Oncology, Neurology Flashcards
How is childhood cancer classified?
ICCC (International classification of childhood cancer)
Based on tumour morphology (cell origin) and primary site
Standard classification is essential for comparing incidence & survival across regions & time periods
When are children more likely to get cancer?
At a younger age (0-4yo)
15-24 yo = another peak as they have an increased risk of germ cell tumours and lymphomas
In 10% what are possible causes that may be identified for cancer?
- Genes (Down, Fanconi, BWS, Li-Fraumeni familial cancer syndrome, neurofibromatosis)
- Environment (radiation, infection(e.g. EBV))
- Iatrogenic (RT, chemo)
Is child cancer sporadic?
Usually yes but it is important to ask about risk factors
What makes the categories for referral in child cancer?
IMMEDIATE=unexplained petechiae, hepatosplenomegaly
URGENT=repeated attendance, same problem, no clear diagnosis OR new neuro symptoms, abdo mass
REFER (to doctor or for urgent investigation)=rest pain, back pain & unexplained lump, lymphadenopathy
What are some examples of oncological emergencies?
- Sepsis/febrile neutropenia
- Raised ICP
- Spinal cord compression
- Mediastinal mass
- Tumour lysis syndrome
What are risks for sepsis/febrile neutropenia?
ANC< 0.5 x10 to the 9
Indwelling catheter
Mucosal inflam
High dose chemo/SCT
How do those with sepsis/febrile neutropenia present?
- Fever (or low temp)
- Rigors
- Drowsiness
- Shock (metabolic acidosis)
If child is not responding to simple measures and has significant shock sometimes they need ionotropic support to help their BP, transferred to PICU
What is the early presentation of raised ICP?
- Early morning headache/vomiting
- Tense fontanelle
- Increasing HC (head circumference)
What are the signs of late presentation of raised ICP?
- Constant headache
- Papilloedema
- Diplopia (VI palsy)
- Loss of upgaze
- Neck stiffness
- Status epilepticus
- Reduced GCS
- Cushing’s triad (low HR, high BP, falling RR)
What is the investigation for raised ICP?
Imaging mandatory if safe
CT is good for screening
MRI is best for more accurate diagnosis
What is the management of raised ICP?
DEXAMETHASONE if due to tumour (reduce oedema & increase CSF flow)
NEUROSURGERY-urgent CSF diversion
- Ventriculostomy-hole in membrane at base of 3rd ventricle with endoscope
- EVD (temporary)
- VP shunt
In whom is spinal cord compression more common (potential complication of nearly all paed malignancies)?
Ewing’s or Medulloblastoma
When does spinal cord compression arise and what is the pathological process of it?
Diagnosis of cancer(65%), relapse, progression
- Invasion from paravertebral disease via intervertebral foramina (40% extradural)
- Vertebral body compression (30%)
- CSF seeding
- Direct invasion
What is the presentation of spinal cord compression?
Symptoms vary with level
- WEAKNESS
- PAIN
- SENSORY
- SPHINCTER DISTURBANCE
How is spinal cord compression managed?
- URGENT MRI
- Start DEXAMETHASONE urgently to reduce peri-tumour oedema
- Definitive treatment with chemo is appropriate when rapid response is expected (surgery or RT are other options)
What does the outcome of spinal cord compression depend on?
- Severity of impairment rather than the duration between symptoms and diagnosis
(Mild impairment >90% recovery, Paraplegic 65% recovery)
SVC syndrome (or SMS) is rare (<1% of new paediatric malignancies): what are the common causes of it?
- LYMPHOMA
- Other=neuroblastoma, germ cell tumour, thrombosis
How does SVC syndrome and SMS present and how is it investigated?
SVCS: facial, neck and upper thoracic plethora, oedema, cyanosis, distended veins, ill, anxious, reduced GCS
SMS: dyspnoea, tachypnoea, cough, wheeze, stridor, orthopnoea
Investigation:
CXR / CT chest (if able to tolerate)
Echo
What is the management of SVCS and SMS?
Keep upright & calm
Urgent biopsy (ideally)
Look to obtain important diagnostic information without GA
FBC, BM, pleural aspirate, GCT markers
Definitive treatment is required urgently:
- Chemotherapy is usually rapidly effective
- Presumptive treatment may be needed in the absence of a definitive histological diagnosis (steroids)
- RT is effective (May cause initial increased respiratory distress)
- Rarely surgery if insensitive
- CVAD-associated thrombosis should be treated by thrombolytic therapy
Most of underlying malignancies have a good prognosis
What is tumour lysis syndrome caused by?
Metabolic derangement
Rapid death of Tumour Cells
Release of intracellular contents
At or shortly after presentation
Secondary to treatment
(rarely spontaneous)
What are the clinical features of tumour lysis syndrome?
INCREASED potassium, urate-relatively insoluble, phosphate
REDUCED calcium
Acute renal failure:
Urate load
CaPO4 deposition in renal tubules
What is the treatment of tumour lysis syndrome?
Avoidance
ECG Monitoring
Hyperhydrate-2.5l/m2
QDS electrolytes
Diuresis
NEVER GIVE POTTASIUM (or phosphate)
Decrease uric acid:
- Urate Oxidase-uricozyme (rasburicase)-acute setting
- Allopurinol
Treat hyperkalaemia:
Ca Resonium
Salbutamol
Insulin
Renal replacement therapy
What do oncologists use to see what cancer is and what harm it is causing?
- Scans
- Biopsy/pathology
- Cytogenetics
- Tumour markers