Chapter 18: Childhood Cancer – Flashcards
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what % of all new cancer dx is childhood cancer
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1%
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symptoms of childhood cancer
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-unusual mass or swelling -unexplained paleness or loss of energy -sudden tendency to bruise -persistent, localized pain -prolonged, unexplained fever or illness -frequent headaches, often w/ vomiting -sudden eye or vision changes -excessive, rapid weight loss
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what are the 2 most common cancers in children 0-19 years of age
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-Leukemia -Central Nervous System Cancer
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leukemia represents ____ % of all cancer cases before 15 years of age
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31%
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what are the 2 major types of leukemia and % of each?
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Acute Lymphoblastic Leukemia (ALL): 75% Acute Myeloblastic Leukemia (AML): 19%
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what is more common, ALL or AML?
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ALL (75% of leukemias)
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where is the highest incidence rate of leukemia in children found?
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ages 1-4
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overall survival for children for ALL and AML
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survival rate-ALL: 90% survival rate AML: 55%
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cause of ALL
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-little is known -prenatal exposure to x-rays -specific genetic syndromes (Down syndrome)
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CNS cancer represents ____ % of all malignancies of childhood and adolescence
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21.3%
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what is the 2nd most common malignancy of childhood
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CNS cancer
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what is the most common solid tumor of childhood
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CNS cancer
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where is the highest incidence of CNS cancer found
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children 1-4 years old
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CNS cancer is the leading cause of cancer among children 1-5 years old, especially for infants with ______ and ________
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ependymomas and primitive neuroectodermal tumors (PNET)
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5 year survival rate for CNS cancer
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71%
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what is leukemia
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a malignant progressive disease; -the bone marrow and other blood-forming organs produce increased numbers of immature or abnormal leukocytes -these leukocytes suppress the production of normal blood cells, leading to anemia and other symptoms
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what is the 3rd most common form of childhood cancer?
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Lymphoma
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what are the 2 major types of Lymphomas
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-Hodgkin's disease (HD)4.3% -non-Hodgkin's Lymphoma (NHL): 3/8%
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what lymphoma is more common for younger children? what lymphoma is more common for adolescents?
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-lymphoma most common for younger children = non-Hodgkin's Lymphoma -lymphoma most common for adolescents = Hodgkin's Disease
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5 year survival rate for Hodgkin's Disease (lymphoma)
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94%
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5 year survival rate for Non-Hodgkin's Lyphoma
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85%
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where do sympathetic nervous system tumors arise from?
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the neural crest tissue
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what % of all cancers among kids under 15 years of age are sympathetic nervous system tumors
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7.8%
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what % of Sympathetic nervous system tumors are neuroblastomas?
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97%
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who gets neuroblastomas?
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almost exclusively in infants and very young children
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what is the most common malignancy in the 1st year of life?
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a neuroblastoma
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where are neuroblastomas most commonly found?
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adrenal gland (usually appears as as swelling in the abdomen)
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5 year survival rate of Sympathetic nervous system tumor
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74%
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what do soft tissue sarcomas derive from?
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derives from primitive mesenchymal cells -arises primarily from the connective tissue of the body (10% in the head and neck)
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what the risk factors of soft tissue sarcoma?
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congenital anomalies and genetic conditions
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what is the most common soft tissue sarcoma of childhood
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rhabdomyosarcoma (3.3%)
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who usually gets rhaabdomyosarcoma?
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children under 10
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5 year survival rate for soft tissue sarcomas
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66%
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what is the predominate form of renal tumors?
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Wilm's tumor (5.2%)
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when does Wilm's tumor occur
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usually before 5 years of age
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overall 5 year survival rate of Renal tumors
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88%
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most common types of Malignant bone tumors
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-Osteosarcoma (56%) -Ewing sarcoma (34%)
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5 year survival rate of malignant bone tumors?
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71% (higher for osteocarcoma than Ewing sarcoma)
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______ is a malignant bone tumor that occurs between the extremities and the central axis
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Ewing sarcoma
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where does osteosarcoma most often occur?
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near the metaphyseal portions of the long bones (especially in the lower liimbs) -pain may worsen at night or with activity
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what is the leading cause of death by disease among US children between 1 and 14 years of age
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cancer
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are incidence rates of cancer increasing or decreasing
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increasing
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major cause of mortality for 5 year survivors of cancer
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primary cancer recurrence with subsequent progression
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what are the long-term treatment related side effects of survivors of childhood cancer?
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-organ malfunction -secondary cancers -cognitive impairments -dental developmental abnormalities
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what is the particular person that is at increase risk of second malignant neoplasms following childhood cancers
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-female sex -childhood cancer at a younger age -childhood Hodgkin's Disease (lymphoma) -soft tissue sarcoma -exposure to alkylating agents (type of chemotherapy drugs)
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what is the most frequently documented source of sepsis in the cancer patient with pre-existing oral disease and poor OH as a major contributing factor
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the mouth
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what are some of the crainofacial and dental developmental problems often seen in children that chemo and radiothearpy when they were under 6 years of age
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-tooth agenesis -microdontia -crown disturbances (size, shape, enamel hypoplasia, pulp chamber abnormalities) -root disturbances (early apical closure, shape, length) -reduced mandibular growth -reduced alveolar process height
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is IE prophylaxis warranted if a central line is present ?
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only if the patient is immunosuppressed
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should pulpotomeis/pulpectomies be done during immunosuppression ?
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no -if not sure about the pulpal status, extract
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rules for a permanent tooth, symptomatic non-vital
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root canal tx at least 1 week before initiation of cancer tx -if not possible, EXT
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rules for permanent tooth, asymptomatic non-vital
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root canal can be delayed until hematological status is stable (except in HSCT)
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can ortho appliances be kept while on chemo/radiotherapy?
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for smooth well fitting appliances but ONLY if pt has good oral hygiene
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should braces be kept on during chemo/radio therapy?
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remove it pt is at risk for moderate/severe mucositis or has poor oral hygiene
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when should extractions be done on pts that will be getting chemo/radio therapy?
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at least 7-10 days prior to therapy initiation
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what to extract on pt that will be getting chemo/radio therapy?
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root tips teeth w/ perio pockets more than 6 mm teeth w/ acute infections significant bone loss involvement of the furcation non-restorable teeth
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if a patient presents with neurotoxicity of the jaws and complains of a "toothache" in the absence of caries or odontogenic infection, they are likely taking what?
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vinca alkaloid agents (vincristine, vinblastine)
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is nystatin prophylaxis good for pts with secondary infections from chemo/radio therapy
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no it is ineffective as a prophylactic measure
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HSCT pts will be immunosuppressed for a long period of time, especially if....
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GVHD is active
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when can ortho be started or restarted after radio/chemo thearpy ?
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at least 2 years of disease-free survival
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what can malignant transformation of oral chronic GVHD result in?
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squamous cell carcinoma
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what is transposition of great vessels ?
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the pulmonary arteries supplied by the left ventricle and the aorta is supplied by the right ventricle
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what is persistent truncus arteriosus ?
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blood from both ventricles move together as it exits through a single valve exiting from the heart
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what is tetralogy of Fallot
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-4 heart defects: VSD, pulmonic stenosis, right ventricular hypertrophy and an overriding aorta - symptoms: blue-tinged skin from poor circulation and shortness of breath, heart murmur or fast heart rate, baby feeding difficulties, shortness of breath, sudden deep blue discoloration, failure to thrive
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what things could cause obstruction of blood flow
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-pulmonary stenosis -coarctation of the aorta
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most common congenital disorders associated with cardiac defects
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-Down Syndrome -Turner syndrome -Osteogenesis Imperfecta -Marfan syndrome -Ehler-Danlos syndrome
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symptoms associated with cardiac defects
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-dyspnea (difficult or labored breathing) -cyanosis (blue skin due to poor circulation) -polycythemia (increased RBC volume) -clubbing of toes/fingers -syncope -coma -weakness -murmur
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complications that can result from cardiac defects
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-brain abscess -infective endocarditis -cerebraovascular problems -congestive heart failure -acute pulmonary edema -bleeding problems -retardation of growth
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cyanosis is late in _____ to _______ shunting
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left to right shunting
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cyanosis is early in _____ to ______ shunting
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right to left shunting
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medical management for cardiac defects
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-surgery to correct defect -medication -treating complications
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tetralogy of fallot may benefit from what operation?
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Balock -Taussig operation
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right to left ventricular failure can be corrected by what medications
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digitalis and anti-coagulation therapy
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describe Rheumatic fever
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-acute inflammatory condition -a complication of group A streptococcal infections (eg, strep throat infections) -arises as a result of an autoimmune rxn
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Rheumatic fever commonly occurs btwn the ages of ...
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5 and 15 years
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Where is rheumatic fever common?
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in temperate zones, high altitudes, and substandard living conditions
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complications of rheumatic fever
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inflammation rxns in the heart, larger joints, skin and lungs
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medical management for rheumatic fever
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-penicillin g benzathine -codeine -salicylates
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describe rheumatic heart disease
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-cardiac damage that can result from rheumatic fever -damage most commonly occurs to the mitral or aortic valve -scarring and calcification in the affected valves result in stenosis or regurgitation
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what part of the heart is most commonly affected by rheumatic heart disease
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mitral valve and aortic valve
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incidence of rehumatic heart disease
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less than 0.05 per 1000 (US population)
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symptoms of rheumatic heart disease
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-murmur -exertional dyspnea -angina pectoris -epistaxis -blood in the sputum -congestive heart failure
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complications of rheumatic heart disease
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-scar tissue and deformity of the valve -mitral stenosis -incompetence of the aortic valve -aortic stenosis -acute percarditis
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medical management for rhemumatic heart disease
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-asymptomatic disease does not require tx other than prevention of recurrent attacks of rheumatic fever
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dental management of rheumatic heart disease
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a pt w/ a past hx of rheumatic fever is in need of medical consultation to rule out rheumatic heart disease
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describe heart murmurs
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sounds caused by turbulence in the circulation through the valves and chambers of the heart
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turbulence in flow is usually the result of:
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-an increased flow rate -a change in viscosity -stenotic or narrowed valves -a vibration of membranous structures
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what are innocent or functional murmurs?
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sounds caused by turbulence in the absence of any cardiac abnormality
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what are organic murmurs
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sounds caused by a pathologic abnormality in the heart
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what is an arrhythmia ?
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any variation in the normal rhythm of the heart beat
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cardiac arrhythmias may be disturbances of ....
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rhythm, rate or conduction
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bradycardia in children
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less than 60 beats per minute
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tachycardia in children
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more than 120 beats per minute
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signs of an arrhythmia
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bradycardia, tachycardia or an irregular heart beat
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symptoms of an arrhythmia
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-can be asymptomatic OR -fatigue, dizziness, syncope, heart palpitations, angina, or congestive heart failure
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complications of an arrhythmia
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-ischemic heart disease -angina -myocardial infarction -congestive heart failure -cardiac arrest -blindness -cerebrovascular accident
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what is a low risk arrhythmia
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-infrequent symptoms (eg, atrial arrhythmias, premature ventricular beats, young patients with sinus bradycardia), no medications necessary
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what is a moderate risk arrhythmia?
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-atrial or ventricular arrhythmias, may be asymptomatic due to chronic medications and/or pacemakers
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what is a high risk arrhythmia?
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-pulse greater than 100 or less than 60 and are symptomatic (eg, irregular pulse rhythm, bradycardic patients w/ pacemakers, irregular pulse and bradycardia) -despite being on chronic medications and /or pacemaker
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medical management for arrhythmias
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-meds: digoxin, quinidine, procainamide, disopryamide, lidocaine, propanolol, verapamil -pacemakers -surgery -cardioversion in an emergency
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dental management for pt with an arrhythmia
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-thorough medical history -medical consult -minimize stressful situations -reduce anxiety (pre-med, nitrous oxide, sedation) -short morning appointments -minimize use of epinephrine -avoid GA -avoid electrical equipment that may interfere with a pacemaker
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oral complications from meds used to control arrhythmias
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-ulceration -lupus-like syndrome -xerostomia -petechiae
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essential hypertension is defined as...
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systolic pressure exceeding the 95th percentile for gender, age and height in children after 3 readings in a non-stressful situation
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when is a child aged 3-5 considered hypertensive
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over 116/76
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when is a child aged 6-9 considered hypertensive
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over 122/78
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when is a child aged 10-12 considered hypertensive
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over 126/82
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when is a child aged 13-15 considered hypertensive
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over 136/86
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what is secondary hypertension
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HTN caused by an underlying medical disorder such as a renal or an endocrine disorder or certain type of medication (ie, oral contraceptives)
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incidence of HTN in newborns
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0.2-3%
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incidence of HTN in children aged 4-15 years
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1.5-2%
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symptoms of HTN
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-normally asymptomatic BUT... -occipital headache -visual bluriness -changes in mental status -weakness -dizziness -angina
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complications of HTN
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-renal failure -cerebrovascular accident -coronary insufficiency -myocardial infarction -congestive heart failure -blindness
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medical management for HTN
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-get comprehensive medical and family hx -identify risk factors -rule out secondary HTN -drug therapy with diuretics or beta blockers, ACE inhibitors, calcium channel blockers, vasodilators
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oral complications of meds for HTN
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-xerostomia -lichenoid rxns -delayed healing -gingival hyperplasia -facial palsy
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what HTN med is associated with xerostomia
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diruetics and other anti-HTN meds
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what HTN med is associated w/ Lichenoid rxns?
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thiazides methyldopa propranolol
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what HTN med is associated with delayed healing and gingival healing
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ACE inhibitors
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what HTN med is associated with gingival hyperplasia
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calcium channel blockers
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what is associated with malignant HTN?
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facial palsy
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what is congestive heart failure
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the inability of the heart to deliver an adequate supply of blood to meet metabolic demands
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etiology of congestive heart failure
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-coronary heart disease -HTN -cardiomyopathy -IE -congenital heart disease -endocrine disease
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symptoms of congestive heart failure
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fatigue, weakness, dyspnea, hyperventilation, low-grade fever, cough, insomnia, weight gain, dizziness, confusion
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compensatory response to congestive heart failure
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-increased peripheral resistance -redistribution of blood flow to the heart and brain -increased erythropoietic activity to increase oxygen carrying capacity of the blood
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complications of congestive heart failure
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-ventricular dysfunction -congestive failure w/ dyspnea -pulmonary congestion -peripheral edema
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meds for congestive heart failure
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ACE inhibitors alone or w/ diuretic -for moderate to severe congestive heart failure, loop diuretics (eg, furosemide)
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dental management for pts with congestive heart failure
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-med consult -avoid procedures which may cause a gag reflex -minimize use of epinephrine -prevent orthostatic hypotension -investigate potential bleeding problems from use of anticoagulants -maintain pt in upright position during treatment if pulmonary edema is present
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you need what INR to be able to proceed with treatment if a patient has congestive heart failure and the patient is on anticoagulants
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INR of 3.5 or less
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oral complications of congestive heart failure
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infection bleeding petechiae ecchymoses drug related side effects: xerostomia, lichenoid mucosal lesions
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describe infective endocarditis
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-microbial infection (fungal or bacterial) of the heart valves or endocardium -often seen in patients w/ congenital defects of the heart
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describe acute bacterial endocarditis
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-sudden onset -can be fatal in less than 6 weeks -causative agent: staphylococcus aureus -staph can infect normal heart valves -males more than females -median age of occurrence: 50 yrs
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describe subacute bacterial endocarditis
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-slower onset -causative agent: streptococcus virdians -strep infects damaged heart valves
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causative agent for acute bacterial endocarditis
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staphylococcus aureus
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causative agent for subacute bacterial endocarditis
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streptococcus virdians
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are pediatric patients more likely to acquire acute or subacute endocarditis ?
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more likely to acquire subacute endocarditis
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incidence of all bacterial endocarditis in the US
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less than 1%
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symptoms of IE
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weakness weight loss fatigue fever chills night sweats anorexia arthralgia (pain in joint)
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complications of IE
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emboli, cerebral abscess, myocardial abscess, mycotic aneurysms, hemorrhage, congestive heart failure
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medical management for IE
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-antibiotic therapy based on culture and sensitivity findings -Ab therapy tx times vary depending on the type of organism causing the endocarditis
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patients w/ the following cardiac conditions are at risk for IE and therefore, antibiotic prophylaxis is recommended
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-prosthetic cardiac valves -previous IE -congenital heart disease -unrepaired cyanotic congenital heart disease, including palliative shunts and conduits -repaired congenital heart defect w/ prosthetic material or device, whether placed by catheter or surgery during the first 6 months after the procedure -repaired congenital heart disease w/ residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) -cardiac transplantation recipients who develop cardiac valvulopathy
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does mitral valve prolapse require Ab prophylaxis?
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NO
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does rheumatic heart disease require Ab prophylaxis?
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NO
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for at risk patients, Ab prophylaxis is recommended for what dental procedures
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all procedures that involve manipulation of the gingival tissue, the periapical region of the teeth or perforation of the oral mucosa
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Ab for IE prophylaxis: standard
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amoxicillin 1 hour before proceure adults 2 g child: 50 mg/kg
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Ab for IE prophylaxis: unable to take oral medication
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Ampicillin IM or IV 30 min before procedure adult: 2 g child: 50 mg/kg
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Ab for IE prophylaxis: allergic to penicillin or ampicillin
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-Clincamycin 1 hour before procedure adult: 600 mg child: 20 mg/ kg -Cephalexin or Cefadroxil adult: 2 g child: 50 mg/kg -Axithromycin or clarithromycin adult: 500 mg child: 15 mg/kg
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Ab for IE prophylaxis: allergic to penicillin or ampicillin and unable to take oral medications
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-Clindamycin IM or IV 30 min before procedure adult: 600 mg child: 20 mg/kg -Cefazolin or cettriaxone adult: 1 g child: 20 mg/kg
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__________should not be used in an individual w/ a history of anaphylaxis, andiodema or urticaria w/ penicillins or ampicillin
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cephalosporins
