indiacancer.org - Childhood Cancers

Specific Cancers

		Brain Tumors
		What are the signs of Brain Tumor?
		Types of treatment used
		Lymphoma
		Hodgkins Disease
		Non hodgkins Llymphoma (N.H.L)
		Neuroblastoma
		Wilms' Tumor
		Sarcomas in Children
		Bone Marrow Transplantation for Children
		What happens after treatment?

	Brain Tumors.

Brain Tumours are the most common tumours in children. They can occur at any age, sometimes in infancy. Although there are different types of brain tumours, astrocytoma and medulloblastoma are the most common. It is generally not known what causes brain tumours. Some tumours are benign as they remain in one part of the brain while others are malignant as they can spread to other parts of the brain and nervous system.

What are the signs of Brain tumor?

Signs of a brain tumour depend on the part of the brain in which the tumour is present. Headaches and vomiting, especially in the morning, are the most common symptoms. Other symptoms include unsteadiness, fits (convulsions), change in eyesight or the development of a squint. The symptoms may be present for a few days or several years depending on the rate of the tumour's growth.

DIAGNOSIS

Once the diagnosis of a brain tumour is suspected, the most important investigations are the CT or CAT scan. These are special x-rays which are painless, although an injection is usually given into an arm vein to help show the tumour in more detail. The scans take a few minutes to complete. Young children may sometimes be given sedation or a general anaesthesia to keep them still during the scan. The scan will show the position of the tumour, but the exact type is determined by examination of the tumour tissue in a laboratory. Sometimes, other x-rays or blood tests may be required before treatment begins.

	Types of treatment used.

The type of treatment for the child depends on a number of factors like the tumour location and the type of the tumour. Sometimes, surgery can be used together with radiation therapy or chemotheapy, and occasionally all three types of treatment will be used. After all the tests have been completed, the doctor will discuss the treatment plan with you.

SURGERY.
Surgery is the main type of treatment for brain tumours. Sometimes, the tumour can be completely removed, especially if it is benign or slow growing. In other cases, only part of the tumour can be removed. In some parts of the brain, an operation is not possible because of the risk of damage to important brain functions.

Some tumours cause the normal flow of fluid circulating around the brain and spinal cord to block. The fluid is known as cerebrospinal fluid (C.S.F.). If this happens, the surgeon may advise the insertion of a plastic tube and valve (shunt) to bypass the site of the blockage of C.S.F. and decrease the pressure in the head. After the operation another CT scan may be done to check that the shunt is working.

Even when the removal of the tumour appears to be complete, it is difficult to be sure that a few tumour cells have not been left behind. Hence further treatment is often advised after surgery, which are radiotherapy and chemotherapy.

RADIOTHERAPY.
Radiotherapy is the use of x-rays for treatment. Most brain tumours are sensitive to x-rays and radiotherapy may be useful both after surgery and when surgery is not possible. Treatment requires careful planning and more x-rays will be taken so that the area of the brain to be treated, and the dose required, can be checked before treatment begins.

Treatment takes several weeks, and marks will be painted on the skin to show the area to be treated. Treatment is usually given daily, 5 days a week. Each treatment takes only a few minutes and is painless. Because it is important to lie quite still during treatment, a short anaesthetic may sometimes be required for young children. The child is alone in the room during treatment but will be able to see people through a window. With some tumours, radiotherapy is given to the spine as well as the brain. This is because some tumours can spread down to the spine. Radiotherapy can cause temporary side effects like nausea or loss of appetite. Some children become drowsy for a while, a few weeks after treatment. The hair in the treated area will fall out, but will grow back again at the end of treatment.

CHEMOTHERAPY.
Chemotherapy is the use of drugs to destroy tumours. It may be given before or after radiotherapy. Some chemotheapy can be given as a tablet and some needs to be given by injection. Chemotherapy is given in short cycles of a few days followed by a few weeks without treatment. The cycle is then repeated. Some chemotherapy drugs have to be given in the hospital, but others can be given as an outpatient or at home. Because the drugs also affect the blood cells, regular blood tests will be taken. Other side effects may occur like nausea or vomiting, particularly on the day the chemotherapy is given and hair loss. The doctor will explain about how to manage any side effects. Treatment usually continues for several months. While on treatment, and for some time afterwards, special precautions have to be taken to eliminate contact with measles or chickenpox. This will be explained in more detail at the time of starting treatment. Children usually return to school while they are on treatment.

WHAT HAPPENS AFTER TREATMENT
After treatment is completed, the child should have regular check ups. Children treated for a brain tumour may experience some long term side effects and regular check ups will help detect any problems. Brain tissue can be affected by the tumour itself or by the treatment and side effects can include speech, growth and educational problems. Help to manage these side effects can be obtained from the doctor with assistance from physio and speech therapists and other specialists.

	Lymphoma.

Lymphoma is a cancer of the lymph glands. Lymph glands are present throughout the body and are part of the body's infection fighting system.

Lymphoma can involve one or more groups of lymph nodes and can also involve other areas like bones, bone marrow, lungs, liver, spinal fluid and skin.

Many types of lymphoma,have different characteristics and with different requirements for treatment. The two main types of lymphoma are called Hodgkins Disease and Non Hodgkins Lymphoma (usually shortened to NHL).

DIAGNOSIS.
It is important to make an accurate diagnosis of lymphoma, both as to the type of lymphoma, its location in the body and the extent of any spread.

It is usually necessary to take a biopsy of the lymph gland to determine the type of lymphoma. X-rays and scans, bone marrow and blood tests are needed to determine the extent of the lymphoma.

	Hodgkins disease.

	Hodgkins Disease can occur at any age, but is most common in teenagers and young adults. It is usually in one lymph node group (eg. neck or groin nodes) and spreads to other lymph gland groups (eg. chest or abdomen). Hodgkins Disease can also spread via the blood and affect bones, bone marrow, liver or lungs. The treatment of Hodgkins Disease involves chemotherapy or radiation treatment, with a combination of both in some patients.
		The location of the lymphoma, the extent of spread and the age of the child will influence the type of treatment given.
		Most, ( but not all) children with Hodgkins Disease, can be cured of their cancer, and research is aiming to improve cure rates.

	Non hodgkins lymphoma (N.H.L).

Non Hodgkins Lymphoma (NHL) is more common in childhood than Hodgkins Disease. There is a large number of NHL sybtypes (eg. B.lymphoma, T.lymphoma, large cell lymphoma) and the type can only be determined by examining the lymphoma cells.

Chemotherapy is the main treatment for NHL with radiation used in addition for some children. The specific drugs used and the length of treatment varies with each type of lymphoma. One type of lymphoma is closely related to leukaemia and is treated with the same chemotherapy.

The effectiveness of treatment for NHL has improved dramatically over the last 20 years and many children with lymphoma can now be cured.

SUMMARY.
Lymphoma is a cancer of the lymph glands and has a number of different types. Many children with lymphoma can be cured with modern treatment, making an accurate diagnosis for appropriate treatment very important.

Neuroblastoma.

Neuroblastoma is one of the solid tumours that occur mostly in babies and young children. It is a cancer arising from nerve cells, most commonly in the abdomen or chest. It spreads to the bones, bone marrow, lymph nodes and liver and has often spread very early in the course of the disease.

CLINICAL FEATURES.
Some children with neuroblastoma may have a lump in their neck, abdomen or groin. Others may have a tumour found by a doctor or from a chest x-ray. Many children show symptoms of the neuroblastoma spreading - they may be pale or have bruises, may have pains in their bones, a limp or be generally unwell.

DIAGNOSIS.
It is important to make an accurate diagnosis, both as to the type of cancer and to determine where the cancer is located. It is also important to find out if the cancer has spread beyond its original (primary) location. A number of tests are needed to determine this.

TREATMENT.
Treatment of neuroblastoma involves a combination of chemotherapy, radiation treatment and surgery. In addition, some children will also have bone marrow transplant or stem cell transplants. During treatment, progress will be carefully monitored with blood, urine, bone marrow tests, x-rays and scans.

NEUROBLASTOMA IN INFANTS.
Neuroblastoma can behave differently in very young babies, with some tumours disappearing without treatment. Some, but not all babies, may not require any chemotherapy and others will need treatment similar to older children.

SUMMARY.
Neuroblastoma is one of the more difficult childhood cancers to treat. Modern treatment programs involving chemotherapy, radiation and surgery mean that cure is now achieved atleast for some children.

	Wilms' Tumor.

Wilms' tumour (or Nephroblastoma) was named after a famous German Surgeon, Dr. Max Wilms, who first described this type of cancer last century. It is a childhood cancer which develops in one kidney and very rarely affects both kidneys. It occurs most often in children less than five years of age. Of all the childhood cancers, Wilms' tumour has one of the best chances for cure, with 80% surviving long term and leading normal lives.

SYMPTOMS.
Often parents notice an unusual abdominal swelling which is brought to the attention of their doctor. Sometimes the child will complain of abdominal pain or discomfort, or may have passed blood in the urine.

INVESTIGATIONS.
Special tests are required in order to find out exactly what type of cancer it is, and to see to what extent it has spread throughout the body. These will include an accurate medical history from the child and parents and a careful physical examination of the child by the doctor. Blood samples may be taken and urine samples collected.

An ordinary chest x-ray may show if the tumour has spread to the lungs. An ultrasound scan of the abdomen directs sound waves through the body, via a special machine, to detect the presence of a tumour. A CT scan (computerised tomography) is a method of taking x-ray pictures of the body and processed by the computer, showing where the tumour is situated.

All these x-rays and scans are quite painless. The child is required to lie still for the CT scan, so a general anaesthetic may be reuired for this procedure.

TREATMENT.
The initial aim of treatment is to remove all signs of cancer. The long term aim is cure, with the child leading a normal life. There are three types of treatment. These are used in various combinations depending on how much the tumour has spread.

SURGERY.
Usually, the first step is surgical removal of the kidney with the tumour. During the operation, the surgeon will examine other organs and lymph nodes within the abdomen, to check whether the tumour has spread. Mostly, one kidney is affected and requires removal. The remaining kidney will easily cope with the body's reequirements.

CHEMOTHERAPY.
Chemotherapy is the use of special drugs to kill any cancer cells that may be left in the body after surgery. These drugs are called cytotoxic drugs. Occasionally, chemotherapy is given before surgery to shrink the tumour so that it an be removed more easily. In Wilms' these drugs are given by injection into a vein because they do not work if given by mouth. Cytotoxic drugs used to treat Wilms' tumour include Vincristine, Dactinomycin and Adriamycin. Chemotherapy is given intermittently over a period of time varying from a few weeks to 18 months depending on how much the tumour has spread. Temporary side effects of chemotherapy include nausea, vomiting, hair loss and tiredness.

RADIOTHERAPY (X-ray treatment).
This also kills cancer cells that lie within the area treated. It may be added to chemotherapy, if the tumour has spread within the abdomen. A special machine called a linear accelerator, directs rays to the area required for a few minutes at a time. This is done daily, over a few weeks. The treatments are painless, but require the child to lie quite still. Temporary side effects of radiotherapy include loss of appetite, vomiting and diarrhoea. Long term, there may be some disturbance of growth and this will be discussed by your radiation oncologist before the radiotherapy is started.

CONCLUSION.
After the initial surgery, most of the treatment can be given as an outpatient. The doctors and staff at the oncology clinic will explain the exact treatment plan for your child.

Following completion of treatment, periodic check ups are required, remembering that 80 per cent of these children are cured and leading normal lives.

	Sarcomas in children.

Sarcoma is a type of cancer which affects bone, muscle and some other tissues. There are different kinds of sarcoma, including rhabdomyosarcoma (muscle tumour) and bone tumours such as Ewing's tumour and osteosarcoma (also known as osteogenic sarcoma). There are less common types of sarcoma. The cause of these tumours is unknown. They may occur at any age but osteosarcoma is very rare in young children.

SYMPTOMS.
One symptom of sarcoma is swelling which may or may not be painful (although severe pain is unusual). Occasionally, especially with bone tumours, the tumour is found after an injury. This does not indicate that the tumour has been caused by the injury, but simply that the injury drew attention to the area, perhaps because of the bleeding into the tumour. They can occur in any part of the body. Sometimes, the tumour appears to be growing quite rapidly, and in other cases the swelling may have been present for some time.

INVESTIGATIONS
When the diagnosis is made, further information has to be obtained so that treatment can be planned for the individual patient. It is essential to find out what kind of tumour is present and to what extent, if any, it has spread from its original site. The extent of spread is usually determined by the use of various types of x-rays including CT or CAT, ultrasound and isotope scans.

None of these procedures are painful, but it may be necessary for the child to lie still for some time. A short general anaesthesia is sometimes needed in young children who are having a CT scan. Blood tests will also be required. Before treatment can be started, it will be necessary to obtain a sample of the tumour tissue for examination in the pathology laboratory so that the exact type of tumour can be determined. This is very important since the treatment varies for different types of tumours. Removal of a piece of the tumour for examination without attempting to remove the whole tumour is known as biopsy.

TREATMENT.
Once the information from the test is compiled, the treatment can be planned. There are three main types of treatment used in the management of childhood cancer. These are surgery, radiotherapy and chemotherapy.

SURGERY.
Surgery is the first line of treatment for many of the non-bony sarcomas which, after investigation, have been shown to be localised and can therefore be nearly or completely removed. However, extensive surgery is not used if it can be avoided by the use of other types of treatment. Sometimes, surgery may be used, after radiotherapy or chemotherapy has been given the chance to reduce the size of the tumour, making the operation easier and safer.

Amputation used to be necessary for some bone tumours in limbs and is still occasionally necessary. Limb salvage is now the treatment of choice. The bone that is affected by the tumour is removed and replaced with artificial bone or bone grafts.

RADIOTHERAPY.
Radiotherapy is the use of x-rays for treatment of the tumour site. It is quite painless and takes only a few minutes each day. Usually, treatment is given once a day, 5 days a week for about three to six weeks. During each treatment session, the child has to be left in the room alone but can be seen through the window. It is very important that the child lies still during the treatment and some time is spent explaining to the child what will happen. This should lessen fear and assist co-operation. With very young children, it may be necessary to give a short general anesthesia for each treatment. Although there is no discomfort during the treatment session, some reddening of the skin in the treatment area may be noticed. Radiotherapy to the abdomen may cause some temporary loss of appetite or bowel disturbance.

CHEMOTHERAPY.
Chemotherapy is the use of drugs to destroy tumours. Drugs may be used singularly or in combination - some are given by mouth and others by injection. They are usually not given continuously but in a short cycle of a few days followed by a few weeks break until the cycle is repeated.

Because the drugs also affect the blood, regular blood tests have to be taken. Various side effects may occur, including nausea or vomiting and a temporary loss of hair. There are drugs available to help control nausea and vomiting.

Treatment usually continues for upto 12 months. While on treatment, and for some time afterwards, special precautions have to be taken in regard to contact with measles and checkenpox. This will be explained in more detail at the time of starting treatment. It is neverthe less important that children are encouraged to return to school while they are on treatment.

	Bone Marrow Transplantation for children.

A bone marrow transplant (BMT) involves replacing diseased bone marrow with healthy marrow cells. If the bone marrow comes from another person this is called an allogeneic transplant (allograft). Sometimes if collected from the patient and stored in a special freezer to be given back at a later date, it is called autologus transplant (autograft).

WHO CAN BE TREATED WITH BMT.
Children who cannot make adequate amounts of their own bone marrow, which occurs in aplastic anaemia, may be able to have a bone marrow transplant from another person. Some types of leukaemia can be treated with bone marrow transplantation, other types are best treated with chemotherapy. It is necessary to be in remission before a BMT, so some chemotherapy is almost always needed beforehand. BMT is sometimes used in children with other cancers and in some children with genetic diseases.

A BONE MARROW DONOR.
To be able to give bone marrow to someone else, both people have to have the same bone marrow type. There is a one in four chance that brothers and sisters will have the same marrow type and it is usually a brother or sister who can be a bone marrow donor. Occasionally, a parent can have a close enough match to be a donor and in rare instances an unrelated person.

WHAT IS INVOLVED FOR THE DONOR.
The bone marrow is taken from the hip bones with a needle, just like in a bone marrow test Instead of a syringe full, we need to collect a small bag full. The donor will have some blood tests and a check up to make sure that they are healthy before donation. The donor always has a general anaesthetic so that the procedure is not painful. They will usually be in hospital the night before and the night-after the bone marrow harvest (collection). Painkillers such as paracetamol are sometimes needed the night after the collection. Everyone has plenty of spare bone marrow, and the bone marrow cells regrow quickly. As there are red blood cells in the bone marrow, the donor sometimes requires a blood transfusion.

PREPARATION BEFORE TREATMENT.
During the week before the transplant, the patient neds to have chemotherapy and sometimes radiation treatment. This is called the conditioning treatment (pre-treatment) and enables the new bone marrow to be accepted by the patient.

HOW IS THE BONE MARROW GIVEN.
The bone marrow looks just like a bag of blood and is given through a central line into the vein, like a blood transfusion. The bone marrow cells find their own way into the bones.

ABOUT ISOLATION.
It takes about four weeks for the bone marrow cells to regrow and make blood cells. During this time the patient will have very little resistance to infection and needs to be protected. This is similar to the period following intensive chemotherapy but is more severe. BMT patients are looked after in single rooms and the number of visitors is limited so that the risk of infection is reduced. Even then, it is likely that an infection will develop during this time and antibiotics will be needed. The patient is also likely to need blood and platelet transfusions during this time.

ABOUT REJECTION.
With any transplant there is the possibility of the graft being rejected and with bone marrow transplants the graft can also react against the patient. This is called graft versus host disease. Drugs which suppress the immune system are given after the transplant to prevent this from happening.

SUMMARY.
Bone marrow transplantation can be used in a number of different diseases. It involves giving big doses of chemotherapy or radiotherapy and then giving the patient some bone marrow cells. As it takes several weeks for the marrow cells to start making new blood cells, the patient needs to be isolated and may become very ill during this time. The chance of a BMT being successful varies with each individual and the doctor will discuss this with you if a BMT is suggested.

	What happens after treatment?

After treatment is completed, the child should have regular check ups. Children treated for a brain tumour may experience some long term side effects and regular check ups will help detect any problems. Brain tissue can be affected by the tumour itself or by the treatment and side effects can include speech, growth and educational problems. Help to manage these side effects can be obtained from the doctor with assistance from physio and speech therapists and other specialists.