Initial Evaluation of

The Child with

a Suspected
Malignancy
Bidasari Lubis
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Incidence
• Childhood cancer
2% of all cancers occur in children
• In 2000
The second leading cause of death in
children aged 1 - 14 years.
• The risk of death
Reduced through intensive monitoring
and early detection and treatment
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• Significant increases in survival
rates association with clinical trials
and the development of new
treatment
( Stiller 1994; National Cancer Institute 1999 )

• USA : 5 – year survival rate

increased from 55.6% in 1974 – 76
to 73.8% in 1989 – 94
( National Cancer Institute 1999 )
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• Mostly sarcomas, which originate in
tissues such as the bone marrow,
nerve tissues, lymph nodes, bone and
muscle
( Simone & lyons 2001 )

• Leukemia ( WBC cancer )

 1/3 of all childhood cancers
 ALL are majority of cases
( Miller et al. 1995 )
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 Incidence rates of cancer in children aged 0 – 14 years, 1991 - 98

Age (years) 1991 1992 1993 1994 1995 1996 1997 1998
Males 0–4 21.1 20.8 24.1 23.6 24.0 23.3 21.6 21.3
5–9 11.6 13.9 10.4 13.2 13.6 10.9 12.8 13.3
10 – 14 11.4 11.4 14.6 13.9 11.9 15.8 13.8 13.7
0 – 14 15.1 15.4 16.4 16.9 16.5 16.7 16.1 16.1
Female 0–4 17.8 19.3 19.1 17.1 18.6 19.2 20.7 19.4
5–9 9.5 10.4 8.3 10.9 9.5 12.1 7.0 11.2
10 – 14 12.4 11.2 13.0 10.4 9.8 14.3 11.9 12.5
0 – 14 13.2 13.7 13.5 12.8 12.7 15.2 13.2 14.4
Personal 0– 14 14.2 14.5 14.9 14.9 14.7 15.9 14.7 15.2

Source : AIHW National Cancer Atatistics Clearing House

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IR of selected cancers in children aged 0 – 14 years, 1998

(Source : AIHW National Cancer Atatistics

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Clearing House)
 Incidence of childhood cancers

Cancer Incidence (%)

Leukemia 30.2
CNS Tumor 21.7
Lymphoma 10.9
Neuroblastoma 8.2
Soft Tissue Sarcoma 7.0
Renal Tumor 6.3
Bone Tumor 4.7
Others 11.0
Source :J natl cancer inst 1999;91:1051-8.
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 Leukemia Cases in Haji Adam Malik Hospital

40
35
30
25

20
15
10
5
0

2001 2003 2003 2004

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 Leukemia Cases in Haji Adam Malik Hospital

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Number of cases

0
6m 1y 2y 3y 4y 5y 6y 7y 8y 9y 10 y 11 y 12 y 13 y 14 y

Ages
2001 2002 2003 2004
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Clinical Signs and
Symptoms
• Headache
• Lymphadenopathy
• Bone pain
• Pancytopenia
• Leukocytosis
• Abdominal mass
• Mediastinal mass
• Bleeding
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Signs and symptoms of childhood cancers & conditions that can mimic these cancers

Sign or symptom Type of cancer Common conditions in the DD

Fever Leukemia, lymphoma Infection
Vomiting Abdominal mass, brain Infection, gastroesophageal reflux
tumor
Constipation Abdominal mass Poor diet
Cough Mediastinal mass Upper respiratory infection, reactive
airway disease, pneumonia
Bone or muscle pain Leukemia, bone tumor, Musculoskeletal injury, viral infection
neuroblastoma
Headache Brain tumor Tension headache, migraine, infection
Lymphadenopathy Leukemia, lymphoma, Lymphadenitis, systemic infection,
(>2 cm) metastatic disease collagen vascular disease
Hematuria Wilms' tumor Urinary tract infection, glomerulonephritis
Voiding difficulty Rhabdomyosarcoma Congenital urinary tract abnormalities
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Common chief complaints given by parents

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Anatomic changes before and after treatment of Rhabdomyosacoma

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Evaluation of the child
with suspected
leukemia
Most of the signs and symptoms that
children with leukemia develop result
from a lack of normal blood cell
producing bone marrow by the
leukemia cell

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• Infection  high fever cause by WBC
deficiency
• Easy bleeding or bruising  poor
production of blood platelets
• Bone pain  accumulation of the
leukemia cells
• Swelling of the abdomen 
enlargement of the liver and spleen
• Swollen lymph nodes  leukemia
spread to lymph nodes
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• Enlargement of the thymus
 can lead to coughing, shortness
of breath, suffocation and SVC
syndrome
• Headache, seizure and vomiting
 extramedullary spread (CNS, the
testicles, ovaries, kidney lungs,
heart, intestine or other organs)
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Laboratory studies
• CBC, reticulocyte count, periphreral
blood smear (blasts)
• Electrolyte, BUN, creatinine , uric
acid, LDH
• SGOT, SGPT, alk. phospatase, total
bil, magnesium, calcium, phosphorus
• Serologies : varicella, CMV, herpes,
hepatitis A, B, and C (obtain prior to
start of therapy)
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Before chemoteraphy With Varicella

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• Quantitative immunoglobulin
• Coagulation studies : PT, aptt, fibrin
degradation products or d-dimers,
fibrinogen
• Types and cross for PRC if necessary
• If febrile or ill-appearing : blood
culture, urine culture

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Radiographic studies
• Chest Radiograph (assess for
mediastinal mass)
• Plain bone film of sites of bone
pain (assess for pathologic
fractures)

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Diagnostic studies
• Bone marrow aspiration
a. Specimens for morfology,
immunophenotyping, karyotype
b. Extra “pulls” as per protocol for
biologic studies
c. For dry taps, bone marrow
biopsy for diagnostic studies

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BONE MARROW ASPIRATION

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• Lumbar puncture
(Platelet count > 30 – 50 x 109/L )
a. Cytology, chamber count (white
cells, red cells, protein, glocose)
CSF culture if patient is febrile
b. Initial procedure done by the
pediatric oncology attending or
fellow, after careful evaluation for
elevated intracranial pressure
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LUMBAR PUNCTURE

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Normal Blood Cord
And
Marrow Histology

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ALL FAB L1

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ALL FAB L2

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ALL FAB L3

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Thank
You
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