SUBMITTED TO:- SUBMITTED BY:

Ms Jahanara Maam MS.Meena

Asst. Professor M.sc (nursing)2nd Yr
 INTRODUCTION

Paediatric oncology is the branch of medicine

concerned with the diagnosis and treatment of cancer in
children. Childhood cancers are a rare but important
cause of morbidity and mortality in children younger
than 15 yrs. of age.
 Common childhood malignancies
include leukaemia’s (30-40%), brain
tumours (20%) and lymphoma
(12%) followed by neuroblastoma,
retinoblastoma and tumours
arising from soft tissues, bones and
gonads
Cancer is a group of diseases involving
abnormal cell growth with the potential to
invade or spread to other parts of the body.
These contrast with benign tumours,
which do not spread to other parts of the
body.
 Possible signs and symptoms include a
lump, abnormal bleeding, prolonged
cough, unexplained weight loss and a
change in bowel movements.
Types of oncological disorder in children :-
 Neuroblastoma
 Wilms tumour
 Non-Hodgkin lymphoma
 Hodgkin lymphoma
 Childhood rhabdomyosarcoma
 Retinoblastoma
 Osteosarcoma
 Ewing sarcoma
 Germ cell tumour
 Pleuropulmonary blastoma
 Hepatoblastoma and hepatocellular carcinoma
NEUROBLASTOMA
Neuroblastoma is the most common intra-
abdominal and extra cranial solid tumour
in children, and the most common
tumour in infancy. Neuroblastoma and
related neoplasms arise from those neural
crest cells which differentiate in to cells of
the sympathetic ganglia and adrenal
medulla.
ETIOLOGY
Neuroblastoma is derived from neural
crest cells that form the adrenal medulla
and the sympathetic nervous system. The
cause is unknown.
Most cases occur in young children; thus,
it is likely that neuroblastoma results from
prenatal and perinatal events.
PATHOPHYSIOLOGY
 Neuroblastomas are soft, solid tumours originating
from neural crest cells that are precursors of the
adrenal medulla and sympathetic nervous system.
Neuroblastomas can occur where sympathetic
nervous tissue is found.
 The majority of tumours are usually in the
abdomen, either in the adrenal gland or the
sympathetic ganglia.
 Less common primary sites include the paraspinal
area of the thorax, the neck, and the pelvis.
 Neuroblastomas often impinge on adjacent tissues
and organs and can metastasize to the lymph nodes,
bone, bone marrow, and/or subcutaneous tissue.
Researchers are studying genetic mutations in the
neuroblastoma cells as they seek to identify the
etiology of neuroblastoma.
CLINICAL MANIFESTATIONS
•Symptoms related to abdominal mass
•Firm, irregular abdominal mass that crosses midline
•Altered bowel and/or bladder function
•Vascular compression with oedema of lower extremities
•Back pain, weakness of lower extremities
•Sensory loss
•Loss of sphincter control
•Symptoms related to neck or thoracic mass
•Cervical and supra clavicular lymphadenopathy
•Congestion and oedema of face
•Respiratory dysfunction and/or distress
•Ecchymotic orbital proptosis
•Horner’s syndrome (unilateral ptosis, myosis,
andanhidrosis)
•Symptoms related to metastasis to bone and/or
bonemarrow
•Fatigue
•Pain
•Fever
•Symptoms related to catecholamine secretion
•Hypertension
•Sweating
•Flushing
•Irritability
COMPLICATIONS
•At diagnosis: Depending on the location of the
tumor, neuromuscular complications can include:
•lower-extremity weakness or paralysis.
•A hematologic complication is metastasis to lymph
nodes, bone, and bone marrow.

•During treatment: Adverse events from

chemotherapy, radiation therapy, and/or surgery can
be life-threatening.
•Infection and
•Organ toxicities.
STAGES
Stage I: Localized tumor confined to the area of origin;
complete excision, with or without microscopic residual
disease; identifiable and contra lateral lymph nodes
negative microscopically
Stage II: Localized tumor with incomplete gross
excision; identifiable ipsilateral and contra lateral lymph
nodes negative microscopically
Stage IIB: Localized tumor with complete or incomplete
gross excision with positive ipsilateral regional lymph
nodes; identifiable contralateral lymph nodes negative
microscopically
Stage III: Tumor infiltrating across the midline
with or without regional lymph node
involvement; or unilateral tumour with
contralateral regional lymph node involvement;
or midline tumor with bilateral regional lymph
node involvement
Stage IV: Tumor disseminated to distant lymph
nodes, bone, bone marrow, liver or other organs
(except stage IVS).
Stage IVS: Localized primary tumor as defined
for stage 1 or2 with dissemination limited to
liver, skin and/ or bone marrow(only in infants)
TREATMENT
•Age and clinical stage are the two most important
independent prognostic factors. Even with advanced disease,
children less than 1-yr-old at diagnosis have a better outcome
than those diagnosed later. Treatment modalities for
neuroblastoma include chemotherapy, surgery and radiation
therapy.
•Localized neuroblastoma has better prognosis; it can be
treated with surgery alone and does not require
chemotherapy. Observation alone is needed for stage 4S
patients.
•Chemotherapy is the chief therapy for most patients with
neuroblastoma in advanced stage. Chemotherapy includes
vincristine and alkylating agents in combination with
anthracycline and epipodophyllo toxins.
Chemotherapy regimens widely used are OPEC
(vincristine, cyclophosphamide, cisplatinum,
teniposide (VM-26), CADO (vincristine,
cyclophosphamide, doxorubicin) and PECADO
(vincristine, cyclophospharnide, doxorubicin,
cisplatinum, teniposide),etc.
Other modalities include surgery, radiotherapy
and autologous bone marrow transplantation.
HODGKIN LYMPHOMA
 INTRODUCTION

Hodgkin’s disease (HD) is a malignant disorder of

lymphoreticular system. Hodgkin’s disease occurs
in 5 to 7 per 1,00,000 population.

It is very uncommon under 5 years of age and

almost never seen under 2 years of age.

In asian population, HD is common even at

younger ages.
The WHO classification of Hodgkin
lymphoma recognizes two major
subtypes:

(i) Nodular lymphocytic-predominant

Hodgkin lymphoma (NLPHL),

(ii) Classical Hodgkin lymphoma.

(i) Nodular lymphocytic-predominant Hodgkin
lymphoma (NLPHL),
NLPHL is most common in males younger than 10
years. Patients with NLPHL generally present with
localized, non-bulky disease. Almost all patients are
asymptomatic.
(ii) Classical Hodgkin lymphoma.
The hallmark of classic Hodgkin lymphoma is
the Reed-Sternberg cell. This is a binucleated or
multinucleated giant cell that is often
characterized by a bilobed nucleus, with two large
nucleoli, giving an owl’s eye appearance to the
cells.
CAUSES

•Variation in the incidence of HD in different

ethnic groups and
•association with human leukocyte antigen
suggests that inherited susceptibility plays an
important role in the pathogenesis.
•Environmental factors such as Epstein-Barr
virus infection, familial clustering of cases
and
•higher incidence in twins may be some of
the other contributing factors.
CLINICAL MANIFESTATIONS
•Lymphadenopathy, usually in the cervical,
supraclavicular, and mediastinal areas; mediastinal
presentation common in adolescents and young adults;
significant mediastinal adenopathy may cause cough,
dyspnea,
• Painless, movable lymph nodes in tissues surrounding
involved area
•Unexplained fever
•Weight loss
•Drenching night sweats
•Malaise
•Painless cervical or supraclavicular lymphadenopathy
STAGES OF HODGKIN LYMPHOMA
STAGE DESCRIPTION
S
I Involvement of single lymph node region (I) or of single extralymphatic or site (IE)
by direct extension

II Involvement of two or more lymph node regions on the same side of diaphragm or
localized involvement of an extra-lymphatic organ or site and of one or more lymph
node regions on the same side of the diaphragm

III1 Involvement of lymph node regions on both sides of the diaphragm Abdominal
disease is limited to the upper abdomen (i.e. spleen, splenic nodes, celiac nodes, porta
hepatitis nodes)

III2 Involvement of lymph node regions on both side of the diaphragm Abdominal
disease includes para aortic, mesenteric, and iliac involvement with or without
disease in the upper abdomen.

IV Disseminated involvement of one or more

Extralymphatic organs or tissues with or without associated lymph node disease.
DIAGNOSIS
1. Complete blood count
2. Erythrocyte sedimentation rate (ESR
3. Serum copper, iron, calcium, and alkaline phosphatase
4. Liver and renal function tests
5. Urinalysis
6. Chest radiographic study
7. Computed tomography—to evaluate mediastinal, pulmonary, and
abdominal disease
8. Gallium and/or positron emission tomography (PET) scan to
determine the extent of involvement
9. Excisional lymph node biopsy—essential to diagnosis and staging
10. Bone marrow biopsy if patient has stage 3 or 4 disease according to
imaging studies
TREATMENT
Treatment of HD in paediatric population is
different in certain respects from adults. Devising the
ideal therapeutic approach for children with HD is
complicated by their increased risk for late adverse
effects.
Treatment modalities have varied from total nodal
radiation therapy to chemotherapy to combination of
chemotherapy and radiotherapy with significant
improvement in survival rate throughout the last
three decades.
All children generally receive combination
chemotherapy as initial treatment.
Inparticular, radiation therapy can cause
profound musculoskeletal growth retardation
and increase the risk for cardiovascular disease
and secondary solid malignancies in children.

desire to cure young children with minimal side

effects has stimulated attempts to reduce the
intensity of chemotherapy(particularly
alkylating agents) and radiation dose or volume.
In general, the use of combined chemotherapy with
radiation broadens the spectrum of potential
toxicities, while reducing the severity of individual
drug relatedor radiation-related toxicities. Current
approaches use chemotherapy alone with or
without low-dose involved-field radiation therapy
(LD-IFRT).

The volume of radiation and the intensity/duration

of chemotherapy are determined by prognostic
factors at presentation, including presence of
constitutional symptoms, disease stage, and bulk.
NURSING MANAGEMENT
NURSING ASSESSMENT
1. Assess child’s physiologic status.
a. Signs and symptoms of Hodgkin’s disease
b. Involvement of other body systems (e.g.,
respiratory,gastrointestinal)
c. Adverse effects of treatment
2. Assess family’s psychosocial needs.
a. Knowledge and education level
b. Body image
c. Family structure
d. Family stressors
e. Coping mechanisms
f. Support systems
3. Assess child’s developmental level .
4. Assess family’s ability to manage home care.
NURSING INTERVENTIONS
Staging Procedure
1. Provide preprocedural education to child and family
2. Prepare child for clinical staging procedures with
age-appropriate approach .
3. Assist and support child in collection of laboratory
specimens.
4. Provide instruction, support, and family crisis
intervention.
RADIATION AND CHEMOTHERAPY PHASE
1. Provide sedation for radiation treatments if needed.
2. Monitor cardio respiratory status during treatments.
3. Prepare for treatment-induced emergencies.
a. Metabolic disturbances, though Hodgkin’s disease is
generally low risk for tumor lysis syndrome
b. Hematologic disturbances, such as febrile neutropenia,
severe anemia
c. Space-occupying tumors, specifically superior vena cava
syndrome
4. Assess for signs of extravasation of chemotherapeutic
agents.
a. Edema, erythema, pain at infusion site
b. Tissue sloughing
5. Monitor for signs and symptoms of infection.
6. Assess skin integrity.
7. Minimize side effects of radiotherapy and chemotherapy.
a. Bone marrow suppression
b. Nausea and vomiting
c. Anorexia and weight loss
d. Oral mucositis
e. Pain
8. Provide ongoing emotional support to child and family.
9. Refer to child life specialist to assist with continued
coping strategies.
10. Provide ongoing education about treatment and follow-
up care, medications—both chemotherapy and supportive
care medications.
11. Refer family to social services for support and resource
utilization.
12. If school age, refer to hospital or home bound teacher or
obtain lessons for teaching.
NON-HODGKIN LYMPHOMA
 INTRODUCTION
Non-Hodgkin’s Lymphoma (NHL) is neoplasm of
a wide range of cell types that comprise the immune
system.
Non-Hodgkin lymphoma (NHL) comprises a
heterogeneous group of lymphoid neoplasm's
derived from cells of the immune system. NHL most
commonly occurs during the second decade of life
and occurs less frequently in children less than three
years of age.
Together with Hodgkin lymphoma they comprise
the third most common childhood malignancy.
NHL of childhood currently falls into three
therapeutically relevant categories:

(1) B-cell NHL (Burkitt lymphoma/ leukaemia

and diffuse large B-cell lymphoma);

(2)Lymphoblastic lymphoma (primarily

precursor T-cell lymphoma and, less frequently,
precursor B-cell lymphoma); and

(3) Anaplastic large cell lymphoma (T-cell or

null-cell lymphomas).
CAUSES

B cells and T cells.

Non-Hodgkin's lymphoma can begin in the:
•B cells: B cells fight infection by producing
antibodies that neutralize foreign invaders.
Most non-Hodgkin's lymphoma arises from B
cells.
•T cells: T cells are involved in killing
foreign invaders directly. Non-
Hodgkin's lymphoma occurs less
often in T cells.
SIGN AND SYMPTOMS
Intra abdominal Involvement
•Possible symptoms mimicking appendicitis
(pain, right lower quadrant tenderness)
•Intussusception
•Ovarian, pelvic, retroperitoneal masses
•Ascites
•Vomiting
•Diarrhoea
•Weight loss
Mediastinal Involvement
•Pleural effusion
•Tracheal compression
•Superior vena cava syndrome
•Coughing, wheezing, dyspnea,
respiratory distress
•Edema of upper extremities
•Mental status changes
Primary Nasal, Paranasal, Oral,
and Pharyngeal
Involvement
•Nasal congestion
•Rhinorrhea
• Epistaxis
•Headache
• Proptosis
•Irritability
•Weight loss
STAGES
The most widely used staging scheme for childhood non-
Hodgkin lymphoma (NHL) is that of the St. Jude Children’s
Research Hospital (Murphy’s Staging), which is outlined in
Table
STAGE DESCRIPTION
Single tumour (extranodal)Single anatomic area(nodal)
I excluding mediastinum or abdomen
II Single tumor (extranodal) with regional node
involvement. Primary gastrointenstinal tumour with
or without involvement of mesentric node.or
On same side of diaphragm:
a. Two or more nodal areas
b. Two single extra nodal tumours with or without
regional node involvement
III All primary intrathoracic tumours. All extensive
primary intra-abdominal disease. Two or more
nodal or extranodal areas on both sides of
diaphragm
IV Any of the above with CNS or bone marrow
DIAGNOSIS
•Bone marrow biopsy—to identify malignant cells
withbone marrow involvement
•Lumbar puncture—to determine presence of
malignantcells in CNS
•Complete blood count—diagnostic for bone marrow
dysfunction; may show elevated white blood cell
count, decreased hemoglobin level, hematocrit, and
platelet count
•Liver and kidney function tests—liver function test
values may be elevated with liver involvement;
kidney function test values may be elevated with
kidney involvement
•Lactate dehydrogenase level—elevated owing to
tumour lysis
•Serum uric acid level—elevated owing to cellular
tumourload
•Epstein-Barr virus test—positive result has been
associatedwith NHL
•Bone scan—to determine the presence of
metastases in thebone
•Chest radiograph—to determine the presence of
metastases in the lung
•Computed tomography and magnetic resonance
imaging—to determine the presence of metastases
in other areasof the body
TREATMENT
Childhood NHL is an extremely chemo
sensitive disease. Surgery plays a very limited
role, mainly for arriving ata diagnosis.
Radiation of primary sites is used very rarely
in emergency situations. Hence, multi-agent
chemotherapy directed to the histologic
subtype and stage of the disease remains the
corner stone of therapy.
There are two potentially life-threatening
clinical situations that are often seen in
children with NHL:
•superior vena cava syndrome (SVCS) often
seen in lymphoblastic lymphoma; and
•Tumour lysis syndrome, most often seen in
lymphoblastic and Burkitt NHL. These
emergent situations should be anticipated in
children with NHL and addressed immediately
NURSING MANAGEMNET
NURSING ASSESSMENT
1. Assess child’s physiologic status.
a. Signs and symptoms of NHL
b. Involvement of other body systems (e.g., gastrointestinal,respiratory)
c. Adverse effects of treatment
d. Signs and symptoms of tumour lysis syndrome (hypocalcemia,
hyperphosphatemia, hyperkalemia, hyperuricemia)
2. Assess child and family for psychosocial needs:
a. Knowledge of disease and treatment regimen
b. Body image
c. Family structure
d. Family stressors
e. Coping mechanisms
f. Support systems
3. Assess child’s level of development .
NURSING DIAGNOSE
•Risk for injury
•Imbalanced Nutrition: less than body
requirements
•Anxiety
•Activity intolerance, Risk for
•Therapeutic regimen management,
Ineffective
•Ineffective coping
NURSING INTERVENTIONS
Diagnosis and Staging Phase
1. Provide preprocedural education to child and family
2. Prepare child for diagnostic procedures with age-
appropriateapproach
3. Observe for signs and symptoms of systems involvement.
a. Respiratory distress
b. Superior vena cava syndrome
c. CNS changes
4. Refer to child life specialist as appropriate for
preproceduralpreparation.
5. Assist and support child in collection of laboratory
specimens.
6. Provide anticipatory guidance and family crisis
intervention.
TREATMENT PHASE
1. Monitor cardiorespiratory status.
2. Prepare for treatment-induced emergencies.
a. Metabolic crises
b. Hematologic crises
c. Space-occupying tumours
3. Administer chemotherapeutic agents
4. Assess for signs of extravasation.
a. Cell lysis
b. Tissue sloughing
5. Minimize side effects of chemotherapy.
a. Bone marrow suppression
b. Nausea and vomiting
c. Anorexia and weight loss
d. Oral mucositis
e. Pain
6. Monitor for signs and symptoms of infection.
6. Monitor for signs and symptoms of infection.
7. Monitor for signs and symptoms of relapse.
a. CNS changes
b. Infection
c. Tumour recurrence
d. Leukemic conversion
8. Provide ongoing emotional support to child and family
9. Refer to child life specialist for continued coping strategies.
10. Provide ongoing education about treatment
andMedications
11.Refer family to social services for support and
resourceutilization.
12. Monitor for tumour lysis syndrome
SUMMARY
The cancer treatment is based on the type of cancer
and the stage of the cancer. In some people, diagnosis
and treatment may occur at the same time if the cancer
is entirely surgically removed when the surgeon
removes the tissue for biopsy.Although patients may
receive a unique sequenced treatment, or protocol, for
their cancer, most treatments have one or more of the
following components: surgery, chemotherapy,
radiation therapy, or combination treatments (a
combination of two or all three treatments).
Palliative therapy (medical care or treatment
used to reduce disease symptoms but unable
to cure the patient) utilizes the same
treatments described above.
 CONCLUSION
Cancer can be treated with the help of certain
medicines ; chemotherapy and surgery of the
cancer. The prognosis (outcome) for cancer
patients may range from excellent to poor. The
prognosis is directly related to both the type
and stage of the cancer. However, as the cancer
type either is or becomes aggressive, with
spread to lymph nodes or is metastatic to other
organs, the prognosis decreases
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