1. Alterations in Cellular Growth
Elizabeth Allen RN, MSN
Alterations in Cellular Growth

2. Childhood Cancers Learning Outcomes
Describe Incidence, Etiologies, and Manifestations of Pediatric Cancers
Categorize different types of cancer prevalent in the pediatric population
Identify the types of isolation and precautions needed for immunocompromised patients
Synthesize Information about Diagnostic Tests and Clinical Therapies to create a plan of care
Identify nursing care unique to pediatric patients with cancer and their families
Childhood Cancers

3. Childhood Cancers Neoplasm = “New Growth” Incidence
Benign = no danger to life or health
Malignant = can grow and spread
Metastasis = spread of malignancy
Incidence
US- approximately 11,000 children diagnosed per year
US- approximately 1,500 die per year (American Cancer Society (ACS))
Overall survival rate is 80% (ACS)
Varies depending on type of cancer
Childhood Cancers

4. Childhood Cancers Etiology Neoplasms caused by Carcinogens
Chemicals, radiation
Cause of more adult cancers
Immune system and Gene Abnormalities
Congenital or triggered by virus
Chromosomal Abnormalities
Congenital risk for specific cancers
For example, leukemia and Down syndrome link
Childhood Cancers

5. Childhood Cancers Pediatric Cancers
Much rarer
Faster growing
Pathophysiology Process is similar to adult cancers
Childhood Cancers

6. Signs of Childhood Cancer
Pain
Cachexia
Fatigue, weakness and significant loss of appetite in someone who is not actively trying to lose weight.
Anemia
Infections
Bacterial, Viral, Fungal
Bruising or Petechiae
Without consistent injury
Neurologic Changes
Palpable Mass
Once found do not continue to palpate
Pain from neoplasm or from nerve pain related to neoplasm
Anemia- iron deficiency or related to bone marrow cancers that decrease RBC production
Infection due to altered or immature immune system cells
Bruising related to decreased platelet production in the bone marrow
Neurologic changes- related to increased ICP or obstruction of CSF, impingement on spinal cord
Palpable mass most commonly in abdomen
Signs of Childhood Cancer

7. Diagnostic Tests Internal Imaging Cell Visualization Direct biopsy CBC
Bone marrow aspiration
Lumbar puncture
Radiograph
Ultrasound
MRI CT
Diagnostic Tests

8. Figure 23–3 Computed tomography (CT) can be a frightening procedure for children. This 2-year-old boy is comforted by his father before the procedure.
(London et al., 2014)
Childhood Cancers

9. Childhood Cancer Treatment
Remove the Cancer
Surgery
Inhibit Growth of Rapidly Growing Cells
Chemotherapy and radiation
Assist Immune System to Destroy Cancer
Biotherapy
Replace Cancerous Bone Marrow
Hematopoietic stem cell transplant (Bone Marrow Transplant)
Treatment Goal may be curative, supportive or end of life care
Often treated with a combination of therapies
Surgery- remove or debulk a solid tumor
Biotherapy- using biologic agents to promote immune system response
Bone marrow transplant may be autologous or allogeneic. Stem cells from umbilical cord blood or circulating blood stem cells
Childhood Cancer Treatment

10. Oncologic Emergencies
Metabolic
Electrolyte imbalance from tumor lysis
Septic shock due to infection toxins
Hypercalcemia from bone breakdown
Hematologic
Pancytopenic effects: bleeding, anemia, infections
Space-Occupying Lesions
Pressure on: spinal cord, circulation, nerves, organs
Tumor Lysis Syndrome is products from a dissolving or decomposing tumor released into the body. Releases uric acid, potassium, phosphates and calcium and decreases sodium. Affects cellular regulation throughout the body
Septic shock risk elevated with immune system suppression
Pancytopenic effects- decreased blood cells cause bleeding, anemia and infections
Oncologic Emergencies

11. Childhood Cancers Wilm’s Tumor (Nephroblastoma)
Discussed with Elimination Disorders
Congenital Renal tumor
Fast Growing
Peak incidence 2-3 years
Do not palpate! Careful handling of patient
Nephrectomy and staging
Childhood Cancers

12. Leukemia “White Blood” Affects bone marrow Anemia Neutropenia
Nonfunctioning WBC
Proliferation of immature WBC
Diagnosis confirmation with bone marrow aspiration
Affects bone marrow
Anemia
Neutropenia
Decreased platelet production
Pancytopenia from bone marrow dysfunction- the malignant WBCs replace the stem cells that produce erythrocytes (RBCs) and platelets. Causes anemia and thrombocytopenia
Nonfunctioning, immature WBCs replace normally functioning WBCs leading to Neutropenia (decreased ability to fight infection)
Leukemia

13. Leukemia Classification Lymphoblastic
Acute Lymphoblastic Leukemia (ALL)
25% of all cancers in children
78% of leukemias in children
Peak age 2-3 years
Acute Myelogenous Leukemia (AML)
17% childhood leukemias
Most common <2 years & adolescents
Nonlymphoblastic (ANLL)
Thing to remember is that ALL more common, peak 2-3 years. AML less common, requires longer hospitalizations and most common in adolescents
Leukemia

14. Figure 23–17 Acute lymphoblastic leukemia is the most common type of leukemia in children and the most common cancer affecting children under 5 years of age.
Childhood Cancers

15. Leukemia Risk Factors for Leukemia Genetic Viral infection
Environmental (Carcinogens)
Radiation
Chemicals
Medications
Genetic factors play a role in some types of the disease- chromosomal abnormalities are present in most children with ALL. Increased incidence with some genetic syndromes (ie Down’s) and with some ethnicities.
Radiation exposure may be from CT scans, previous radiation treatment for other type of cancer
Leukemia

16. Leukemia Assessment Assessment Fever Fatigue, lethargy Pallor Anorexia
Petechiae, bleeding
Large joint/bone pain
Hepatosplenomegaly
Lymphadenophathy
CNS infiltration by Leukemia
Signs of Increased ICP
Headache, vomiting
Papilledema
Sixth Cranial Nerve Palsy
Petechiae, frank bleeding and joint pain are cardinal signs of bone marrow failure
Papilledema- swelling of the optic disk related to increased ICP, sixth nerve palsy- eye can’t move laterally
Leukemia

17. Diagnostic Tests WBC (Increase in Leukocytes) H/H Decreased
Platelet count Decreased
Leukemic blast (immature) phase cells – fill the bone marrow
CXR
CBC will show elevated WBC count with large amounts of immature WBCs and decreased neutrophils on differential. The immature WBCs crowd the bone marrow replacing stem cells that produce RBCs and Platelets.
CXR can detect enlarged thymus or lymph nodes in chest, possible pneumonia
Diagnostic Tests

18. Nursing Care Bleeding Control Nutrition Chemotherapy (4 Phases)
Platelet transfusion
Packed RBC’s
Nutrition
Age appropriate
Nasogastric
TPN/ IL
Chemotherapy (4 Phases)
Induction
Intensification or consolidation
Central nervous system prophylactic
Maintenance
The high metabolic rate of cancer growth depletes the child’s nutritional stores, nausea and vomiting from treatments. Child needs increased nutritional intake oral, NGT or TPN/IL
Nursing Care

19. Childhood Cancers Retinoblastoma Retinal malignancy
White pupil, changes in red reflex
40% of cases are autosomal dominant gene
Pathophysiology
Intraocular malignancy of the retina
Leukokoria
Red reflex absent
Strabismus
Glaucoma
Heterochromia
Leukokoria is a white reflection in the pupil- seen here. Usually first sign
Heterochromia is different colored eyes on the same person
Childhood Cancers

20. Retinoblastoma Usually diagnosed between 1-2 years Treatment
Family history- frequent ophthalmologic examinations
Treatment
Cryotherapy
Photocoagulation
Radiation
Chemotherapy
Assessment
Height/Weight/Tumor area
No palpation
GI/GU
Surgery for removal of the eye
Conformer
Usually radiation with retinoblastoma because chemo doesn’t penetrate very well into retinal tissue
Gastrointestinal and genitourinary function may be altered by tumor and by treatment. Monitor I/O
Retinoblastoma

21. Childhood Cancers Nursing Care Reduce Fear through Education Resource
Cancer, treatment, treatment effects
Coping skills
Resource
National Cancer Institute
Childhood Cancers

22. Childhood Cancers Psychosocial Support Developmental Level Child
Siblings
Family
Resource:
American Cancer Society
Childhood Cancers

23. Figure 23–9 One of the most common threats to a child’s body image at any age is hair loss induced by chemotherapy. Use of hats can improve self-concept.
Childhood Cancers

24. Bone marrow suppression: Nadir is the lowest point of WBC count approx 10 days after chemo
(London, et. al., 2014)

25. Nursing Care ANC: Absolute Neutrophil Count Protective Isolation
What type of isolation
do these kids need?
Infection control
Skin
Respiratory
IV contamination
ANC: Absolute Neutrophil Count
Protective Isolation
Neutropenic Precautions, Reverse Isolation
Reverse Isolation
Positive Pressure Room
Daily Cleaning of Surfaces
No live plants or fresh foods
(London, et. al., 2014)
Nursing Care