It is important to explore quality, duration, location, severity,and precipitating events of the chief complaint. A prominentlymph node that does not resolve (with or without antibiotics)may warrant a biopsy. A limp that does not improve within weeksshould prompt a CBC and a radiograph or a bone scan. Persistent headaches or morning vomiting should prompt a computed tomography (CT) or magnetic resonance imaging (MRI)scan of the head. Fever, night sweats, or weight loss should raisethe concern for lymphoma. In addition it is important to obtainthe birth history, medical and surgical history, growth history,developmental history, family history, and social history.
Growth parameters and vital signs are important to obtain in all patients. Pulse oximetry should be obtained if respiratory symptoms are present. The overall appearance of the patient should be noted, particularly general appearance, pain, cachexia, pallor, and respiratory distress. Palpable masses should be measured. Lymphadenopathy and organomegaly should be quantified, if present. A thorough examination of the skin may reveal rashes, bruises, and petechiae. Careful neurologic and ophthalmologic examinations are crucial if headache or vomiting is present, because the vast majority of patients with CNS tumors have abnormal neurologic examinations.
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Visual Impairment and Leukocoria Vomiting Hepatomegaly Splenomegaly Headaches Lymphadenopathy Anemia Petechiae/Purpura Pancytopenia Fever of Unknown Origin
The most common manifestations of childhood cancer are fatigue, anorexia, malaise, pain, fever, abnormal lump ormass, pallor, bruising, petechiae, bleeding, headache, vomiting, visual changes, weight loss, and night sweats (Table 153-2). Lymphadenopathy and organomegaly are commonin leukemia, particularly with T-cell acute lymphoblasticleukemia (ALL) or non-Hodgkin lymphoma. Patients withsolid tumors usually have a palpable or measurable mass.Other signs and symptoms may include limp, cough, dyspnea, cranial nerve palsies, and papilledema. In generalmalignant masses are firm, fixed, and nontender, whereas masses that are infectious or inflammatory in nature are relatively softer, mobile, and tender to palpation.
Neuroblastoma IV Retinoblastoma V Renal VI Hepatic VII Bone VIII Soft tissue IX Germ cell X Other malig. epithelial neo. XI Other XII
Retinoblastoma Primitive   neuroectodermal tumor (PNET) Sarcomas Osteosarcoma Ewing sarcoma Soft-tissue sarcoma Hodgkin disease Testicular cancer Ovarian cancer Acute lymphoid   leukemia Non-Hodgkin lymphoma Glioma Birth 5 10 18 Age (yr) Figure 153-2 Incidence of the most common types of cancer in children by age. The cumulative incidence is shown as a dashed line. (Courtesy of Archie Bleyer, MD).
Distinguishing a malignant process from another diseasecan be difficult. Ultimately a tissue diagnosis (from bonemarrow or solid tumor biopsy) with pathologic confirmation is required to confirm a diagnosis of cancer. Infection 7.8 3.1 6.3 2.2 9.2 12.4 11.9 16.9 0.5 47.1 43.1 25.1 0 10 20 30 40 50 60 Rate per 1,000,000