Practical Guidelines For the Management of Children with Cancer · 2018-07-06 · SIOP PODC Adapted Treatment Guidelines ..... 11 7. Burkitt Lymphoma ... Practical uidelines for the

Practical GuidelinesFor the Management of Children with Cancer‘SOBO’ Paediatric Oncology Ward, Queen Elizabeth CentralHospital College of Medicine, Blantyre, Malawi

December 2017 | Trijn Israels | George Chagaluka | Simon Bailey | Liz Molyneux

© 2017 T. Israels. No part of this manual may be reproduced or transmitted in any form or by any means without permission of the authors.

ISBN 978-90-9024383-2

Layout: Freestyle Print

Printed by: Freestyle Print

Photographs by T. Israels

Financial support for the production and printing of this manual was kindly provided by World Child Cancer.

We would like to acknowledge financial support over the years from the following partners for the department of paediatric oncology: The KiMa foundation, World Child Cancer, Children with Cancer in Malawi, the St Baldrick’s Foundation and VOKK.

We would like to thank Sister in Charge and all the nursing staff, Mr Banda and Mrs Eunice Chimata for their help and care for the patients.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

1. General Approach to Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52. When is Treatment with Curative Intent (not) Feasible? – Some Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63. Routine Investigations at Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74. Side Effects of Chemotherapeutic Drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85. Supportive Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96. SIOP PODC Adapted Treatment Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117. Burkitt Lymphoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Clinical Presentations of Patients with Burkitt Lymphoma (BL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138. Non Hodgkin’s Lymphoma (other than BL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149. Wilms Tumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1510. Hodgkin’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1611. Acute Lymphoblastic Leukaemia (ALL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1712. Neuroblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1813. Rhabdomyosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1914. Retinoblastoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2015. Brain Tumours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2116. Hepatocellular Carcinoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2217. Osteosarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2318. Germ Cell Tumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2419. Kaposi’s Sarcoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Appendix: Treatment Flow Sheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

eBL 1st Presentation – Stage I – Localized Tumours Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27eBL and Other NHL Protocol 1st Presentation – All Other Stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28eBL and NHL Relapse Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Wilms Tumor – 1A – Preoperative Chemotherapy for Localized Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30Wilms Tumor – 1B – Preoperative Chemotherapy for Metastatic Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Wilms Tumor – Optional – Prolonged and Intensified Preoperative Chemotherapy for Localized Diseaseto Improve Resectability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Wilms Tumor – Post-operative Chemotherapy – AV4 – Localized Disease at Diagnosis –Pathology: Stage I, Intermediate Risk (IR) – Not for Surgical Staging Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33Wilms Tumor – Post-operative Chemotherapy – AV14 Localized Disease at Diagnosis – Pathology: Stage I, High Risk (HR) and Stage II, IR and Stage II, III LR or Surgical Stage I or II / Easy Surgery . . . . . . . . . . . . . . . . . . . . . . 34Wilms Tumor – Post-operative Chemotherapy – AVD 14 – Metastatic Disease at Diagnosis – Localized Diseaseat Diagnosis – Pathology: Stage II High Risk, Stage III IR and HR or Surgical Stage III / Difficult Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . 35OEPPA – Hodgkin’s Disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36Flow Sheet: Prednisolone Pre-Phase ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Flow Sheet: Induction ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Flow Sheet: Continuation ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39Flow Sheet: Intensification ALL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40Doxorubicin / Cisplatin – Osteosarcoma, Hepatocellular Carcinoma (Neuroblastoma) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41Etoposide / Cisplatin / Bleomycin – Germ Cell Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42Kaposi Sarcoma Vincristine, Bleomycin and Etoposide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Low Grade Glioma – Vincristine and Carboplatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44Retinoblastoma – Chemotherapy – JOE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Practical Guidelines for the Management of Children with Cancer Practical Guidelines for the Management of Children with Cancer

32

What Is It? (The Diagnosis)

This question is usually answered by a careful and thorough history and examination followed by a Fine Needle Aspirate (FNA) or an open biopsy.

When dealing with a malignancy, or the suspicion of a malignancy, one would like to make a definitive diagnosis. In malignancies, this is most commonly done through obtaining tissue and looking at it through a microscope.

This can be done by fine needle aspirate and looking at the cells with a microscope (cytology).

At times one will need to do a tissue biopsy to be able to see the structure of the tumour tissue (histology) to make a definite diagnosis.

Where Is It? (The Extent of Disease/Staging)

After a careful history and examination this question is usually answered by X-rays, ultrasound, CSF sampling, bone marrow aspiration or some other specific investigations. For almost all tumours it is useful to know where it is: what is the primary tumour and has it metastasized to other places. Some additional investigations (e.g. imaging, bone marrow aspirate, CSF) are aimed at assessing involvement of preferential sites for metastases. The presence of distant metastases will often worsen the prognosis of the patient and will sometimes change the management. Is It Safe to Treat?

This question may be answered by looking for evidence of anaemia (FBC and differential) malaria (Rapid Diagnostic Test (RDT) for malaria or thick blood films), stool and urine microscopy. An HIV test is also helpful in anticipating problems and it is important to assess for malnutrition.

In general, there are three treatment modalities in paediatric oncology; chemotherapy, surgery and radiotherapy. Radiotherapy is not available yet in Malawi. Surgery of the primary tumour is often needed in solid tumours to achieve complete cure. Chemotherapy kills malignant (cancer) cells, but will also kill normal cells of the body. This especially affects all rapidly dividing cells; i.e. bone marrow, mucosa (mouth and gastrointestinal tract) and hair follicle cells.

One needs to consider the intensity of the chemotherapy, level of supportive care and tolerance of the patient (malnutrition) in deciding which treatment is safe for a particular patient.

Quality of Life

Palliative care becomes the major focus of treatment when cure is no longer feasible. Adequate pain control, control of other symptoms such as vomiting, and giving psychological, religious and spiritual support are important to improve quality of life. Often the child and parents will prefer to go home with the best available symptomatic control.

Different tumours have differing presenting symptoms and sites, preferential sites for primary tumours and metastases, degrees of aggression of tumour cells and sensitivity to chemotherapy. To know what the diagnosis is and how best to treat we need to ask some simple questions:

This booklet with treatment guidelines is written for the paediatric oncology ward (‘SOBO’) of the Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi.

It is meant to be a practical manual for the physicians working on the ward (and those covering the ward when on call), nurses, visiting nurses, clinical officers, physicians and students.

The information is not extensive, for more information on the different diseases please refer to a paediatric oncology textbook. The treatment strategies are the optimal treatments currently available to us in QECH.

We hope this manual will help us to further improve the treatment for children with cancer in Malawi.

Dr. Trijn IsraelsProf. Simon BaileyDr. George ChagalukaProf. Liz Molyneux

December 2017

Introduction 1.General Approach to Management


54

2.When is Treatment with Curative Intent (not) Feasible? – Some Considerations

3.Routine Investigations at Admission

Weigh the balance between toxicity of treatment, burden for the patient and parents and the chance of survival. At times deciding on treatment with palliative intent is a fair choice and in the best interest of the child and his / her family if chances of cure are not realistic.

Patients with a relatively good prognosis include: endemic Burkitt lymphoma (especially stage I – III), Wilms tumour (especially localized disease), Hodgkin’s disease (especially lower stage), retinoblastoma – intra ocular disease only, acute lymphoblastic leukaemia (especially if very chemo sensitive disease) and germ cell tumour.

Patients with a poor prognosis include those with: neuroblastoma (especially metastatic disease), rhabdomyosarcoma (especially if a large (> 5 cm) primary tumour or metastatic disease), acute myeloid leukaemia and most brain tumours.

Multidisciplinary Teams (MDTs)

Clinicians caring for children with cancer in low-income countries often do so in isolation. Cancer diagnosis and care requires the expertise of several disciplines such as pathology, surgery, radiology, oncology and palliative care. It is very helpful to have the input of all these teams in decisions about diagnosis and in planning treatment. The best way of bringing these groups together is to hold regular (e.g. every fortnight or every month) meetings together. These are called Multidisciplinary Teams Meetings (MDTs) and are routine in high income settings.

MDTs are held every month in the QECH and attended by members of SOBO, by surgeons, pathologists and ophthalmologists.

Fine Needle Aspirate (FNA)The pathologist will examine the cells and attempt to make a diagnosis. Only cytology (examination of cells) can be done on a fine needle aspirate.

Remote Pathology ServiceWhen a Fine Needle Aspirate (FNA) or Bone Marrow sample is taken on the ward, it is put on to microscope slides and stained. When viewed with a microscope this shows the type and number of cells on the slide and is helpful in diagnosing several common tumours such as Burkitt lymphoma. It is important to make a diagnosis as soon as possible and our pathology department are overwhelmed with the amount of work they have; and so the slides in the paediatric annexe are photographed with a microscope camera and immediately uploaded by computer and sent to Newcastle where an expert reviews them and gives an opinion as to what the diagnosis is likely to be. This takes about two days. This is called a remote pathology service.

HistopathologyHistopathology is when a surgical sample (i.e. biopsy) is taken and looked at in the lab. This is necessary for some diagnoses and to be able to tell between some cancer subtypes. This is done in the QECH histopathology lab and results of a biopsy have often delayed in Malawi. Recently, because of an improvement in staffing, the reports have been coming back to the ward more quickly.

Ultrasound Abdomen (USS)An abdominal USS is important:

• In solid abdominal tumours as a scan helps to define a location of the tumour and its relation to organs. The structure of the tumour aids in diagnosis.

• To assess abdominal involvement, especially in patients with Burkitt lymphoma.

• To assess the kidneys and anticipate problems if they are involved.

• To rule out bilateral renal involvement in Wilms tumour.

Elisa HIVIt is important to assess the HIV status of the patient. A newly diagnosed child with HIV will need to commence antiretroviral therapy as soon as possible.

Full Blood Count (FBC)• The FBC helps to assess involvement of

bone marrow in the disease process, to look for anaemia, the possible need for a blood transfusion and the tolerance of this patient for chemotherapy.

• To review the platelet count for likelihood of bleeding.

Urine and Stool MicrobiologyLook for schistosoma eggs in urine and parasites / worms in the stool. These infections / infestations need to be treated before a child receives chemotherapy.

Malaria Parasitaemia (MPs)Malaria is a common condition in Malawi and needs to be treated before a child receives chemotherapy.

OtherIn certain circumstances it may be necessary to exclude TB (CXR, sputum if child old enough to produce some etc.)


76

4.Side Effects of Chemotherapeutic Drugs

5.Supportive Care

Vincristine: Neuropathy (constipation, neuropathic pain, areflexia, foot drop), jaw pain, severe tissue necrosis with extravasation.

Precautions to prevent extravasation: Always place a fresh cannula, make sure it is well positioned in the vein! Flush cannula with water for injection first to see that there are no leaks, then follow the vincristine bolus injection with another flush of water for injection.

Cyclophosphamide: Bone marrow suppression, nausea and vomiting, haemorrhagic cystitis.Precaution: Patient must be well hydrated with lots of fluids before and after the dose.

Cisplatin: Bone marrow suppression (especially platelets, delayed), nausea and vomiting, kidney damage, deafness.

Actinomcyin: Nausea and vomiting, bone marrow suppression (mild), veno-occlusive disease (VOD) characterized by fluid retention, ascites, jaundice, painful liver. (This can be life threatening).Precaution: Give enough fluids. Reduce dose in children <12kg body weight.

Doxorubicin (=Adriamycin): Bone marrow suppression, nausea and vomiting, oral sores. Late effect: Cardiomyopathy (dependant on cumulative dose).Precaution: Review the total cumulative dose received regularly. Avoid going above 150 mg/m2.

Prednisolone: Weight gain, Cushing’s syndrome, hypertension, osteoporosis, adrenal suppression (stress hormones), increased susceptibility to and severity of infections.Precaution: Use short courses.

Procarbazine: Bone marrow depression, nausea.

Etoposide: Bone marrow depression, nausea and vomiting (both relatively mild when given orally), mucositis.

Bleomycin: Nausea and vomiting, bone marrow suppression, mucositis, pulmonary fibrosis (dependent on cumulative dose).

Methotrexate: Bone marrow suppression, mucositis and diarrhoea. Leucovorin (folinic acid) is given after MTX infusions to prevent severe side effects.

Fever Protocol

Background: Chemotherapy often causes bone marrow suppression. This can cause the white blood cells to drop with a lowered resistance to, especially bacterial, infections. Neutropenia is defined as a neutrophil count of less than 0.5 x 109 per litre. Children who are neutropenic have an increased risk of bacterial infections which can develop very rapidly.

Protocol: If a child on the ward has a fever (axillary temperature above 38° Celsius):

X Check Malaria parasites (MPs)

If MPs are negative:

X Take a blood culture (important to get information as to which bacteria are causing the infection and sensitivity / resistance to antibiotics).

X Start antibiotics: Benzyl penicillin (50,000 i.u. per kg/day divided over three doses IV). Gentamicin (6mg per kg once daily IV).

• If fever persist for more than 48 hours, 2nd line antibiotics need to be considered.

• Usual choice: ceftriaxone (50mg per kg once daily IV)

• If fevers still persist add amikacin (and stop gentamicin).

• Change antibiotics when needed based on the results of a positive blood culture.

• Antifungal therapy (fluconazole) and antiviral therapy (acyclovir) are added early to the antibiotics if the child has had prolonged or ‘heavy’ chemotherapy (e.g. in ALL) or if the child is malnourished.

• G-CSF (Granulocyte cell stimulating factor) promotes the production of granulocytes (neutrophils) and is useful in preventing febrile neutropenia. If G-CSF is available it is sometimes prescribed in this circumstance.

Mouth Care

• Children may develop a painful mouth (mucositis) from the chemotherapy. Adequate pain control is important to enable the child to eat and drink.

• 1% gentian-violet paint (“GV paint”) three times a day can be used when there are oral sores and/or thrush.

• Thrush (candida infection) can also be treated with nystatin oral drops three times daily.

• If fungal infection is severe fluconazole needs to be added.

• When herpetic lesions (pain, blisters) are suspected clinically, add oral acyclovir (older than 2 years: 200mg 5 times daily x 5/7; younger than 2 years: 100mg 5 times daily x 5/7).


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Nutrition

Children with cancer are often malnourished. • Malnutrition will reduce their immunity to infections,

tolerance to chemotherapy and increase the risk of surgery.

• Try to encourage children to eat.• Encourage the children to eat one sachet of

chiponde every day.• If a child cannot eat, but can drink; milk (F100) is a

nutritious alternative.• If a child cannot or will not eat or drink adequately a

nasogastric tube (NGT) should be inserted and used for feeds.

Pain control: ‘Pain is what the patients says hurts.’Do not wait for pain, anticipate it and try to prevent it.

Non-pharmacological interventions:Distraction (e.g. for procedures), play therapyPhysical comfort (positioning or massage).

Pharmacological interventions:WHO analgesic ladder for children.

Step 1: Non-opioid +/- adjuvante.g. paracetamol 10-15mg/kg every 4-6 hours oral or ibuprofen 5-10mg/kg every 6-8 hours oral.

Step 2: Strong opioid (morphine) +/- adjuvant+/- step 1

e.g. starting dose: oral morphine 0.15-0.3mg/kg every 4 hours.

Titrate against pain and side effects (nausea, vomiting, and constipation).

Do not use codeine and morphine concurrently.

Use of Adjuvants

1. For raised intracranial pressure: Dexamethasone 10mg/m2 per day orally Usually in daily practice we would give 5mg once daily. (For a maximum of 3 days to limit side effects.)

2. For neuropathic pain (burning, stinging in extremities): Amitriptyline (0.2 – 0.5mg/kg) orally Age 1 – 5 years 6.25mg. Age 6 – 12 years 12.5mg.

Anti-Emetics

• Anti-emetics are given to reduce chemotherapy associated vomiting.

• Give oral metoclopramide (10 mg or 100 – 400 μg/kg) 30 minutes before chemotherapy.

• If needed add oral (0,15mg/kg, max 8 mg) or IV (0,01mg/kg, max 4 mg) ondansetron 8 hourly. If needed add dexamethasone IV ( 5mg/m2 – max 4 mg stat 30 minutes before chemotherapy, followed by 5mg/m2 divided in two to three doses).

Reference for Further Reading

Israels T, Renner L, Hendricks M, Hesseling P, Howard S, Molyneux E. SIOP PODC: Recommendations for Supportive Care of Children with Cancer in a Low-Income Setting. Pediatr Blood Cancer 2013, Jun;60(6):899-904.

6.SIOP PODC Adapted Treatment Guidelines

The PODC (Pediatric Oncology in Developing Countries) Committee of the International Society of Pediatric Oncology (SIOP) has a working group on adapted treatment guidelines. These are guidelines adapted to the local realities in low income countries which means that they are often of reduced intensity to avoid undue treatment-related toxicity and mortality.

Some of these guidelines (e.g Wilms tumour and KS) are very similar to the treatment guidelines currently used in Malawi. Others are different, but may still provide useful further reading with reference to the principles and considerations taken into account.

So far SIOP PODC has published guidelines on acute lymphoblastic leukaemia (ALL), endemic Burkitt lymphoma (eBL), Wilms tumour, supportive care, retinoblastoma, Kaposi sarcoma (KS), neuroblastoma and medulloblastoma. All guidelines are published in Pediatric Blood & Cancer.

References for Further Reading

Parikh NS et al. SIOP-PODC adapted risk stratification and treatment guidelines: Recommendations for neuroblastoma in low- and middle-income settings. Pediatr Blood Cancer. 2015 Mar 21. doi: 10.1002/pbc.25501.

Hunger SP et al. Treatment strategies and regimens of graduated intensity for childhood acute lymphoblastic leukemia in low-income countries: A proposal. Pediatr Blood Cancer 2009, May;52(5):559-65.

Parkes J et al. SIOP PODC adapted treatment recommendations for standard-risk medulloblastoma in low and middle income settings. Pediatr Blood Cancer 2015, Apr;62(4):553-64.

Chantada G et al. SIOP-PODC recommendations for graduated-intensity treatment of retinoblastoma in developing countries. Pediatr Blood Cancer 2013, May;60(5):719-27.

Hesseling P et al. Practical recommendations for the management of children with endemic Burkitt lymphoma (BL) in a resource limited setting. Pediatr Blood Cancer 2013 March; 60(3):357-62.

Israels T et al. SIOP PODC: clinical guidelines for the management of children with Wilms tumour in a low-income setting. Pediatr Blood Cancer 2013 January; 60(1):5-11.

Israels T et al. SIOP PODC: Recommendations for Supportive Care of Children with Cancer in a Low-Income Setting. Pediatr Blood Cancer 2013 Jun;60(6):899-904.

Molyneux E et al. The management of children with Kaposi sarcoma in resource limited settings. Pediatr Blood Cancer 2013 April;60(4):538-42.


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Girl (8) with jaw tumour

Girl (10) with abdominal BL

Boy (6) with upper jaw tumour

Girl (10) with displaced teeth in BL

7.Burkitt Lymphoma

Clinical Presentations of Patients with Burkitt Lymphoma (BL)

Clinical Presentation• Rapidly growing tumour, peak age 4 – 7 years, boys

more often affected than girls.• Site of presentation: Jaw, retro-orbital, abdomen

(including kidneys), paraspinal (can cause paraplegia, urinary/stool incontinence) and in CNS. Relatively common childhood cancer in Malawi (~ 40% of patients).

• Treatment is needed urgently when children present with neurological symptoms or orbital disease to try to prevent irreversible damage.

Differential Diagnosis• Other lymphoma. • Face/jaw: Abscess, dental cyst.• Eye: Retinoblastoma, rhabdomyosarcoma. • Kidney: Wilms tumour.• Extremity (arm/leg): Osteosarcoma, osteomyelitis.

Investigations at Admission• For routine investigations please see chapter 13.• For final diagnosis: Fine needle aspirate (FNA).• For staging: Bone marrow aspiration (BMA),

cerebrospinal fluid (CSF), ultrasound abdomen (USS). (Treatment is currently no different for different stages of disease, but a higher stage of disease does affect outcome; stage IV (with bone marrow and/or CSF involvement) has a poorer prognosis).

Supportive CareTumour Lysis Syndrome:The rapid destruction of tumour cells (breakdown products) may cause a tumour lysis syndrome, characterized by renal failure (‘blockage of kidney’) and laboratory abnormalities (especially potassium�, phosphate�, calcium�).

To prevent/manage tumour lysis syndrome: • Allopurinol 5mg/kg tds orally x 5/7; starting the day

before chemotherapy.• Hyperhydration according to age / weight.• Watch for decreased urine output and/or fluid

overload as signs of tumour lysis syndrome. • Close monitoring (sometimes daily) of the

electrolytes in important and can be measured quickly on the blood gas analyser in the paediatric annexe. Samples for analysis by the blood gas machine need to be taken in a heparinised syringe that is available in the annexe lab.

Nausea and vomiting. Prevent with metoclopramide (maxolon) 10mg po; half an hour before and ~ 5 hours after chemotherapy. If remain nauseated and vomiting or develops despite metoclopramide, add ondansetron 4mg IV or PO stat (<5 years – 2 mg).

Neutropenia do weekly full blood counts (FBC). If neutrophils are lower than 1.0 x 109/L it is necessary to delay chemotherapy until recovery of the neutrophil count (above 1.0 x 109/L).

Treatment• Chemotherapy.• See flow sheets: eBL localized stage I, eBL and NHL

all other stages, eBL and NHL relapse.

Reference for Further Reading:

Hesseling P, Israels T, Harif M, Chantada G, Molyneux E. Practical recommendations for the management of children with endemic Burkitt lymphoma (BL) in a resource limited setting. Pediatr Blood Cancer 2013 March; 60(3):357-62.


1312

Boy (3) with Wilms tumour Boy (3) with Wilms tumour (and malnutrition)

Boy (16) with NHL before treatment Boy (16) after treatment

8.Non-Hodgkin Lymphoma Other Than BL

9.Wilms Tumour

Burkitt lymphoma is one of the non-Hodgkin lymphomas. Others include lymphoblastic lymphoma, large B-cell lymphoma and anaplastic large cell lymphoma.

Lymphoblastic leukaemia is best treated on the leukaemia protocol.

Clinical Presentation • Clinical presentation is varied and depends on

primary site, histological subtype and extent of disease. Non-Hodgkin lymphomas often present in the abdomen, mediastinum and head and neck, less commonly in superficial lymph nodes and bone.

Differential Diagnosis• Other causes of lymph node swelling (e.g.

tuberculosis), HIV, Kaposi Sarcoma, Burkitt lymphoma, Hodgkin’s disease.

Investigations at Admission:• Routine investigations (Chapter 13).• Mantoux if possible, CXR and FNA for AFBs when

TB is a possible diagnosis.• For final diagnosis: Fine needle aspirate (FNA) If this

fails to provide a diagnosis a biopsy will be needed.

Treatment• Chemotherapy.• See flow sheets: eBL localized stage I, eBL and NHL

all other stages, eBL and NHL relapse.

Clinical Presentation• Slow growing painless mass in the flank. Usually

clinically relatively well. Peak age 3 years. Relatively common tumour.

• Patients often found to have hypertension and (microscopic) haematuria.

• Metastasizes to lungs (Chest X-ray), less frequently to the liver (USS).

Differential Diagnosis• Burkitt lymphoma (more rapidly growing, more

weight loss), Neuroblastoma (adrenal mass, patients usually more severely ill and in more pain and often anaemic).

Investigations at Admission• Routine investigations (chapter 13).• Ultrasound abdomen (renal tissue visible? cystic

tumour? IVC involved? local spread to lymph node or liver? other kidney normal?).

• Blood pressure, urine dipstick for blood.• For cytology: Fine needle aspirate.• For staging / metastases: Chest X-ray (lungs),

Ultrasound abdomen (liver).

Treatment • Chemotherapy and surgery.• See flow sheets:

Preoperative chemotherapy – 2 different protocols* Postoperative chemotherapy – 3 different protocols**

* Preoperative chemotherapy depends on the absence / presence of distant metastatic disease i.e. chest X-ray (metastases lungs) and USS (metastases liver).** Postoperative chemotherapy depends on stage and risk group of the tumour at surgery (pathologist’s report) – or, if no pathology report is available on surgical staging and difficulty of the surgery.

References for Further Reading:

Israels T, Moreira C, Scanlan T, Molyneux L, Kampondeni S, Hesseling P et al. SIOP PODC: clinical guidelines for the management of children with Wilms tumour in a low-income setting. Pediatr Blood Cancer 2013 January; 60(1):5-11.

Israels T, Chagaluka G, Pidini D, Caron H, de Kraker J, Kamiza S et al. The efficacy and toxicity of SIOP preoperative chemotherapy in Malawian children with a Wilms tumour. Pediatr Blood Cancer 2012 October; 59(4):636-41.


1514

Boy (13) with Hodgkin’s disease Boy (13) with Hodgkin’s disease

10.Hodgkin’s Disease

11.Acute Lymphoblastic Leukaemia (ALL)

Clinical Presentation • Usually adolescents, more common in boys;

painless enlarged lymph nodes in the neck (80%), often with a widened mediastinum on chest X ray.

• Can also involve other lymph nodes, lymphatic structures (abdomen, LN in the groin or axilla, spleen).

• B symptoms (systemic disease): fever, night sweats, pruritus (itch), weight loss – especially with advanced disease.

Differential Diagnosis• Other causes of lymph node swelling (e.g.

tuberculosis), Burkitt lymphoma (usually younger children), Kaposi’s sarcoma (usually HIV positive) and other non-Hodgkin’s lymphoma.

Investigations at Admission• Routine investigations (Chapter 13).• Mantoux skin test if possible or FNA for AFB

(acid fast bacilli) when TB is a possible diagnosis. GenExpert on body fluid sample.

• For final diagnosis: Fine needle aspirate (FNA) – histology with a tissue diagnosis is much preferred in Hodgkin’s disease.

• For staging: Chest X-ray, USS abdomen.

Treatment• See flow sheets for ABVD, OEPPA or COPP (last p =

procarbazine) depending on availability of drugs.

Acute leukaemia can be classified as acute myeloid and acute lymphoblastic leukaemia. Acute lymphoblastic leukaemia is the most common.

Clinical PresentationPatients present with signs and symptoms caused by invasion of the bone marrow by leukaemic cells.Anaemia, bleeding tendency (low platelets), fever (reduced immunity) and bone pain are common symptoms. The history will usually be short (a few weeks).

Differential DiagnosisMalaria, acute viral infection such as EBV, aplastic anaemia.

Investigations at Admission• Routine investigations (Chapter 13).• Blood film for morphology (send to haematology).• Bone marrow aspirate if platelets are adequate.

Treatment• Please see the ALL flow sheets.• Start with a prednisone and allopurinol pre-phase

treatment. Start with a low dose and gradually increase the dose if the child is in a poor condition or at risk for tumour lysis syndrome (high white cell count, massive hepatosplenomegaly).

References for Further Reading:

Chagaluka G, Carey P, Banda K, Schwab C, Chilton L, Schwalbe E et al. Treating childhood acute lymphoblastic leukemia in Malawi. Haematologica 2013 January;98(1):e1-e3.

Hunger SP et al. Treatment strategies and regimens of graduated intensity for childhood acute lymphoblastic leukemia in low-income countries: A proposal. Pediatr Blood Cancer 2009 May;52(5):559-65.


1716

12.Neuroblastoma

13.Rhabdomyosarcoma

Clinical Presentation • Solid tumour, clinical manifestations vary, at times

with hypertension, peak age 0-4 years. Patients often ill at presentation, especially with metastatic disease. Pain and anaemia are common.

• Site of presentation: Abdomen (adrenal), sympathetic chain, 25% primaries are in neck or thorax, 70% abdomen, 5% pelvis.

• Metastases: Bone, lymph nodes, bone marrow, (skin), often present with metastatic lumps on the head, or racoon eyes.

• Prognosis is usually poor if metastatic disease is present.

• Patients who are below one year often have less aggressive disease and a better prognosis.

Differential Diagnosis• Burkitt lymphoma (in widespread disease). • Other solid tumours (abdomen).

Investigations at Admission• Routine investigations (Chapter 13).• Ultrasound abdomen (? adrenal tumour). Plain X-ray

may identify calcification.• MRI if there is doubt about the origin of the mass.• For final diagnosis: Fine needle aspirate (FNA) and

Bone Marrow Aspirate.• Urine for tumour markers if available.• Tumour markers: Metabolites of catecholamines in

urine (VMA and HVA).

Treatment• Chemotherapy and surgery.• See flow sheet VAC (good empirical treatment to

start with, if neuroblastoma confirmed, consider carboplatin instead of cyclophosphamide).

• Surgery of primary tumour with curative intent if no residual metastases post chemotherapy.

Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood.

Clinical Presentation• Solid tumour. Most common primary sites: Head

and neck; orbit of eye, nose and throat (40 %), bladder, vagina (20 %), extremities (20 %).

• Prognosis is very poor in metastatic disease.• Prognosis is better in small primary tumours

(smaller than 5 cm).

Investigations at Admission• Routine investigations (please see chapter 13).• Measure the tumour (important for prognosis in

localized tumours).

Treatment• Chemotherapy and surgery.• See flow sheet VAC, with A = Actinomcyin.• Surgery of primary tumour if completely resectable

and no metastases.


1918

Patient (1 year) with a rhabdomyosarcoma of the lower arm

Patient with advanced,Metastatic retinoblastoma

Patient after enucleation of the left eye. Relapse (metastases) on the right side

14.Retinoblastoma

15.Brain Tumours

Clinical Presentation• Early: Leukocoria (white pupil reflex in the eye),

strabismus (squint).• Late: Proptosis (eye pushed forward), orbital mass,

and often destruction of the eye ball.• Can be inherited (then more often bilateral disease).• Average age at diagnosis 2 years (unilateral

disease), 1 year (bilateral disease), but often older in Malawi.

• Metastases: Intracerebral, bone, peri-auricular (around the ear).

Differential Diagnosis • When advanced disease: Burkitt lymphoma

(BL usually develops more rapidly + ask about white pupil reflex in eye to differentiate), orbital rhabdomyosarcoma, metastatic neuroblastoma, other lymphoma.

Investigations at Admission• Routine investigations (chapter 13).• Bone marrow and CSF examination to assess

tumour spread.• Usually referred from ophthalmologist. Need both

eyes examined by ophthalmologist.

Treatment• Chemotherapy with JOE.• Amount of treatment depends on the stage of

disease.• If intraocular only: 2 courses of JOE then surgery

(enucleation of the eye).• If extra ocular disease: 2 - 4 courses of JOE and

then exenteration. • If distant metastases: (palliative) chemotherapy.

Post op needs further chemotherapy to complete 6 courses in total.

Palliative Chemotherapy:• 1st choice: cyclophosphamide orally 40mg/kg, once

weekly (tablets are 50mg).• Alternative: cisplatin IV or oral etoposide 100mg/

m2 weekly.

Inform the guardian about the risk of another child in the family having retinoblastoma (especially if the patient is below 1 year or bilateral disease) and early signs (white pupil). If possible, refer mother with any further children to ophthalmologist for early screening.


Chantada G, Luna-Fineman S, Sitorus RS, Kruger M, Israels T, Leal-Leal C et al. SIOP-PODC recommendations for graduated-intensity treatment of retinoblastoma in developing countries. Pediatr Blood Cancer 2013 May;60(5):719-27.

Clinical Presentation • Often signs and symptoms of raised intracranial

pressure: Headache, vomiting, disturbed vision.• Differential diagnosis• Important to exclude curable conditions• Burkitt lymphoma, infectious causes

Investigations at Admission• Routine investigations (Chapter 13)• MRI head

Treatment• As radiotherapy is not available treatment is mainly

symptomatic.• Dexamethasone for raised ICP; VP shunt for

hydrocephalus.

Some low grade gliomas can be managed with surgery and/or chemotherapy and depending on the site of the tumour.


Parkes J, Hendricks M, Ssenyonga P, Mugamba J, Molyneux E, Schouten-van Meeteren A, Qaddoumi I, Fieggen G, Luna-Fineman S, Howard S, Mitra D, Bouffet E, Davidson A, Bailey S. SIOP PODC adapted treatment recommendations for standard-risk medulloblastoma in low and middle income settings. Pediatr Blood Cancer. 2015 Apr;62(4):553-64.


2120

Boy (12) with hepatocellular carcinoma

Osteosarcoma Patient with Burkitt lymphoma. Essential to differentiate from osteosarcoma.

16.Hepatocellular Carcinoma

17.Osteosarcoma

Clinical Presentation• Abdominal pain, enlarged hard, lumpy, not tender

liver (and spleen), weight loss.• Occasionally: Fever, jaundice.• More common with endemic hepatitis B infection

(as in Malawi before Hep B vaccination was introduced). Usually children older than 5 years; boys more than girls. A relatively rare tumour.

Differential Diagnosis• In young children (usually < 2 years)

hepatoblastoma.• Hepatitis (usually shorter history, often low grade

fever, liver smoothly enlarged, more painful).

Investigations• Routine investigations (chapter 13).• Serum alpha feto protein (AFP), CXR.• For final diagnosis: FNA.

Treatment• Chemotherapy and surgery.• Curative only if resection is possible (this depends

on the site and extent of the liver infiltrates).• Chemotherapy is used in an attempt to shrink the

tumour and reduce pain.• Please see flow sheet cisplatin / doxorubicin.

Clinical Presentation• Painful swelling arising from affected bone. More

common in teenagers.• Common sites: distal femur (upper leg) ≈ 30 %,

proximal tibia (lower leg) ≈ 15%, proximal humerus (upper arm) ≈ 10 %.

• Metastases: lungs, always check for regional lymphadenopathy.

• Extent of the disease at presentation is the most important prognostic factor.

Differential Diagnosis• Burkitt lymphoma has to be excluded before

treatment.• Ewing sarcoma: Usually affects the diaphysis (mid

bone) and flat bones.

Investigations at Admission• X-ray of the affected bone may show bone

destruction, periosteal elevation and new bone formation.

• For final diagnosis: Fine needle aspiration.• For metastases: chest X-ray; check groin and lower

abdomen for LNs.

Treatment• Chemotherapy and surgery.• First choice: Please see flow sheet cisplatin /

doxorubicin. • (Alternative is VAC (A = Adriamycin)).• Surgical treatment may improve quality of life in

metastatic disease.


2322

Oste Skin lesions foot (painful) osarcoma A 1 year old patient on oxygen (pulmonary disease) and with axillary lymphadenopathy.

18.Germ Cell Tumour

19.Kaposi’s Sarcoma

Often in children below 3 years or above 12 years.Most common germ cell tumours: teratoma (often sacrococcygeal) and yolk sac tumour.

Yolk sac tumour

Clinical Presentation• Usually a painless mass.• In infancy usually sacrococcygeal region. In older

children usually testes or ovaries affected.• Tumour markers; serum α-fetoprotein and serum β–HCG are often raised.

Investigations at Admission• Routine investigations: please see chapter 13.• Ultrasound abdomen.• Tumour markers can be done in the college lab• For final diagnosis: Fine needle aspirate, but can

often go straight for surgery.

Treatment• Complete resection is often curative.• Preoperative chemotherapy may be needed to

shrink the tumour and make surgery possible. Please see flow sheet cisplatin, etoposide and bleomycin.

Clinical Presentation• Usually in HIV infected patients but can also occur

in HIV negative patients.• Varied clinical presentation. • Enlarged, often generalized, hard, lymph nodes.• Dark raised patches and nodules in the skin

and subcutaneous tissue of feet, legs, face and genitalia.

• Often painful brawny, lymphoedema especially of legs (difficulty to walk).

• Oral cavity, dark, pigmented lesions on hard palate.• Gastrointestinal disease is common and associated

withbloody rectal discharge, abdominal pain and sometimes obstruction.

• Pulmonary disease with bloody pleural effusion is often life threatening (differential diagnosis TB).

Differential Diagnosis• TB, lymphoma if LNs involved.

Investigations at Admission• Routine investigations please see chapter 13.• Consider TB when appropriate, beware of false

negative Mantoux result in HIV infected children.• Fine needle aspirate only if diagnosis in doubt.

(Aspirate often bloody).

• Treatment is symptomatic.• If HIV positive:

1. ARVs (anti retrovirals) are first line treatment. 2. Chemotherapy includes vincristine, bleomycin and etoposide (VBE) see flow charts.

• If HIV negative: Give chemotherapy (VBE).

Thalidomide is often helpful in palliative care.Thalidomide 3 mg/kg nocte for 2 months can be used but it is expensive.

Be sure to warn the guardian never to give thalidomide to anyone else as it is teratogenic (can goes congenital abnormalities if taken in early pregnancy).

References for Further Reading Molyneux E, Davidson A, Orem J, Hesseling P, Balagadde-Kambugu J, Githanga J et al. The management of children with Kaposi sarcoma in resource limited settings. Pediatr Blood Cancer 2013 April;60(4):538-42.Chagaluka G., Stanley C., Banda K., Depani S. Katangwe K., Israels T et al Kaposi’s sarcoma in children: an open randomised trial of vincristine, oral etoposide and a combination of vincristine and bleomycin. Eur. J. Cancer.


2524

eBL

1st P

rese

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ion

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age

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rapy

to re

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rinol

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tds

for 5

day

s to

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vent

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or ly

sis

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rom

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At A

dmis

sion

:

Cycl

opho

spha

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e

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---

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r)Cy

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ide

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8, 2

8: -

----

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......

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:

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our:

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sult:

......

......

......

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......

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818

28

Appendix:Treatment Flow Sheets

27

Practical Guidelines for the Management of Children with Cancer

26

eBL

and

Oth

er N

HL

Prot

ocol

1st

Pre

sent

atio

n –

All

Oth

er S

tage

s

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nt N

ame:

Max

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(met

oclo

pram

ide)

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mg

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hem

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rapy

to re

duce

vom

iting

.Al

lopu

rinol

5 m

g/kg

tds

for 5

day

s to

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vent

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or ly

sis

synd

rom

e.

At A

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sion

:

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mid

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ght

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: 60

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Dose

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day

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, 15,

28,

42:

1.5

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m2 (

max

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Intra

thec

al M

etho

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te: 1

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mg

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roco

rtiso

ne 1

2.5

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if >

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......

....

......

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......

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Age:

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of A

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:

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:

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815

28

eBL

and

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L Re

laps

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nt N

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(met

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hem

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rapy

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duce

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.Al

lopu

rinol

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for 5

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our l

ysis

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drom

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At A

dmis

sion

:

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o

Doxo

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Pred

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ght

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ht

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face

Are

a

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8 1

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al M

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trexa

te 1

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n 12

.5 m

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......

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Date

of A

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sion

:

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YS

Date

Give

n:

Size

Tum

our:

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:

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815

22

2928

Wilm

s Tum

our

1A –

Pre

oper

ativ

e Ch

emot

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py fo

r Loc

alize

d D

iseas

e

Nam

e of

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ient

:

At a

dmis

sion

:

Wei

ght (

kg)

Heig

ht (c

m):

Body

sur

face

area

(m2 ):

Both

dru

gs a

re g

iven

i.v. p

ush.

Date

of B

irth:

Dose

Vin

cris

tine

(1.5

mg/

m2 (

max

2 m

g))

Dose

Act

inom

ycin

(45μ

g/kg

(max

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wei

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uce

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)

Date

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23

4

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re C

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• Ch

est X

-Ray

• Bl

ood

pres

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• Ur

ine

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rot)

• FN

A•

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/ El

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ze tu

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r (ta

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• M

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e Ch

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tic D

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Nam

e of

Pat

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:

At a

dmis

sion

:

Wei

ght (

kg)

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ht (c

m):

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sur

face

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(m2 ):

Vinc

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d ac

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ycin

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give

n i.v

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h.Do

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n is

give

n in

a 6

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usio

n.

Date

of B

irth:

Dose

Vin

cris

tine

(1.5

mg/

m2 (

max

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g))

Dose

Act

inom

ycin

(45μ

g/kg

(max

2 m

g))

Dose

Dox

orub

icin

(30m

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2 )

Body

wei

ght <

12kg

?(If

‘yes

’ red

uce

dose

of b

oth

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)

Date

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34

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78

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• Si

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• M

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)•

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** In

vest

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ions

: FBC

, BP,

Ches

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ipst

ick

urin

e (p

rot/b

lood

), El

isa,

MPs

® C

hest

X-r

ay a

nd /

or u

ltras

ound

abd

omen

to d

eter

min

e re

gres

sion

and

rese

ctab

ility

of m

etas

tase

s.®®

3130

Wilm

s Tum

our

Opt

iona

l – P

rolo

nged

and

Inte

nsifi

ed P

reop

erat

ive

Chem

othe

rapy

for L

ocal

ized

Dise

ase

to Im

prov

e Re

sect

abili

ty

Nam

e of

Pat

ient

:

At a

dmis

sion

:

Wei

ght (

kg)

Heig

ht (c

m):

Body

sur

face

area

(m2 ):

Vinc

ristin

e an

d ac

tinom

ycin

are

give

n i.v

. pus

h. D

oxor

ubic

in is

give

n in

a 6

hou

r inf

usio

n.

Date

of B

irth:

Dose

Vin

cris

tine

(1.5

mg/

m2 (

max

2 m

g))

Dose

Act

inom

ycin

(45μ

g/kg

(max

2 m

g))

Body

wei

ght <

12kg

?(If

‘yes

’ red

uce

dose

of b

oth

drug

s to

2/3

)

Date

of A

dmis

sion

:

Doxo

rubi

cin

Actin

omyc

in D

Vinc

ristin

e

See

prev

ious

pre

op c

hem

o 1A

Surg

ery

1 ......

......

23 ...

......

...

45 ...

......

...

67 ...

......

...

8W

EEKS

Date

Give

n:

Befo

re C

hem

o:•

USS

(+ s

ize tu

mou

r)•

FBC

• Ch

est X

-Ray

• Bl

ood

pres

sure

• Ur

ine

dips

tick

(blo

od, p

rot)

• FN

A, M

Ps /

Elis

a, S

ize

tum

our (

tape

mea

sure

)•

MUA

C

Befo

re P

rolo

ngat

ion:

• Tu

mou

r res

pons

e•

Size

tum

our (

tape

mea

sure

)•

Repe

at U

SS•

Clin

icia

n’s

asse

ssm

ent

Befo

re S

urge

ry:

• Tu

mou

r res

pons

e•

Size

tum

our (

tape

mea

sure

)•

Repe

at U

SS•

Clin

icia

n’s

asse

ssm

ent

*

Wilm

s Tu

mou

rPo

st-o

pera

tive

Chem

othe

rapy

– A

V4 –

Loc

alize

d D

iseas

e at

Dia

gnos

isPa

thol

ogy:

Sta

ge I,

Inte

rmed

iate

Risk

(IR)

– N

ot fo

r Sur

gica

l Sta

ging

Onl

y

Nam

e of

Pat

ient

:

At a

dmis

sion

:

Wei

ght (

kg)

Heig

ht (c

m):

Body

sur

face

area

(m2 ):

Both

dru

gs a

re g

iven

i.v. p

ush.

Date

of B

irth:

Dose

Vin

cris

tine

(1.5

mg/

m2 (

max

2 m

g))

Dose

Act

inom

ycin

(45μ

g/kg

(max

2 m

g))

Body

wei

ght <

12kg

?(If

‘yes

’ red

uce

dose

of b

oth

drug

s to

2/3

)

Date

of A

dmis

sion

:

Actin

omyc

in D

Vinc

ristin

e

1W

EEKS

Date

Give

n:...

......

......

.....

......

......

......

.....

......

......

.....

......

......

......

..

23

4

3332

Wilm

s Tum

our

Post

-ope

rativ

e Ch

emot

hera

py –

AV1

4 Lo

caliz

ed D

iseas

e at

Dia

gnos

isPa

thol

ogy:

Sta

ge I,

Hig

h Ri

sk (H

R) a

nd S

tage

II, I

R an

d St

age

II, II

I LR

or S

urgi

cal S

tage

I or

II /

Easy

Sur

gery

Nam

e of

Pat

ient

:

At a

dmis

sion

:

Wei

ght (

kg)

Heig

ht (c

m):

Body

sur

face

area

(m2 ):

Vinc

ristin

e an

d ac

tinom

ycin

are

give

n i.v

. pus

h.

Date

of B

irth:

Dose

Vin

cris

tine

(2.0

mg/

m2 (

max

2 m

g))

Dose

Act

inom

ycin

(45

μg/k

g (m

ax 2

mg)

)

Body

wei

ght <

12kg

?(If

‘yes

’ red

uce

dose

of b

oth

drug

s to

2/3

)

Date

of A

dmis

sion

:

Actin

omyc

in D

Vinc

ristin

e

WEE

KS

Date

Give

n:

Give

1st

dos

e Vi

ncris

tine

whe

n pe

rista

lsis

is re

-est

ablis

hed

and

no o

bvio

us s

urgi

cal p

robl

ems

1 ......

......

2 ......

......

34

5 ......

......

67

8 ......

......

910

11 ......

......

1213

14 ......

......

Wilm

s Tum

our

Post

-ope

rativ

e Ch

emot

hera

py –

AVD

14 –

Met

asta

tic D

iseas

e at

Dia

gnos

isLo

caliz

ed D

iseas

e at

Dia

gnos

is –

Path

olog

y: S

tage

II H

igh

Risk

, Sta

ge II

I IR

and

HR

or S

urgi

cal S

tage

III /

Diffi

cult

Surg

ery

Nam

e of

Pat

ient

:

At a

dmis

sion

:

Wei

ght (

kg)

Heig

ht (c

m):

Body

sur

face

area

(m2 ):

Vinc

ristin

e an

d ac

tinom

ycin

are

give

n i.v

. pus

h. D

oxor

ubic

in is

give

n in

2-

6 ho

urs.

Date

of B

irth:

Dose

Vin

cris

tine

(2.0

mg/

m2 (

max

2 m

g))

Dose

Act

inom

ycin

(45

μg/k

g (m

ax 2

mg)

)

Dose

Dox

orub

icin

(30

mg/

m2 )

Body

wei

ght <

12kg

?(If

‘yes

’ red

uce

dose

of b

oth

drug

s to

2/3

)

Date

of A

dmis

sion

:

Doxo

rubi

cin

Actin

omyc

in D

Vinc

ristin

e

WEE

K

Date

Give

n:

Give

1st

dos

e Vi

ncris

tine

whe

n pe

rista

lsis

is re

-est

ablis

hed

and

no o

bvio

us s

urgi

cal p

robl

ems.

1 ......

......

2 ......

......

34

5 ......

......

67

8 ......

......

910

11 ......

......

1213

14 ......

......

3534

OEP

PAH

odgk

in’s

Dise

ase

Nam

e of

Pat

ient

:

At a

dmis

sion

:

Wei

ght (

kg)

Heig

ht (c

m):

Body

sur

face

area

(m2 ):

Max

olon

(met

oclo

pram

ide)

10

mg

befo

re a

nd a

fter (

afte

rnoo

n) c

hem

othe

rapy

to re

duce

vom

iting

.Al

lopu

rinol

5 m

g/kg

tds

for 5

day

s to

pre

vent

tum

or ly

sis

synd

rom

e.

Date

of B

irth:

Vinc

ristin

e IV

day

1 -

-- (1

.5m

g/m

2 max

dos

e 2m

g)

Etop

osid

e IV

day

s 1,

2, 3

---

(100

mg/

m2 )

Pred

niso

lone

day

s 1-

5 --

- (4

0mg/

m2 )

Proc

arba

zine

days

1-1

4 --

- (1

00m

g/m

2 )

Doxo

rubi

cin

day

1 --

- (5

0mg/

m2 )

Date

of A

dmis

sion

:

Doxo

rubi

cin

Vinc

ristin

e

Etop

osid

e

Proc

arba

zine

(14d

ays)

Pred

niso

lone

(5 d

ays)

1W

EEKS

Date

Give

n:...

......

......

.....

......

......

......

.....

......

......

.....

......

......

......

..

1428

38

Size

Tum

our:

USS:

Pres

entin

g Co

mpl

aint

s:FN

A Da

te:

FNA

Resu

lt:

(Pre

sum

ed) D

iagn

osis

:

Flow

She

et: P

redn

isol

one

Pre-

Phas

e A

LL

Nam

e of

Pat

ient

:

Date

of B

irth:

Hosp

ital N

umbe

r:

Full

Bloo

d Co

unt:

Pred

niso

lone

dos

e gi

ven:

Bone

Mar

row

:

Intr

athe

cal

Met

hotr

ixat

e:

Pred

niso

lone

:

1-2

Year

s Ol

d -

8mg

2-3

Year

s Ol

d -

10m

g3+

Yea

rs O

ld -

12m

g

40m

g/m

2 /da

y in

2 d

ivide

d do

ses

Pred

niso

lone

– 4

0mg/

m2 /

x7da

ys

Wei

ght:

Surf

ace

Area

:

Haem

oglo

bin

Whi

te B

lood

Cou

nt

Neut

roph

ils

Plat

elet

s

Day

Wee

k

Date

Dosi

ng m

ay b

e st

arte

d gr

adua

lly fo

r hig

h pr

esen

ting

WBC

med

iast

inal

dis

ease

and

if v

ery

unw

ell

Mal

awi A

LL 3

Shee

t 1

12

34

56

7

PRED

NISO

LONE

PRE

-PHA

SE

3736

Flow

She

et: I

nduc

tion

ALL

Nam

e of

Pat

ient

:

Date

of B

irth:

Hosp

ital N

umbe

r:

Full

Bloo

d Co

unt:

Trea

tmen

t giv

en:

Bone

Mar

row

:

Intr

athe

cal

Met

hotr

exat

e:

Aspa

ragi

nase

:

Vinc

ristin

e:

Pred

niso

lone

:

Dose

Dose

Dose

Dose

1-2

Year

s Ol

d -

8mg

2-3

Year

s Ol

d -

10m

g3+

Yea

rs O

ld -

12m

g

6000

IU/m

2 per

dos

e (in

tram

uscu

lar)

Day

4 –

1st d

ose

1.5m

g/m

2 per

dos

e

40m

g/m

2 /d

ay in

2 d

ivide

d do

ses

then

wea

n ov

er 5

day

s

Wei

ght:

Surf

ace

Area

:

Haem

oglo

bin

Whi

te B

lood

Cou

nt

Neut

roph

ils

Plat

elet

s

Day

Wee

k

Date

Mal

awi A

LL 3

Shee

t 2

Indu

ctio

n

18

1522

23

45

Flow

She

et: C

ontin

uatio

n A

LL

Nam

e of

Pat

ient

:

Date

of B

irth:

Hosp

ital N

umbe

r:

Full

Bloo

d Co

unt:

Trea

tmen

t giv

en:

Intr

athe

cal

Met

hotr

exat

e:

6 M

erca

ptop

urin

e:

Vinc

ristin

e:

Pred

niso

lone

:

Cotr

imox

azol

e:

Dose

Dose

Dose

Dose

1-2

Year

s Ol

d -

8mg

2-3

Year

s Ol

d -

10m

g3+

Yea

rs O

ld -

12m

g

60m

g/m

2 /da

y -

in th

e ev

enin

g

1.5m

g/m

2 per

dos

e

40m

g/m

2 /d

ay in

2 d

ivide

d do

ses

then

wea

n ov

er 5

day

s

Daily

Wei

ght:

Surf

ace

Area

:

Haem

oglo

bin

Whi

te B

lood

Cou

nt

Neut

roph

ils

Plat

elet

s

Day

Wee

k

Mal

awi A

LL 3

Shee

t 4

5764

7178

1011

1213

Give

hou

r afte

r mea

l – n

ot w

ith m

ilk

May

nee

d to

adj

ust d

ose

afte

r blo

od c

ount

3938

Flow

She

et: I

nten

sific

atio

n A

LL

Nam

e of

Pat

ient

:

Date

of B

irth:

Hosp

ital N

umbe

r:

Full

Bloo

d Co

unt:

Trea

tmen

t giv

en:

Intr

athe

cal

Met

hotr

exat

e:

Doxo

rubi

cin:

Etop

osid

e:

Cyta

rabi

ne:

6 M

erca

ptop

urin

e:

Vinc

ristin

e:

Pred

niso

lone

:

Dose

Dose

Dose

Dose

Dose

Dose

Dose

1-2

Year

s Ol

d -

8mg

2-3

Year

s Ol

d -

10m

g3+

Yea

rs O

ld -

12m

g

45m

g/m

2 per

dos

e

100m

g/m

2 per

dos

e

100m

g/m

2 per

dos

e

60m

g/m

2 in

the

even

ing

1.5m

g/m

2 per

dos

e

40m

g/m

2 /d

ay in

2 d

ivide

d do

ses

for 5

day

s

Wei

ght:

Surf

ace

Area

:

Haem

oglo

bin

Whi

te B

lood

Cou

nt

Neut

roph

ils

Plat

elet

s

Dox

orub

icin

/ C

ispl

atin

Patie

nt N

ame:

At A

dmis

sion

:

Cisp

latin

Doxo

rubi

cin

Wei

ght

Heig

htBo

dy S

urfa

ce A

rea

Doxo

rubi

cin

......

... (5

0mg/

m2 ,

max

70m

g)Ci

spla

tin, d

ay 1

+2

(50m

g/m

2 , m

ax 7

0mg)

......

....

......

....

......

....

Age:

Date

of A

dmis

sion

:

1W

EEKS

Date

Give

n:

Size

Tum

our:

USS:

FNA

Date

:

Pres

entin

g Co

mpl

aint

s:

......

......

......

..

Ches

t X-R

ay:

FNA

Resu

lt:

(Pre

sum

ed) D

iagn

osis

:

......

......

......

..

2 ......

......

......

..

3 ......

......

......

.

......

......

......

..

4 ......

......

......

..

......

......

......

..

5 ......

......

......

..

6 ......

......

......

..

7 ......

......

......

..

......

......

......

..

Ost

eosa

rcom

a, H

epat

ocel

lula

r Car

cino

ma

(Neu

robl

asto

ma)

4140

Etop

osid

e / C

ispl

atin

/ Bl

eom

ycin

Patie

nt N

ame:

At A

dmis

sion

:

Cisp

latin

Bleo

myc

in

Etop

osid

e

Wei

ght

Heig

htBo

dy S

urfa

ce A

rea

Etop

osid

e da

y 1-

3 IV

; OR

1-5

po ..

... (1

00m

g/m

2 )Ci

spla

tin, d

ay 1

+2

.....

(50m

g/m

2 )Bl

eom

ycin

day

1 ..

... (1

5 IU

/m2 )

......

....

......

....

......

....

Age:

Date

of A

dmis

sion

:

0W

EEKS

Date

Give

n:

Size

Tum

our:

Alph

a Fe

topr

otei

n:

USS:

FNA

Date

:

Pres

entin

g Co

mpl

aint

s:

......

......

......

..

Ches

t X-R

ay:

FNA

Resu

lt:

(Pre

sum

ed) D

iagn

osis

:

......

......

......

..

12

3 ......

......

......

..

......

......

......

..

45

6 ......

......

......

..

......

......

......

..

Ger

m C

ell P

roto

col

Kapo

si S

arco

ma

Vin

cris

tine,

Ble

omyc

in a

nd E

topo

side

Patie

nt N

ame:

At A

dmis

sion

:

Etop

osid

e

Vinc

ristin

e

Bleo

myc

in

Wei

ght

Heig

htBo

dy S

urfa

ce A

rea

Etop

osid

e 1-

3 IV

1 h

r inf

usio

n, o

r 1-5

day

s po

.....

(100

mg/

m2 )

Vinc

ristin

e da

y 1,

IV b

olus

(1.5

mg/

m2 ,

max

2 mg)

Bleo

myc

in d

ay 1

IV 1

5 m

in in

fusi

on 1

5 IU

/m2

......

....

......

....

......

....

Age:

Date

of A

dmis

sion

:

12

34

56

78

910

WEE

KS

Date

Give

n:

Size

Sen

tinel

Nod

e:

Lans

ky S

core

:

Pres

entin

g Co

mpl

aint

s:

USS:

FNA:

......

.....

......

.....

Pres

umed

) Dia

gnos

is:

Ches

t X-R

ay:

Date

:

......

.....

......

.....

......

.....

......

.....

Resu

lt:

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

......

.....

HIV

pos

Y/N

CD4

coun

t...

On A

RTs

Y/N

If ‘Y

es’ s

ince

whe

n?

4342

Low

Gra

de G

liom

a –

Vin

cris

tine

and

Car

bopl

atin

Freq

uenc

y.

The

Initi

al p

hase

con

sist

of w

eekl

y ch

emot

hera

py fo

r 10

wee

ks w

ith V

incr

istin

e an

d 3

wee

kly

with

Car

bopl

atin

.Th

e ne

xt p

hase

last

s fo

r 10

cour

ses

of V

incr

istin

e an

d Ca

rbop

latin

at a

ppro

ximat

ely

28 d

ay in

terv

als,

whe

n th

e ne

utro

phils

are

>1x

109

/l an

d pl

atel

ets

> 1

00 x

109

/l.

Drug

: Vi

ncris

tine

Dosa

ge:

1.5

mg/

m2 f

or c

hild

ren

>10

kg

(max

tota

l dos

e 2m

g)

Drug

: Ca

rbop

latin

Dosa

ge:

600

mg/

m2 f

or c

hild

ren

>10

kg

Both

: Re

com

men

datio

ns fo

r chi

ldre

n un

der 1

0kg

in w

eigh

t:

Less

than

6 m

onth

s of

age

: 50%

of c

alcu

late

d do

se b

y bo

dy s

urfa

ce a

rea

6

mon

ths

to 1

yea

r of a

ge: 7

5% o

f cal

cula

ted

dose

by

body

sur

face

are

a

Over

1 y

ear o

f age

: 100

% o

f cal

cula

ted

dose

by

body

sur

face

are

a

VCR/

Carb

o

Wee

k 1

VCR

Wee

k 2

VCR

Wee

k 3

VCR/

Carb

o

Wee

k 4

VCR

Wee

k 5

VCR

Wee

k 6

VCR/

Carb

o

Wee

k 7

VCR

Wee

k 8

VCR

Wee

k 9

VCR/

Carb

o

Wee

k 10

VCR/

Carb

o

Wee

k 14

VCR/

Carb

o

Wee

k 18

VCR/

Carb

o

Wee

k 22

VCR/

Carb

o

Wee

k 26

VCR/

Carb

o

Wee

k 30

VCR/

Carb

o

Wee

k 34

VCR/

Carb

o

Wee

k 38

VCR/

Carb

o

Wee

k 42

VCR/

Carb

o

Wee

k 46

VCR/

Carb

o

Wee

k 50

Retin

obla

stom

a –

Che

mot

hera

py –

JOE

Eye

exam

inat

ion

Date

Che

mot

hera

py G

iven

Cour

se n

umbe

r

MPS

/PCV

Seru

m c

reat

inin

e

HB WBC

/Neu

t

Plts

Any

toxic

ity

Carb

opla

tin D

ose

600

mg/

m2 f

or c

hild

ren

>10

kg

Reco

mm

enda

tions

for c

hild

ren

unde

r 10k

g in

wei

ght:

Less

than

6 m

onth

s of

age

: 50%

of c

alcu

late

d do

se b

y BS

A6

mon

ths

to 1

yea

r of a

ge: 7

5% o

f cal

cula

ted

dose

by

BSA

Over

1 y

ear o

f age

: 100

% o

f cal

cula

ted

dose

by

BSA

Etop

osid

e Do

se30

0 m

g/m

2 for

chi

ldre

n >

10 k

gRe

com

men

datio

ns fo

r chi

ldre

n un

der 1

0kg

in w

eigh

t:Le

ss th

an 6

mon

ths

of a

ge: 5

0% o

f cal

cula

ted

dose

by

BSA

6 m

onth

s to

1 y

ear o

f age

: 75%

of c

alcu

late

d do

se b

y BS

AOv

er 1

yea

r of a

ge: 1

00%

of c

alcu

late

d do

se b

y BS

A

Vinc

ristin

e Do

se1.

5 m

g/m

2 for

chi

ldre

n >

10 k

gRe

com

men

datio

ns fo

r chi

ldre

n un

der 1

0kg

in w

eigh

t:Le

ss th

an 6

mon

ths

of a

ge: 5

0% o

f cal

cula

ted

dose

by

BSA

6 m

onth

s to

1 y

ear o

f age

: 75%

of c

alcu

late

d do

se b

y BS

AOv

er 1

yea

r of a

ge: 1

00%

of c

alcu

late

d do

se b

y BS

A

PRE

12

34

56

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