Primary prevention strategies for most pediatric malignancies are unknown. Two exceptions are the use of hepatitis Bvaccine to lower the rates of hepatocellular carcinoma and theuse of human papillomavirus vaccine to reduce the risk of cervical, vulvar, and vaginal cancers. Childhood malignancies arenot associated with tobacco or alcohol use, dietary factors, orsun exposure. Treatment with certain chemotherapy agents andradiation therapy increases the rate of second malignancies.Secondary prevention may be accomplished by screening the at-risk child (e.g., a child with Beckwith-Wiedemann syndromeor twin of a leukemia patient), but these opportunities are rare.
Adverse effects of tumors and treatments may result in oncologic emergencies in children and adolescents (Table 154-1).
Mediastinal masses from lymphoma can cause life-threatening airway obstruction. Tumors with a large tumor burden (e.g., lymphoma, leukemia) may affect renal function adversely from tubular deposition of uric acid crystals. Allopurinol or rasburicase can be administered before chemotherapy to minimize this effect.
A common metabolic emergency is tumor lysis syndrome,often seen in treatment of leukemia and lymphoma. Large amounts of phosphate, potassium, and uric acid are released into the circulation from lysed cells. Overwhelming infection and spinal cord compression with neurologic compromise are other oncologic emergencies.
Appropriate imaging (usually with computed tomography [CT] or magnetic resonance imaging [MRI]) for solidtumors presenting as a palpable mass or mass-relatedsymptoms (pain, respiratory distress, intestinal obstruction) should be obtained and followed by resection (whenpossible) or biopsy (if complete resection is not feasible).An exception to this is a suspected lymphoma, for which a biopsy may be needed. However, almost all pediatric lymphomas are chemosensitive and do not require surgicalresection.
It is crucial to determine the amount of tissue required and the appropriate distribution of the tissue for testing so that all necessary studies are performed. A general oncologic surgery principle is to resect not just the tumor, but also, in most cases, a surrounding margin of normal tissue to ensure the entire tumor has been resected.
Hyperuricemia Uric acid nephropathy; Tumor lysis syndrome Lymphoma, leukemia Allopurinol, hydration, gout
Hyperkalemia Arrhythmias, cardiac arrest Tumor lysis syndrome Lymphoma, leukemia Kayexalate; sodium bicarbonate, glucose, and insulin
Anemia Pallor, weakness, heart Bone marrow suppression Any with chemotherapy Packed red blood cell failure or infiltration; blood loss
Thrombocytopenia Petechiae, hemorrhage Bone marrow suppression Any with chemotherapy Platelet transfusion or infiltration
Disseminated Shock, hemorrhage Sepsis, hypotension, Promyelocytic leukemia, Fresh frozen plasma; intravascular coagulation tumor factors others platelets, treat infection
Tracheal compression Respiratory distress Mediastinal mass Lymphoma Radiation therapy, compressing trachea
CNS, Central nervous system; CT, computed tomography; G-CSF, granulocyte colony-stimulating factor; MRI, magnetic resonance imaging.