_\_\_\_\_**
poorly differentiated (immature) cells in **osteoblasts**
59
**Theorized that osteosarcoma results from ERROR that occurs in what?**
Error in the **cells responsible for development and remodeling of bones**
* **DESTROYS CORTEX ===\> Pathological Fx**
60
What do **Osteosarcoma tumors** look like?
LARGE, vicious w/ a **_moth-eaten_** pattern of destruction
* weakens bone structure
* **Dx'd bc fx from MINOR trauma EASILY**
61
Clinical manifestations **osteosarcoma**
## Footnote
**Often appear in BONES during what?**
Appears in bones during **active growth phases AND in ado's @ the epiphyseal plate during growth spurts**
62
PRIMARY COMPLAINT OF PAIN w/ **Osteosarcoma**
Tumor growth into **joint space an surrounding tissues @ tumor site**
**\*Often mistaken for "growing pains" \*\*\*\***
63
Osteosarcoma and PAIN
At first, **pain is min. and intermittent, as tumor GROWS, pain intensifies in _severity and duration_** **and will eventually req. meds for pain relief**
64
PAIN assoc'd w/ **Osteosarcoma**
NO resolution w/ rest (**Red Flag)**
May cause night-time waking (**Red Flag)**
65
**PAIN and Osteosarcoma**
pain may be present several weeks to mo's w/ **notable mass dev. prior to dx**
**\*NOTE: diffuse pain reports prolong dx**
66
TUMOR GROWTH and **Osteosarcoma**
Tumor grows RAPIDLY
Swelling @ joint
**ROM restricts after only a few weeks**
67
Integumentary manifestations and **Osteosarcoma**
Warming of the skin surrounding tumor
68
Systemic symptoms and **Osteosarcoma**
RARE, but **fever may occur in SEVERE cases**
69
HOW are **osteosarcoma dx made?**
* Radiographs
* **MRI**
* **more precise**
* **CT**
* **more precise**
* **etc....**
70
POSSIBLE presentation of **Osteosarcoma**
## Footnote
**Jt. Swelling**
see pics
71
Radiographys of **Osteosarcoma**
## Footnote
**AP and Lateral views**
see pics
72
MRI **Distal Left Femur OSTEOSARCOMA**
SEE PICS
73
MEDICAL MGMT **OSTEOSARCOMA**
## Footnote
**3 MAJOR GOALS:**
1. **Completely** and **permanently** control the **primary tumor**
2. **Control and prevent _micro-static_ and** **_metastatic disease_**
3. **Preservation of FUNCTION\*\***
**\*NOTE:** To achieve these goals, Tx regimens typ COMBINE **Sx w/ BOTH pre-and post-op chemo+radiation**
74
**Bennies of Chemotherapy**
**3:**
* Control **growth and development** of tumor
* **Shrink size of primary tumor** in order to **INC feasibility of _limb salvage proc's_** **OR DEC amt of amputation needed**
* Control **undetected micrometastatic lesions**
* ****w/ **Osteosarcoma--\>** we get tiny areas of Mets
* WANT TO CONTROL THESE!!!
75
Prognosis for **Osteosarcoma**
## Footnote
**DEPENDS ON: 2**
1. **Stage @ Dx**
**2. Excision (removal) success**
76
Osteosarcoma
## Footnote
**Chemo + Sx results**
5yr cure rates of 70-80% \*\*\*
77
Osteosarcoma Prognosis
## Footnote
**Poor prognosis assoc'd w/:**
* Axial lesions
* INCd tumor size
* Poor response to chemo
* **Presence of metastatic dis.**
* **often to LUNGS**
* **Local reoccurrence**
78
Talk about Sx options, types of Sx w/ **Osteosarcoma**
## Footnote
**This all depends on what ?**
* TYPE of Sx performed depends on:
* **pts age**
* **loc+size of tumor**
* **extramedullary extent**
* **presence of Mets**
* **skeletal development**
* **overall lifestyle**
79
Actual TYPES of Sx intervention **Osteosarcoma**
1. Amputation
2. Limb Salvage
3. Rotationplasty or **turnabout procedure**
80
**Osteosarcoma Sx Interventions**
**Amputation**
**3 things to know:**
* surgical margin==**6-7cm ABOVE most prox extent of tumor**
* allows for removal of **tumor AND small lesions in the area _surrounding the primary tumor site_**
* affords pts w/ the **greatest length of residual limb possible**
81
Amputation example:
## Footnote
**Resected Left Distal Femur Osteosarcoma**
TAKE NOTE: **size of prox femur bone and condyles compared to tumor site**
82
Osteosarcoma Sx Intervention
## Footnote
**Limb Salvage**
* involves **excision of the bone tumor AND surrounding tissue** w/ **reconstruction of the limb** **in order to _preserve function_**
* Components:
* **allografts**
* **endoprosthetic implants**
* **\*\*80-90% of pts w/ Osteosarcoma are tx'd w/ Limb Salvage Sx**
83
Osteosarcoma Sx Intervention
## Footnote
**Rotationplasty**
**\*Ankle functions as the knee one\*\*\***
**Indicated for WHAT pts?**
* indicated for those pts w/ **tumor sites @ _proximal tibia_ OR _distal femur_**
84
Osteosarcoma Sx Interventions
## Footnote
**Rotationplasty**
**\*Ankle functions as knee one\*\*\***
* tumor sites @ Prox tibia OR Dist Femur
* Involves **excision of tumor site, dist femur AND prox tibia w/ 180deg rotation of the ENTIRE LIMB including neurovascular supply\*\*\***
* **AFTER rotation--**the rotate **ankle** functions as a **knee joint,** thereby powering a **custom-made below-knee prosthesis**
* Requires **functioning hip joint** and that the tumor NOT have invaded surrounding **soft tissue or neurovascular supply**
85
POST- Rotationplasty
## Footnote
**osteosarcoma Sx intervention**
see pics!
86
Rotationplasty
see pics
87
Osteosarcoma Specific Tx
## Footnote
**Phase ONE: ACUTE CARE PHASE**
* MOST pts referred to PT **after medical mgmt initiated....but you may be FIRST healthcare worker to recognize s/s in pts w/ _diffuse jt pain in outpatient_**
* Tx's vary slightly **based on sx intervention**
* **work closely w/ medical staff** to coord. meds
* **Be aware of** **_immune system precautions_**
* Lab values should be checked for contraindications DAILY
* be mindful of **chemo SE's**
88
**Osteosarcoma Specific Tx**
**Phase ONE: ACUTE CARE PHASE**
* Usually referred IMMEDIATELY POST-OP:
* **early mobilization**
* **prevent neg. bed rest comps**
* **document skin integrity is INTEGRAL in assisting in skin healing and prevents comps**
* **education regarding _positioning_**
* **__In general...**
* **avoid pos's of COMFORT**
* **promote PRONE**
* **may begin desensitization programs for residual limb**
* Caution w/ **WB status**
* Strengthen and maint ROM in surrounding tissues and joints
* Chest PT indicated w/ **pulm involvement**
89
Osteosarcoma Specific Tx
Phase ONE: ACUTE CARE PHASE
**WHY would chest PT be indicated in this phase??**
* Post-sx
* **prolonged anasthesia predisposes us to residual fluid in lungs**
* **assist w/ breathing and clearing fluid**
* **assisted cough\*\* BIG for post-sx**
* **incentive spirometer\*\*\***
90
Osteosarcoma Specific Tx
## Footnote
**Phase TWO: REHAB**
* cont'd strengthening of BOTH **sound limb** AND **operative limb** as well as **abdomen and UEs (we don't want overuse injuries)**
* **BALANCE training (esp if COM changed from amputation)**
* Endurance building/energy conservation
* Maximize FUNCTION w/ approp ADs
* Pre-prosthetic and prosthetic fitting/training
* **remember to incorporate age approp play and ADLs into sessions w/ children. This also include acts needed for school ie; circle time, gym class**
91
**Osteosarcoma Specific Tx**
**Phase THREE: OUTPATIENT**
* Cont'd adjustment and prosthetic training
* endurance/CV training
* INC **diversity of function** in diff environments
* ex. progress AD, uneven surfs
* sports/play/age approp activity
\***NOTE:** some children will not req this phase
92
Gen PT Tx Considerations
## Footnote
**Oncology overall**
* Med mgmt may have mult. comps
* monitor VITALS and pt responses during tx\*\*
* Pt/parent/family education:
* **safety awareness**
* **energy conservation**
* **fall prevention**
* **positioning**
* **Refer pt and family members as needed to other disciplines**
* **Cx devastating/debilitating @ any age**
* **PSYCHOLOGY IMPORTANT!!!**
93
GEN ONCOLOGY TX
LAB VALUES!!!
**WBC: modify when?**
* if **severe leukopenia (neutropenia)**
94
**GEN ONCOLOGY TX**
**LAB VALUES!!!**
**HGB: modify when?**
* if **severe Anemia**
95
**GEN ONCOLOGY TX**
**LAB VALUES!!!**
**Hct: modify when?**
* if **severe anemia**
96
**GEN ONCOLOGY TX**
**LAB VALUES!!!**
**Plts: modify when?**
* if **Thrombocytopenia (hemorrhaging risk)**
97
**GEN ONCOLOGY TX**
**BED REST SKILLS**
* GET Pts MOVING
* **aids in combating _cx related fatigue_**
* **Mind and Body tx's--\> confidence, coping abilities**
* ****breathing
* massage
* visualization
98
**GEN ONCOLOGY TX**
**OTHER**
* Work to resolve **clinical impairs**
* Incorporate **preferred acts into tx**
* **try to CONNECT**
* **take interest in THEIR interests**
99
CRITICAL BLOOD COUNT GUIDELINES\*\*
WBCS
**NORMAL: 5-10 cells/mm^3**
* **1.0-5.0 W/OUT fever + stable or trending UP**
* **PROCEED W/ PT**
* **1.0-5.0 w/ fever + trending DOWN**
* **Leukopenia (neutropenia)==MODIFY PT**
* **\<1.0--\> MODIFY for SEVERE leukopenia (neutropenia)**
**\***Exercise is diff than low lvl mobilization
\*Simple low lvl acts can be performed in bed or chair
* ankle circles
* quad and glute sets
* arm circles
100
CRITICAL BLOOD COUNT GUIDELINES\*\*
**HEMOGLOBIN (Hb or HgB)**
**NORMAL: Males=14-17 g/dL Females=12-16 g/dL**
* O2 carrying capacity of blood
* **Hb \<7--MODIFY PT for _Severe_ Anemia**
* **NO EX. permitted; essential daily act only**
* **Hb 7-8--MODIFY PT for anemia**
* **light ex OK; light aerobics, lt wts**
101
CRITICAL BLOOD COUNT GUIDELINES\*\*
## Footnote
**Hematocrit (HCT)**
**NORMAL: Males=42-52% Female=37-47%**
* **% of Whole blood volume which is composed of RBCs**
* **HCT \<15-20%-- MODIFY PT for _severe_ anemia**
* **NO ex; essential ADLs only**
* **HCT 20-25%--MODIFY PT for anemia**
* **lt ex OK, lt aerobics, lt wts**
102
CRITICAL BLOOD COUNT GUIDELINES\*\*
## Footnote
**Platelets (PLT)**
**NORMAL=**
* **Sm cell components involved in _hemostasis_**
* **__\<20,000--MODIFY PT for bleeding or hemorrhage risk**
* ****NO EX; essential ADLs only
* **20,000-50,000--MODIFY PT**
* ****lt ex OK, lt aerobics, lt wts
* trending DOWN==**thrombocytopenia**
103
PEDS Oncology Summary
* PTs play **integral role** in **care and mgmt** of oncology pop. across all therapy settings and can make a **diff in a pts overall functioning and QOL!!!**
104
