1. When to suspect cancer
in pediatric age
Prof. Safinaz El-Habashy
Prof. of Pediatrics,
Ain Shams University
MD, MHPE, TQM

2. Objectives
• To recognize conditions that mimic
cancer.
• To recognize symptoms suggestive of
cancer.
• To interpret results of initial work up.
• To appreciate the importance of early
referral of suspected cases.

3. Childhood Cancers
Brain Leukemia
Tumors
Retino-
blastoma
Bone tumors
Other
Kidney tumors
Soft tissue sarcomas
Lymphoma Neuroblastoma

4. Incidence of Childhood Cancers
Leukemia--------------------------- 30.2
Central nervous system tumor-- 21.7
Lymphoma------------------------- 10.9
Neuroblastoma-------------------- 8.2
Soft tissue sarcoma--------------- 7.0
Renal tumor----------------------- 6.3
Bone tumor------------------------ 4.7
Others------------------------------ 11.0

5. Specific Signs and Symptoms
Depend on
•type of cancer
•site(s) of disease
• age of patient

6. What are the symptoms?
 Anemia
 Bleeding
 Bone tenderness
 Lymphadenopathy
 Hepatospleenomegaly
 Headaches
 Mass; Abdominal / Mediastinal
 Fever

7. Cancer in children may present
as
• A mass
• Symptoms directly related to tumor
• Non specific symptoms related to
tumor or metastatic growth

8. Symptoms that may indicate the presence of
a malignancy in children
•Unexplained paleness and fatigue
•Loss of energy (limited time at play)
•Persistent localized pain or swelling
•Prolonged unexplained fever or illness,
especially with bone pain
•Frequent headaches, especially in the morning,
often with vomiting
•Sudden eye or vision changes
•Lymphadenopathy

9. Symptoms that may indicate the presence of
a malignancy in children
•Excessive rapid weight loss
•Swelling of the face and neck
•Cat’s eye reflex
•Limping
•Vaginal bleeding in a premenstrual child, or
prolonged bleeding between or with periods,
excessive bleeding during periods.

10. Signs and Symptoms of Childhood Cancers and
Conditions That Can Mimic These Cancers
Fever Leukemia, Infection
lymphoma
Vomiting Abdominal mass, Infection, gastroesophageal
brain tumor reflux
Constipation Abdominal mass Poor diet
Cough Mediastinal mass Upper respiratory infection,
reactive airway disease,
pneumonia
Bone or muscle Leukemia, bone Musculoskeletal injury, viral
pain tumor, infection
Neuroblastoma

11. Signs and Symptoms of Childhood Cancers and
Conditions That Can Mimic These Cancers
Headache Brain tumor Tension headache, migraine,
infection
Lymphadenopathy Leukemia, lymphoma, Lymphadenitis, systemic
(>3 cm) metastatic disease infection, collagen vascular
disease
Hematuria Wilms' tumor Urinary tract infection,
glomerulonephritis
Voiding difficulty Rhabdomyosarcoma Congenital urinary tract
abnormalities

12. Symptoms Suggestive of Childhood
Cancers:
Pallor, fatigue, malaise
Leukemia, lymphoma, neuroblastoma,
Wilms Tumor
Iron deficiency anemia

13. Symptoms Suggestive of Childhood
Cancers:
Weight loss, night sweats
Hodgkin lymphoma
Neuroblastoma
Wilms Tumor
Viral infections, TB

14. What can permit an early diagnosis?
• Careful clinical examination
• Screening laboratory tests
• Appropriate radiologic studies
• Biopsy procedures

15. What guidelines say
Differential Diagnosis of Abnormal Complete Blood Count
Infections
Nonspecific viral syndrome
Epstein-Barr virus infection
Cytomegalovirus infection
Human immunodeficiency virus infection
Autoimmune disorders
Systemic lupus erythematosus
Systemic-onset juvenile rheumatoid arthritis
Hematologic disorders
Aplastic anemia
Leukemia

16. Anemia
Features suggestive of malignancy
Rapidly progressive anemia.
Anemia requiring repeated blood / red cell
transfusions.
Anemia associated with bleeding, lymph-
adenopathy, bone pains and lumps in the
body.

17. When to do Bone Marrow Examination?
Significant depression of one or more cell lines or
abnormal blood counts in absence of
infection/inflammation.
Abnormal blood counts with unexplained
lymphadenopathy or hepatospleenomegaly.
Presence of atypical or blast cells in peripheral blood
smears.
* Both aspiration and trephine bone biopsies are
recommended in cases of acute leukemia to
determine morphology and marrow cellularity.

18. What guidelines say
Tiny red spots or larger red areas
An urgent referral is always needed if a child has tiny red spots
(petechiae) or larger areas where there has been abnormal
bleeding into the skin (purpura).
Tiredness
If your child is tired and was previously healthy, an urgent referral
is recommended if he or she also has swelling of the lymph nodes
or enlargement of liver and spleen.

19. What guidelines say
Pain in the bones
• the pain is widespread or involves the
back;
• or it always occurs at the same place;
• or your child needs to take pain killers to
control it;
• or the pain is preventing him or her from
doing some things.

20. What guidelines say
Swelling of the lymph glands:
 a lump is firm or hard, not tender, and more than 3cm
(1 inch) across; or a lump is getting bigger;
 there are other signs of illness, such as a high
temperature or loss of weight;
 the swelling is in the armpit or in lymph nodes above
the collar bone (unless there is an infection nearby that
could be causing swelling of these lymph glands);
 swollen lymph glands are seen on an x-ray of the
chest.

21. When to do fine needle aspiration
cytology (FNAC)
It is used for any mass lesion or
enlarged lymph nodes. It could
even be used safely for deep-
seated masses/mediastinal nodes
either by USG or CT scan. It
must, however, be followed by a
biopsy if results are inconclusive
or reported as reactive
hyperplasia.

22. What guidelines say
Headaches
Referral if the headaches are recent and have at least
one of these features:
•getting more frequent or more severe
•worse in the mornings, or wake your child up early in
the morning;
•child is also being sick;
•there are signs of nerve damage, such as a squint or
loss of co-ordination;
•child’s behaviour has changed or he or she is doing
less well at school than usual.

23. What guidelines say
A lump in a soft tissue
Consider referral for any lump if it has at least one of
these features: it is growing steadily or rapidly; it is
more than 3cm (1 inch) across; it does not move when
examined, or it is deep within the tissue; there are
swollen lymph glands near the lump.
Development of breasts or starting periods earlier
than usual

24. When to do excisional/ incisional
biopsy?
• When mass is localized to an
organ e.g. adrenal gland or
kidneys, with no evidence of
metastatic disease. Total
removal should be the aim.
• When FNAC is inconclusive.

25. When and How to Evaluate Signs and Symptoms for
Cancer
Fever
Vomiting Fever lasts > 14 days with CBC with differential
no identifiable cause.
Vomiting lasts > 7 days Abdominal and head
with no identifiable cause. CT scans
Vomiting is associated Head CT scan
Constipation with headache during
sleep.
Constipation is prolonged Abdominal and
(>1 month) and does not pelvic CT scans
respond to conventional
Cough measures.
Chest radiograph
Cough is prolonged (>2
Bone or weeks) and has no
muscle pain identifiable cause. Plain-film
Pain is prolonged (>2 radiograph, bone
weeks) and has no and CT scans, CBC
identifiable cause.

26. When and How to Evaluate Signs and Symptoms for
Cancer
Headache occurs during Head CT scan
Headache
sleep, is associated with
neurologic signs
and vomiting, or in the
absence of a family
history of migraine.
Evaluate immediately if Abdominal U/S
Hematuria
hematuria has no
identifiable cause.
Evaluate immediately if Abdominal U/S
Voiding difficulty
voiding difficulty has no
identifiable cause.
Lymphadenopathy
Evaluate if CBC with
(>3 cm)
lymphadenopathy does differential, lactate
not respond to a 7-day dehydrogenase
course level
of antibiotic.

27. Clinical and epidemiological clues
Age and Cancer
Infancy - Embryonal tumors, neuroblastoma,
retinoblastoma and hepatoblastoma.
Childhood: – Acute lymphatic leukemia and brain
tumors.
Adolescents: - Lymphomas, rhabomyosarcoma and
Ewing’s tumor.

28. Clinical and epidemiological clues
• Signs and symptoms according to 1 ry site and
mets
Pulmonary
Abdominal
Neurologic
• Congenital anomalies

29. Laboratory tests
Essential lab.
CBC
Chemical profile; hepatic, renal, lytes and
urinalysis
Bone marrow aspirate and/or biopsy
Lumber puncture
Tumor markers
NSE
AFP
HCG

30. Do’s and don’ts for diagnosis of
Pediatric Cancer
• Do not administer steroids in a suspected case
of JRA without doing a BM aspiration.
• Do not start anti TB therapy/ antibiotics in
patients with lymphadenopathy without a
definite diagnosis.

31. Do’s and don’ts for diagnosis of
Pediatric Cancer
• Do a lymph node biopsy if FNAC is
inconclusive and neoplasia is suspected.
• Give a blood transfusion prior to a definite
diagnosis only if Hb is <5gm/dl or if there are
impending features of CCF.
• Refer children suspected to have a neoplastic
disease as early as possible.

32. Thanks
• Any Questions
• QUIZ

33. Case Presentation
A 15-year-old white female reports that she has had fever,
weight loss, and night sweats for 3 months. On physical
examination, she has painless swelling of the left cervical
and supraclavicular lymph nodes. Her liver and spleen are
not enlarged. The initial evaluation of the patient should
include
• A. bone marrow aspiration
• B. abdominal CT
• C. chest radiograph
• D. head CT
• E. erythrocyte sedimentation rate

34. Case Presentation
The chest radiograph of the patient described
reveals mediastinal lymphadenopathy. The
next appropriate diagnostic test is
• A. abdominal CT
• B. head CT
• C. bone marrow biopsy
• D. lymph node biopsy
• E. thoracic CT

35. Case Presentation
A mother states that her 14-month-old infant's eye has a "cat's
eye" appearance. On routine office ophthalmoscopic
examination, you have a hard time seeing the fundus but
observe no gross abnormalities. The extraocular muscles
and remaining head and neck and general physical findings
are normal. You should
• A. reassure the mother that nothing is wrong
• B. obtain toxoplasmosis titers
• C. culture for rubella
• D. refer the patient to an infectious disease specialist
• E. refer the patient to an ophthalmologist for examination
under general anesthesia