Clinical assessment of the child with suspected cancer
- Kathleen A Neville, MD, MS
Kathleen A Neville, MD, MS
- Director, Experimental Therapeutics Program
- Professor of Pediatrics, University of Arkansas for Medical Sciences
- C Philip Steuber, MD
C Philip Steuber, MD
- Professor of Pediatric Hematology and Oncology
- Baylor College of Medicine
Childhood cancer often is difficult to detect in its early stages because the associated signs and symptoms are nonspecific, insidious in onset, and mimic more common disorders . The time from onset of symptoms to diagnosis of pediatric cancer is variable and ranges from a median time of 21 days for neuroblastoma to 72 days for Ewing Sarcoma .
Primary practitioners may have little experience in diagnosing childhood malignancies and may be reluctant to consider the diagnosis because of the ominous implications. Nonetheless, whether or not they express their concern, patients and parents often are worried about childhood cancer, and the possibility of cancer should be discussed when the initial signs and symptoms are suspicious .
Optimal treatment of childhood cancer requires a high level of suspicion by the primary care practitioner and early referral to the pediatric oncologist. Early detection and treatment may reduce disease-related morbidity and complications.
The topic will provide an overview of childhood cancer and reviews the evaluation of children and adolescents who present with common signs and symptoms that are suspicious for cancer. The evaluation and treatment of specific malignancies are discussed separately.
The following facts about childhood cancer set the stage for a discussion of issues surrounding clinical assessment of the child with suspected cancer:
- Linabery AM, Ross JA. Trends in childhood cancer incidence in the U.S. (1992-2004). Cancer 2008; 112:416.
- Pollock BH, Krischer JP, Vietti TJ. Interval between symptom onset and diagnosis of pediatric solid tumors. J Pediatr 1991; 119:725.
- Malogolowkin, MH, Quinn, JJ, Steuber, CP, et, al. Clinical assessment and differential diagnosis of the child with suspected cancer. In: Principles and Practice of Pediatric Oncology, 5th, Pizzo, P, Poplack, DG (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.145.
- American Cancer Society. Cancer Facts and Figures, 1997.
- Ellison LF, De P, Mery LS, et al. Canadian cancer statistics at a glance: cancer in children. CMAJ 2009; 180:422.
- Centers for Disease Control and Prevention (CDC). Trends in childhood cancer mortality--United States, 1990-2004. MMWR Morb Mortal Wkly Rep 2007; 56:1257.
- Dang-Tan T, Franco EL. Diagnosis delays in childhood cancer: a review. Cancer 2007; 110:703.
- Lethaby CD, Picton S, Kinsey SE, et al. A systematic review of time to diagnosis in children and young adults with cancer. Arch Dis Child 2013; 98:349.
- Plon S, Malkin D. Childhood cancer and heredity. In: Principles and Practice of Pediatric Oncology, 5th ed, Pizzo PA, Poplack DG (Eds), Lippincott-Raven, Philadelphia 2006. p.14.
- Clericuzio CL. Recognition and management of childhood cancer syndromes: a systems approach. Am J Med Genet 1999; 89:81.
- Steuber C. General considerations of neoplastic diseases. In: Oski's Pediatrics: Principles and Practice, 4th ed, McMillan JA, Feigin RD, DeAngelis C, Jones MD (Eds), Lippincott, Williams & Wilkins, Philadelphia 2006. p.1748.
- Green DM, Zevon MA, Reese PA, et al. Second malignant tumors following treatment during childhood and adolescence for cancer. Med Pediatr Oncol 1994; 22:1.
- Hawkins MM, Draper GJ, Kingston JE. Incidence of second primary tumours among childhood cancer survivors. Br J Cancer 1987; 56:339.
- Kingston JE, Hawkins MM, Draper GJ, et al. Patterns of multiple primary tumours in patients treated for cancer during childhood. Br J Cancer 1987; 56:331.
- Corrigan JJ, Feig SA, American Academy of Pediatrics. Guidelines for pediatric cancer centers. Pediatrics 2004; 113:1833.
- Pizzo PA, Lovejoy FH Jr, Smith DH. Prolonged fever in children: review of 100 cases. Pediatrics 1975; 55:468.
- Chantada G, Casak S, Plata JD, et al. Children with fever of unknown origin in Argentina: an analysis of 113 cases. Pediatr Infect Dis J 1994; 13:260.
- Mouaket AE, el-Ghanim MM, Abd-el-Al YK, al-Quod N. Prolonged unexplained pyrexia: a review of 221 paediatric cases from Kuwait. Infection 1990; 18:226.
- Fletcher BD, Pratt CB. Evaluation of the child with a suspected malignant solid tumor. Pediatr Clin North Am 1991; 38:223.
- Margolin, JF, Steuber, CP, Poplack, DG. Acute lymphoblastic leukemia. In: Principles and Practice of Pediatric Oncology, 5th, Pizzo, PA, Poplack, DG (Eds), Lippincott-Raven, Philadelphia 2006. p.538.
- Pollack IF. Pediatric brain tumors. Semin Surg Oncol 1999; 16:73.
- Wilne SH, Ferris RC, Nathwani A, Kennedy CR. The presenting features of brain tumours: a review of 200 cases. Arch Dis Child 2006; 91:502.
- Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child 1982; 136:121.
- Knight PJ, Mulne AF, Vassy LE. When is lymph node biopsy indicated in children with enlarged peripheral nodes? Pediatrics 1982; 69:391.
- Oguz A, Karadeniz C, Temel EA, et al. Evaluation of peripheral lymphadenopathy in children. Pediatr Hematol Oncol 2006; 23:549.
- Soldes OS, Younger JG, Hirschl RB. Predictors of malignancy in childhood peripheral lymphadenopathy. J Pediatr Surg 1999; 34:1447.
- HEINRICH WA, JUDD ES Jr. A critical analysis of biopsy of lymph nodes. Proc Staff Meet Mayo Clin 1948; 23:465.
- Williamson HA Jr. Lymphadenopathy in a family practice: a descriptive study of 249 cases. J Fam Pract 1985; 20:449.
- Trapani S, Grisolia F, Simonini G, et al. Incidence of occult cancer in children presenting with musculoskeletal symptoms: a 10-year survey in a pediatric rheumatology unit. Semin Arthritis Rheum 2000; 29:348.
- Pritchard DJ, Dahlin DC, Dauphine RT, et al. Ewing's sarcoma. A clinicopathological and statistical analysis of patients surviving five years or longer. J Bone Joint Surg Am 1975; 57:10.
- McKenna RJ, Schwinn CP, Soong KY, Higinbotham NL. Sarcoma of the osteogenic series (osteosarcoma, fibrosarcoma, chondrosarcoma, parosteal osteogenic sarcoma and sarcomata arising in abnormal bones). J Bone Joint Surg 1966; 48A:1.
- Widhe B, Widhe T. Initial symptoms and clinical features in osteosarcoma and Ewing sarcoma. J Bone Joint Surg Am 2000; 82:667.
- Kim HJ, Chalmers PN, Morris CD. Pediatric osteogenic sarcoma. Curr Opin Pediatr 2010; 22:61.
- Yaw KM. Pediatric bone tumors. Semin Surg Oncol 1999; 16:173.
- Rogalsky RJ, Black GB, Reed MH. Orthopaedic manifestations of leukemia in children. J Bone Joint Surg Am 1986; 68:494.
- Hann IM, Gupta S, Palmer MK, Morris-Jones PH. The prognostic significance of radiological and symptomatic bone involvement in childhood acute lymphoblastic leukaemia. Med Pediatr Oncol 1979; 6:51.
- Jonsson OG, Sartain P, Ducore JM, Buchanan GR. Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hematologic indexes. J Pediatr 1990; 117:233.
- Barbosa CM, Nakamura C, Terreri MT, et al. [Musculoskeletal manifestations as the onset of acute leukemias in childhood]. J Pediatr (Rio J) 2002; 78:481.
- Vidal C, Baer MR, Bloomfield CD. Uncommon patterns of presentation of leukemia. Hematol Oncol 1999; 17:11.
- Cabral DA, Tucker LB. Malignancies in children who initially present with rheumatic complaints. J Pediatr 1999; 134:53.
- Murray MJ, Tang T, Ryder C, et al. Childhood leukaemia masquerading as juvenile idiopathic arthritis. BMJ 2004; 329:959.
- Ostrov BE, Goldsmith DP, Athreya BH. Differentiation of systemic juvenile rheumatoid arthritis from acute leukemia near the onset of disease. J Pediatr 1993; 122:595.
- Edeiken J, Hodes PJ, Caplan LH. New bone production and periosteal reaction. Am J Roentgenol Radium Ther Nucl Med 1966; 97:708.
- Ragsdale BD, Madewell JE, Sweet DE. Radiologic and pathologic analysis of solitary bone lesions. Part II: periosteal reactions. Radiol Clin North Am 1981; 19:749.
- Yoshikawa H, Shimizu K, Nakase T, Takaoka K. Periosteal sunburst spiculation in osteosarcoma. A possible role for bone morphogenetic protein. Clin Orthop Relat Res 1994; :213.
- Wallendal M, Stork L, Hollister JR. The discriminating value of serum lactate dehydrogenase levels in children with malignant neoplasms presenting as joint pain. Arch Pediatr Adolesc Med 1996; 150:70.
- Révész T, Kardos G, Kajtár P, Schuler D. The adverse effect of prolonged prednisolone pretreatment in children with acute lymphoblastic leukemia. Cancer 1985; 55:1637.
- Davies AM. Imaging in skeletal paediatric oncology. Eur J Radiol 2001; 37:79.
- Uslu L, Donig J, Link M, et al. Value of 18F-FDG PET and PET/CT for evaluation of pediatric malignancies. J Nucl Med 2015; 56:274.
- Wright CD, Mathisen DJ. Mediastinal tumors: diagnosis and treatment. World J Surg 2001; 25:204.
- Sandlund JT, Downing JR, Crist WM. Non-Hodgkin's lymphoma in childhood. N Engl J Med 1996; 334:1238.
- Naeem F, Metzger ML, Arnold SR, Adderson EE. Distinguishing Benign Mediastinal Masses from Malignancy in a Histoplasmosis-Endemic Region. J Pediatr 2015; 167:409.
- Young G, Toretsky JA, Campbell AB, Eskenazi AE. Recognition of common childhood malignancies. Am Fam Physician 2000; 61:2144.
- Ribeiro RC, Pui CH. The clinical and biological correlates of coagulopathy in children with acute leukemia. J Clin Oncol 1986; 4:1212.
- Hasegawa D, Bloomfield C. Thrombotic and hemorrhagic manifestations of malignancy. In: Oncologic Emergencies, Yarbo J, Bornstein B (Eds), Grune & Stratton, New York 1981. p.141.
- Sather H, Coccia P, Nesbit M, et al. Disappearance of the predictive value of prognostic variables in childhood acute lymphoblastic leukemia: a report from Childrens Cancer Study Group. Cancer 1981; 48:370.
- Choi SI, Simone JV. Acute nonlymphocytic leukemia in 171 children. Med Pediatr Oncol 1976; 2:119.
- HOLLAND P, MAUER AM. Myeloid leukemoid reactions in children. Am J Dis Child 1963; 105:568.
- Troxell ML, Mills GM, Allen RC. The hypereosinophilic syndrome in acute lymphocytic leukemia. Cancer 1984; 54:1058.
- GENERAL PRINCIPLES OF EVALUATION
- COMMON SIGNS AND SYMPTOMS
- Constitutional symptoms
- - Fever
- Weight loss
- - Evaluation
- - Neuroimaging
- - Diagnostic tests
- - Biopsy indications
- Bone and joint pain
- - Evaluation
- Mediastinal masses
- - Evaluation
- Abdominal masses
- - Evaluation
- - Evaluation
- Blood count abnormalities
- - Evaluation
- ESTABLISHING THE DIAGNOSIS