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Incidence of Childhood Cancer
10%
8%7%6%5%5%2%5%
20%32%
Leukaemia
Brain tumours
Lymphoma
Rhabdomyosarcoma
Neuroblastoma
Wilms' tumour
Bone tumours
Retinoblastoma
Germ cell tumours
Others
• What is cancer ?
Uncontrolled growth of cells
• Are these cancer cells abnormal?
No, but their behaviour is.
Combination Chemotherapy
• Use of two or more drugs administered together, which usually act at different phases of cell cycle and therefore kill more cells.
What is a clinical trial?
• A standardised approach to the treatment of a certain disease which is treated the same in all participating centres.
Why the need for clinical trials?
• So that the best approach to treatment is arrived at as quickly as possible by treating the largest number of patients in the shortest possible time.
Treatment of Cancer
• Surgery
• Chemotherapy
• Radiotherapy
Childhood Leukaemia
• Acute Lymphoblastic (ALL) 70%
• Acute Myeloid Leukaemia (AML) 20%
• Acute Undifferentiated (AUL) <5%
• Chronic Myeloid (CML) and Juvenile Chronic Myeloid (JCML) 5%
Acute Leukaemia
• 30% childhood cancers
• 4/100,000 children <15years
• Peak incidence 1-5 years
ALL - Clinical Features
• Fever
• Lymphadenopathy
• Hepatosplenomegaly
• Bleeding
• Bone pain
ALL - Differential Diagnosis
• Non malignant -
• Infectious mononucleosis
• ITP
• Aplastic anaemia
• Malignant-
• Neuroblastoma
• Bone tumours
Lymphoma
• 80% childhood lymphomas are NHL
• Almost all high grade
• Tendency to BM and CNS involvement
• Disease free survival 70-85%
Hodgkins Lymphoma
• Lower incidence than NHL
• Rare in children< 10yrs
• Usually present with cervical adenopathy
• Often localised disease
• Disease free survival good
• Late effects considerable
Brain Tumours
• Infratentorial -
disturbance of gait and co-ordination
cranial nerve palsy
headaches and vomiting
Brain Tumours
• Supratentorial -
Headaches
Convulsions
UMN signs
Visual disturbance
Brain Tumours
• Post fossa commonest site
• Gliomas >PNET>ependymoma >others
• Surgery offers best chance of cure
• Some tumours chemosensitive
• Most tumours radiosensitive but avoid if possible <4yrs.
• Overall survival 50% approx
Differential Diagnosis of Malignant Abdominal Tumours
• Neuroblastoma
• Wilms’ tumour
• Non Hodgkins lymphoma
• Soft tissue sarcoma
• Hepatoblastoma
Neuroblastoma
• Commonest extracranial tumour
• Tumour of neuroectodermal origin
• Incidence 7-8/million < 15 years
• Peak incidence 2-5 years
Neuroblastoma - Clinical Features
• Depends on local, regional and metastatic spread
• Metabolic effects
• Greatest mimicker in paediatric practice
NBL – Survival Curve Patients Diagnosed 1993 to 2003
Stage12344S
Kaplan Meier 1993 to 2003
0 2 4 6 8 10 12
Time
100
90
80
70
60
50
40
30
20
10
0
Su
rv
iva
l P
rob
ab
ilit
y (
%)
Stage 1 N = 3
Stage 2 N = 12
Stage 3 N = 9
Stage 4 N = 34
Stage 4S N = 6
(30%)
(76%)
Wilms’ Tumour
• Arises from the kidney
• Incidence 7/million <15 years
• Peak incidence 2-5 year age group
Wilms’ Tumour - Clinical Features
• Asymptomatic abdominal mass
• Abdominal discomfort
• Haematuria
• Hypertension
Rhabdomyosarcoma
• Tumour of mesenchymal origin
• Commonest STS in childhood
• Incidence 5-6% of childhood cancers
Rhabdomyosarcoma - Clinical Features
• Occurs in all sites - 35% head &neck
• Prognosis depends on primary site -
paratesticular >90%, head & neck 30%
peripheral - worst prognosis, usually alveolar.
Histology major prognostic indicator
Bone Tumours
• Comprise 5% of childhood cancers.
• Unusual <5years of age
• Ewing & osteosarcoma commonest
• Up to 20% will have metastases at diagnosis.
Ewing Sarcoma- Clinical Features
• Pain usually >6 months
• Palpable mass
• Pathological fracture
• Fever
Osteosarcoma - Clinical Features
• Pain usually weeks cf months
• Commonest around knee
• Commoner in adoloscence
• Up to 20% metastases at presentation.
Bone Tumours - Differential Diagnosis
• Ewing sarcoma
• Osteosarcoma
• Non Hodgkins lymphoma
• Langerhan cell histiocytosis
• Aneurysmal bone cyst
• Acute osteomyelitis
Hepatoblastoma
• Presents most commonly 1-3yrs
• Large mass R hypochondrium
• αFP usually grossly elevated
• Usually chemosensitive
• DFS >80%
• Liver transplant rarely indicated.
Germ cell tumours
• 40% sacrococcygeal
• May arise in gonads
• Usually chemosensitive
• AFP sensitive indicator
Oncology Survival Curve Patients Diagnosed 1983 to 2003
Years1983 to 19931993 to 2003
Kaplan Meier 1983 to 2003
0 10 20 30
Time
100
90
80
70
60
50
40
30
20
10
0
Su
rv
iva
l P
rob
ab
ilit
y (
%)
1983 to 1993 N= 729
1993 to 2003 N = 1,160
59%
70%
Late Effects of Childhood Cancer
Depend on:
• Disease
• Age
• Treatment
SMN
• Depends on - primary cancer
- treatment
- genetic predisposition
- age at diagnosis.
• Adult survivors of childhood cancer 10-20 times greater risk of SMN than peers.
• 12-20% within first 20 years.