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New diagnosis - work up when oncology diagnosis suspected

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History

In addition to a detailed history of the presenting complaint and systematic inquiry, make sure you have covered the following:

  • Detailed family history particularly of cancers - multiple cancers in individuals (e.g., bilateral breast cancer) and cancers occurring in family members < 50 years old are of particular interest.
  • In older females, attempt to discuss sexual activity and possibility of pregnancy.
  • Ask about DVT and bleeding tendencies in the family.
  • Detailed history of immunisations and viral exanthema especially chickenpox and measles. Have siblings been immunised?
  • Family relationships including names and ages of parents and all siblings. Are there any pre-existing psychosocial problems? If the parents are separated, what is the relationship like? Are there financial or transportation issues?
  • Ask about pain. Parents may not be aware that their child has been in pain so specifically ask about disrupted sleep, wincing when picked up, etc.

Examination

General      Plot weight and height, and head circumference in brain tumours 
Temperature, pulse and BP 
Evidence of cachexia 
Pallor, jaundice, oedema 
Phenotypic features of cancer predisposition syndromes 
Bruising and petechiae 
Cardiovascular system    Perfusion, BP, pulse, auscultation 
Evidence of SVC obstruction for patients with anterior mediastinal masses (dilated neck veins, swollen eyelids/face, dusky face) 
Evidence of pericardial effusion with chest masses 
Respiratory system    Evidence of distress, cyanosis, SaO2 in air, any positioning associated with mediastinal masses 
Tracheal obstruction/deviation with anterior mediastinal masses 
Evidence of pleural effusion with chest or abdominal masses 
Abdomen   General examination - measure enlargement of liver, spleen, masses (look, feel, precuss for ascites, etc., then listen for bruits, bowel obstruction, etc) 
Bimanual palpation for renal masses 
Neurological       General examination 
Visual acuity and fields in brain tumour patients 
Fundoscopy and careful examination of 7th and 3rd cranial nerves for patients with leukaemia 
Careful assessment of bulbar function and CN VI palsies for patients with brain stem tumours or cancers eroding through the base of the skull 
Horner's syndrome with neck and posterior mediastinal tumours (smaller pupil, apparent enophthalmos, but heterochromia unusual as this usually reflects a prenatal origin) 
Assessment of limb strength, sensory level, bowel and bladder in patients with spinal/paraspinal masses 
Genito-urinary      Document pubertal status 
Evidence of precocious puberty (germ cell tumour, hepatoblastoma)
Testicular enlargement (germ cell tumour, ALL) 
Undescended testes (dysgerminoma) 
Other developmental abnormalities - Wilm's
 Lymph nodes   Feel carefully for all groups including cervical, pre/post auricular, supraclavicular, axillary, inguinal and around knee and elbow joints 
Left supraclavicular gland (Virchow Trosier) in patients with abdominal masses (particularly neuroblastoma) 
Remember that Waldeyer's ring is part of the lymphoid system - examine carefully in patients with neck masses 
ENT     Examine for dental problems and oral petechiae 
Gum hypertrophy and infiltration may occur with AML, JMML, LCH 
Evidence of middle ear disease which could signal problems when neutropenic 
Sarcoma can arise from the middle ear 
 Eyes  Aniridia with Wilms' 
Fundal/subconjunctival haemorrhage with leukaemia 

Work up of the new oncology patient in shared care centres

Children presenting to shared care centres with a possible malignant diagnosis need to have some investigations to ensure safe and appropriate transfer. Extensive investigations should be avoided as the oncology centre will have an investigation profile that needs to be performed at laboratories that have been accredited by the international study groups.

Ensure a full history and examination as above.

General investigations for patients before transfer to oncology unit

Acute Leukaemia/Lymphoma

  • CBC+Film, Coags, Group and Hold
  • Biochemistry including sodium, potassium, creatinine, phosphate, calcium and uric acid
  • if the child needs any form of blood product transfusion prior to transfer, then take 1-2 six ml red top tubes for serology and 1 five ml EDTA tube for TPMT level assay before blood products are given and send with the patient to the oncology unit
  • CXR - PA and lateral
  • Patients with mediastinal masses should not be positioned supine and should have an anaesthetic opinion on appropriate level of support for transfer
  • Tumour lysis syndrome can be present prior to starting treatment. These children will need to start treatment for this prior to transfer - please refer to tumour lysis syndrome guideline.

Solid Tumours

  • Baseline biochemistry as above may be needed for aggressive stage IV tumours.
  • Patients with suspected spinal tumours and neurological signs should be discussed with the paediatric oncologist or neurosurgeon on call at the oncology centre before undertaking imaging investigations.
  • Patients with mediastinal masses should have an anaesthetic opinion on appropriate level of support for transfer
  • Patients with abdominal tumours and pain should have AXR to look for bowel obstruction and if indicated, e.g., raised creatinine, an USS to look for genitourinary obstruction
  • Tumour lysis can occur rarely with solid tumours, e.g., stage IV neuroblastoma. If present, children will need to start treatment for this prior to transfer - please refer to tumour lysis syndrome guideline and discuss with the paediatric oncologist on call.

Brain Tumours

  • Please discuss imaging requirements with the paediatric oncologist or neurosurgeon on call prior to imaging if a brain tumour is suspected from history and clinical signs.
  • In Auckland, suspected brain tumours are admitted under neurosurgery and so must be accepted by them. In Christchurch they are admitted jointly to CHOC ward managed by both services.
  • Dexamethasone should be started prior to transfer 0.25 - 1 mg/kg/day in 4 divided doses (max 16 mg/day) after discussion with the paediatric oncologist or neurosurgeon on call.
  • A radiological or neurosurgical opinion should be sought prior to transfer if there is any raised intracranial pressure or decreased level of consciousness.
  • Please send radiology with the patient or arrange electronic transfer.

Work up in oncology units

These are generic investigations for patients presenting with these conditions. Patients will be enrolled on appropriate clinical trials whenever possible. These trial protocols all have their own requirements for investigations prior to starting treatments, and the study requirements should be followed in preference to this list where possible.

This is not an exhaustive list and additional work up may be required depending on the clinical presentation of the patient. Plan your investigations then check with the treating oncologist before arranging them.

Ensure that blood taken for serology testing is taken before any blood products are administered so that antibody levels properly reflect the patients pre-transfusion infective status.

Please check that serology results are pending (i.e., that the blood arrived in the lab and the amount was sufficient before transfusing for the first time).

Routine Work Up on All Patients

Please note that the minimum volumes are for collection in specific paediatric microtainers.

  • CBC+F (1-5 ml pple), Coag screen - APTT, PT, TCT, Fibrinogen (1-5 ml blue)
  • Group and Hold (0.5 to 6 ml pink top)
  • Na, K, Ur, Cr, Gluc, LFTs, Ca, Mg, Phosphate, Urate/Uric acid, LDH (1-5 ml green)
  • Serology: HAV IgG, HBV sAg, HCV Ab, HIV Ag and Ab, VZV IgG, HSVg IgG, CMV IgG, EBV IgG, Measles IgG, Toxoplasma IgG (in Christchurch this is PAO1 and PAO2 panels 5 mls red to required)
  • Blood for tissue banking if consented (5 ml pple)
  • Dental consult
  • Pregnancy test if menstruating (1-5 ml red top)
  • Consider cryopreservation for fertility.

Tumour Specific Investigations

Follow this link to view a pdf of the Tumour Specific Work Up information.

Coagulation Investigations

  • Possible DIC, including all patients who may have Acute Promyelocytic Leukaemia (AML M3):
    • d-dimers or fibrinogen degradation products as well as routine coagulation profile.
  • Family history of venous thromboembolic events.
    •  There is no good evidence on thrombophilia screening in children or on thromboprophylaxis in children with cancer and central line so screening is generally not recommended. Current guidelines do not recommend primary prophylaxis1.
    •  Thrombosis screen as part of a risk of thrombosis scoring system2. This may be considered in certain circumstances (see reference (2) below).
    • Personal or family bleeding history - von Willebrand's disease screen (PFA-100) as well as routine coagulation profile.

Further Supportive Care

  • Some chemotherapy regimens have high rates of infertility associated with them. Cryopreservation should be discussed with senior medical staff and then with families if appropriate. National guidelines on cryopreservation are currently being drafted.
  • Menstruating females will need to start hormonal therapy to suppress menstruation if they are having chemotherapy that is likely to cause thrombocytopenia. See guideline for suppression of Menstruation.
  • All patients should receive an information sheet regarding the New Zealand Children's Cancer registry (NZCCR).
  • All new patients are offered tissue banking through the Cancer Society Tissue Bank (CSTB) or the Bone Marrow Trust Bank (BMCTB). Families should be asked to sign gifting consents for the tissue bank.
    • In Christchurch the curator is Helen Morrin (page through the Christchurch Hospital switchboard).
  • According to NZBS guidelines, patients with Hodgkins disease, Aplastic Anaemia, those who will receive fludarabine, cladribine, ATG or alemtuzemab, and those who will receive an autologous or allogeneic transplant require irradiated blood products. In Auckland all patients receive irradiated products.
  • See Blood Component Irradiation, and, in Christchurch, use the Request for Irradiated Blood form.

References

  1. Monagle et al Antithrombotic therapy in neonates and children: American college of chest physicians evidence based clinical practice guidelines. Chest 2008;133; 887S-968S
  2. Mitchell et al. validation of a predictive model for identifying an increased risk for thromboembolism in children with acute lymphoblastic leukemia: results of a multicentre cohort study. Blood 2010; 115(24) 4999-5004

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Document Control

  • Date last published: 01 December 2010
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network