- Fever can be present at diagnosis of many forms of childhood cancer, but it is usually associated with other signs and symp- toms that lead to the diagnosis.
- With malignancy, symp-toms such as bone pain, mass, weight loss, or pallor often accompany the fever or develop soon thereafter and prompt investigations that lead to the correct diagnosis.Alternatively, investigations performed early in the evaluation of FUO lead to the diagnosis. These investigations commonly are complete blood count (CBC) with differential WBC count, sedimenta-tion rate, and lactic dehydrogenase (LDH) and uric acid levels
- It should also be noted that fever may be associated with the malignancy itself or with associated infection, and appro- priate evaluation for infection is warranted for patients with fever in the early evaluation of malignancy. Lymphomas, especially advanced Hodgkin lymphoma and anaplastic large cell lymphoma (ALCL), may have fever as a prominent manifesta- tion of disease. Indeed, ALCL is a great mimic, with its initial features often suggesting an infectious or inflammatory process rather than cancer. Patients with acute leukemia may have fever as a manifestation of the disease itself but are also at high risk of fever from associated infection due to impaired immunity at presentatioN
- A diagnosis of lymphoma or another malignancy must always be considered when evaluating the child with an enlarged peripheral lymph node. However, other causes of lym- phadenopathy are much more common. One review noted approximately 50% of children older than 5 years seen for well or sick visits had lymphadenopathy. 106 A nodal mass, unlike an abdominal, pelvic, or mediastinal mass, is not always an indi- cation for a detailed workup or for a prompt surgical procedure to establish a diagnosis. The likelihood of malignancy within the node will determine the urgency with which biopsy or other invasive procedures are undertaken. It must be emphasized that not all palpable nodes are pathologically enlarged and that most pathologically enlarged nodes are benigN.
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- Mediastinal masses are fre-quently malignant. A number of series reported 55% to 70% of them to be malignant.
- Anterior masses are common in older patients and, in them, are more likely to be malignant. Common masses include lymphomas, thymic origin masses, teratomas, angiomas, lipomas, and thyroid tumors
- Middle mediastinal masses are often malignant and of nodal origin, although infectious lymphadenopathy including from tuberculosis and histoplasmosis, pericardial cysts, bron- chogenic cysts, esophageal lesions, and direct extension of abdominal masses are also encountered
- Posterior mediastinal tumors are generally neurogenic in origin and range from neuroblastomas to benign tumors such as ganglioneuroma and neurofibroma. In younger children, tumors of the posterior mediastinum are more likely to be malignant. Many of them are neuroblastomas, some of which are asymptomatic and picked up as incidental findings on chest radiograph, but others can produce symptoms including cord compression, from growth through the intervertebral foramina into the epidural space, or stridor, from airway compression
- Pain is a common symptom of childhood cancer.Severe or persistent back pain, often in association with stiffness, is common in adults but rare in children. Its presence demands evaluation Patients with primary bone tumors usually present with localized pain at the site of involvement. More than 80% of patients with the two most common primary bone tumors,Ewing’s sarcoma and osteosarcoma, complain of pain that may be intermittent initially but over time increases in severity and becomes constant
- Diffuse or multifocal bone pain is seen with disseminated malignancy, especially acute leukemia, and also in patients with bony metastases from tumors such as neuroblastoma and Ewing’s sarcoma. Bone pain is one of the cardinal manifesta-tions of childhood acute leukemia and is seen more commonly in ALL than in AML
- Some children who present with musculoskeletal pain are referred to rheumatologists or orthopedists because they are thought to have arthritis or bone or joint infections. They may present with a limp, refusal to walk, or arthritis limited to one joint.
- Distinguishing musculoskeletal pain due to malignancy from other causes may not always be easy initially and can delay diagnosis. Associated laboratory findings that may suggest malignancy are elevated sedimentation rate, which is unassociated with thrombocytosis due to marrow infiltration, and elevation of serum LDH, as can be frequently seen with leukemia, NHL, Ewing’s sarcoma, and neuroblastoma. Finally, careful review of radiographs or other imaging of the involved bones may uncover findings suggestive of leukemia or metastatic tumor
- Signs and symptoms associated with childhood brain tumors are usually nonspecific.hese symptoms range from more general symptoms such as an enlarging frontal-occipital circumference (FOC) in an infant, chronic or recurrent headaches, vomiting, visual disturbances, and changes in behavior or in school per- formance to more specific signs such as hemiparesis, cranial nerve palsies, seizures, ataxia, and visual field deficits
- Headache is a common symptom among children and ado- lescents. Although it is always important to consider a brain tumor when dealing with a pediatric patient with headaches, it is important to recognize that the incidence of brain tumors among children is low. However, the classic triad of headaches,
which awaken the child from sleep or are present on arising, vomiting, and papilledema occurs in fewer than a third of the patients. - children with brain tumors indicated the importance of the following symptoms in sug- gesting a brain tumor: recurrent morning headache; headaches that awaken the child; intense and incapacitating headache; and changes in the quality, frequency, and pattern of the headaches. Further, approximately 95% of children with a headache and a brain tumor had abnormal neurologic find-ings on clinical examination
- A palpable abdominal mass is one of the most common pre- senting findings of malignant solid tumors in children.Age plays a major role in the diagnostic considerations. A mass found in the neonatal period most often represents a congenital malformation and generally has a good progno- sis. In this age period, abnormalities of the genitourinary and gastrointestinal systems should be considered, because malignant tumors are uncommon. Malignant tumors are most often found in older infants and children, with a peak incidence between 1 and 5 years of age. Both Wilms’ tumor and neuroblastoma commonly present during these years.
- NHL can present during these years but is more common in older children and adolescents. Most cases in older children are of Burkitt’s lymphoma, which manifests in the abdomen in one of two ways. The first is as a rapidly enlarging abdominal mass producing pain and obstructive symptoms of the gastrointestinal and urinary tracts, often in association with metabolic derangements from tumor
lysis
Dr. Jayaprakash
Superintendent, ICH.
Institute of Child Health.
Gov. Medical College Kottayam.
Kerala, India.