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Solid Tumours - new diagnosis

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If a biopsy or primary excision of a tumour is planned

  • Christchurch:Contact the Path lab (80594) to let them know that a sample will be arriving and also contact Dr Martin Whitehead via pathology (80580) or the pathologist of the day so that they know to wait for the sample. Please also contact them if the surgery is cancelled!
  • Auckland:Contact Dr Jeannette McFarlane or Dr Mike Watson. For contact details check the intranet phone list.
  • If the sample is taken late in the day, check that it has been received by the lab.
  • The surgeon or interventional radiologist will decide on the appropriate biopsy specimen in conjunction with the pathologist. Fine needle aspiration should be avoided in new patients as they have a high false negative rate and give a poor sample meaning that the patient will need a second procedure anyway. They may sometimes be used to confirm relapse in patients.
  • If a fresh frozen sample is required the lab should be contacted in advance and again at the time the sample is sent to the lab. The specimen needs to be transported to the lab and processed as quickly as possible (within 15 minutes) to prevent tissue degradation.
  • If a flow cytometry is required, discuss with pathology. Ideally the specimen should be collected in the morning to allow same day processing.
  • Specimens are sent from theatre or radiology to anatomical pathology fresh for:
    • Histology diagnosis
    • Conventional cytogenetics
    • Molecular tests as appropriate
    • Study requirements
    • Tissue banking (once signed parental consent is obtained). The anatomical pathology department will arrange for samples to be sent to the appropriate labs.
  • LP for paraspinal tumours and some brain tumours - send fluid for cytology exam (Anatomical Pathology). Ensure lab is expecting, and has received, specimen as cytospin needs to be expedited.

Neuroblastoma

  • Ensure biopsy material is sent for molecular studies.
  • Investigations for neuroblastoma need to be organised in a certain order because of interactions of the MIBG with other agents (see below). The general order is:
    • CT scan or MRI at diagnosis
    • Renal function assessment which can be a calculated GRF and formal EDTA GFR if calculated value is abnormal
    • Bone scan
    • MIBG scan

Baseline toxicity evaluation for patients receiving chemotherapy

  1. If protocol contains Cisplatin/carboplatin, needs pre-chemo audiology and renal function assessment with calculated GFR, and ETDA GFR if value is abnormal. 
  2. If protocol contains anthracyclines, needs pre-chemo Echo for cardiac function including LV fractional shortening and ejection fraction.

123I-MIBG Scan

Principle: MIBG localises in adrenal medullary and sympathetic tissue. Structurally it is similar to norepinephrine and guanethidine.

Patient preparation:

  • The patient should not have a bone scan less than 3 days before or until 5 days after the 123I-MIBG injection. A GFR study should not be performed until at least 6 days after the 123I-MIBG injection.
  • The patient must not have either CT with contrast or a Barium study within 5 days of the 123I-MIBG injection or until after imaging has finished (usually 26 hours after the injection). These xray studies will interfere with MIBG imaging.
  • Lugol's Iodine (thyroid blocking agent) needs to be started 1 day before the injection of the radiopharmaceutical and it should be continued for about 3 days. 1 or 2 drops to be taken daily in milk.
  • Substances such as chocolate (including chocolate milk), blue-veined cheese, decongestants and nasal sprays can block the uptake of MIBG. They must be avoided for 4 days before the MIBG scan if possible.
  • MIBG imaging takes about 1.5 hours (including tomography). Infants and children with neuroblastoma will often need sedation or anaesthesia. This needs to be arranged by the registrar with the anaesthetic service.

Comments:

MIBG is an expensive investigation and requires a lot of organisation between departments and the suppliers of the radiopharmaceutical. At least 2 - 3 weeks notice is usually required to arrange the study.

  • Christchurch:
    Usually the 123I-MIBG arrives and is injected on Tuesday afternoons. The registrar will need to insert a peripheral IV prior to this even if the patient has a CVL as the MIBG "sticks" to the catheter. The imaging is performed 24 hours later, i.e., Wednesdays.
  • Auckland
    Discuss with nuclear medicine about timing of investigation. A peripheral iv canula will be required.

Wilms' Tumour

Patients with Wilms' tumour can have acquired von Willebrand Disease. Watch for coagulopathy. Check and document any clinical dysmorphic features which may indicate underlying tumour predisposition syndrome and consult Genetics. Check IVC and contralateral kidney carefully.

Toxicity evaluation

If protocol contains anthracyclines, needs pre-chemo echo for cardiac function including LV fractional shortening and ejection fraction.

Soft Tissue Sarcoma

  • Local examination if appropriate e.g., cystoscopy/vaginoscopy/ENT.
  • PET scan for staging. This is currently performed in patients who do not require GA for assessment.
  • Biopsy material sent for molecular studies.

Toxicity evaluation

  1. If protocol contains anthracyclines, needs pre-chemo echo for cardiac function including LV fractional shortening and ejection fraction. 
  2. If protocol contains carboplatin, needs pre-chemo audiology and EDTA GFR for renal function assessment and chemotherapy dosing.
  3. If protocol contains ifosfamide, needs renal function assessment including calculated GFR and tubular function, and formal EDTA GFR if calculated value is abnormal.

Ewing's Sarcoma

Biopsy material sent for molecular studies.

Toxicity evaluation

  1. If protocol contains anthracyclines, needs pre-chemo echo for cardiac function including LV fractional shortening and ejection fraction. 
  2. If protocol contains ifosfamide, needs renal function assessment including calculated GFR and tubular function, and formal EDTA GFR if calculated value is abnormal.

Osteosarcoma

Toxicity evaluation

  1. If protocol contains anthracycline, needs pre-chemo echo for cardiac function including LV fractional shortening and ejection fraction. 
  2. If protocol contains cisplatin, needs pre-chemo audiology and renal function assessment including calculated GFR, and formal EDTA GFR if calculated value is abnormal.
  3. If protocol contains methotrexate, needs pre-chemo calculated GFR.
  4. If protocol contains ifosfamide, needs pre-chemo calculated GFR and tubular function assessment.

Hepatoblastoma

Toxicity evaluation

  1. If protocol contains anthracycline, needs pre-chemo echo for cardiac function including LV fractional shortening and ejection fraction.
  2. If protocol contains cisplatin or carboplain, needs pre-chemo audiology and EDTA GFR for carboplatin dose calculation.

Germ Cell Tumour (extracranial)

Serum AFP and beta HCG

Toxicity evaluation

  1. If protocol contains carboplatin or cisplatin, needs pre-chemo audiology and EDTA GFR for renal function assessment and carboplatin dose calculation.
  2. If protocol contains bleomycin, needs pre-chemo lung function tests (these are generally only reliable in children > 6 years).

Retinoblastoma

RB1 gene testing on all affected patients and their tumours. Clinical genetics team need to be involved in the genetic counselling of families affected. Investigations to confirm diagnosis and stage in sporadic unilateral or in hereditary disease:

  • MRI brain ( to look for Trilateral disease)

Then decide if further investigations are necessary if high risk features present (applies to both hereditary and sporadic cases):

High risk features (any 1 of the following)

  • Cut end of optic nerve involved, or
  • involvement of optic nerve beyond the lamina cribrosa, or
  • "massive" choroidal infiltration, or
  • infiltration of sclera, or
  • infiltration into the orbit
  • involvement of the ciliary body or structures more anterior
  • CNS disease on MRI
  • Suspicion of distant spread clinically - enlarged pre-auricular gland, bony pains, depression of blood count.

Investigations to be done on all high risk cases:

  • MRI brain and spine
  • LP for cytology (Anatomical Pathology)
  • Bone scan
  • Bilateral posterior iliac crest aspirate and trephine biopsy.

Brain Tumours

On all patients

  • Discuss with neurosurgeon
  • Commence dexamethasone 0.25 - 1 mg/kg/day in 4 divided doses IV/PO(max 16mg/day) - if evidence of elevated intracranial pressure
  • Brain MRI (CT head alone is insufficient) - include contrast study and diffusion imaging. Include spectroscopy for brainstem tumours.
  • Spine MRI.

Medulloblastoma

  • Require lumbar CSF cytology for staging - generally done 10-14 days post-surgery. Discuss with neurosurgeons regarding timing and clinical safety.
  • Need post-op MRI to assess for residual tumour within 48 hours of resection.

Toxicity evaluation

  1. If protocol contains cisplatin or carboplatin, needs pre-chemo audiology and renal function assessment including calculated GFR and tubular function, and EDTA GFR for carboplatin dosing.

Germ cell tumour (around hypothalamus or pineal)

Blood and CSF (if clinically safe) AFP and tumour HCG.

Toxicity evaluation

  1. If protocol contains cisplatin or carboplatin, needs pre-chemo audiology and renal function assessment including calculated GFR and tubular function, and EDTA GFR for carboplatin dosing.
  2. If protocol contains ifosfamide, needs pre-chemo renal function assessment including calculated GFR and tubular function.

Low grade glioma

Requires a one-off MRI spine at diagnosis to exclude any metastatic lesion.

Toxicity evaluation

  1. If protocol contains carboplatin, needs pre-chemo audiology and EDTA GFR for renal function assessment and carbopatin dosing

Molecular Tests for solid tumours

Click on this link to access a pdf of molecular tests for solid tumours.

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Document Control

  • Date last published: 23 February 2017
  • Document type: Clinical Guideline
  • Services responsible: National Child Cancer Network
  • Owner: Karen Tsui
  • Review frequency: 2 years