Infections Epstein-Barr virus is associated with increased risk.
Non-Hodgkin lymphoma Immunodeficiency Acquired and congenital immunodeficiency disorders and immunosuppressive therapy increase risk.
Infections Epstein-Barr virus is associated with increased risk.
Osteosarcoma Ionizing radiation Cancer radiation therapy and high radium exposure increase risk.
Genetic factors Increased risk is apparent with Li-Fraumeni syndrome and hereditary retinoblastoma.
Ewing sarcoma Race Incidence is about nine times higher in white children than in black children in the United States.
Neuroblastoma Genetic factors Chromosome 6p22 variants and mutations in the ALK and PHOX genes are associated with increased risk.
Retinoblastoma Genetic factors Mutations in the Rb gene on chromosome 14
Wilms tumor Congenital anomalies Aniridia, Beckwith-Wiedemann syndrome, and other congenital and genetic conditions are associated with increased risk.
Renal medullary carcinoma Sickle cell trait Etiology is unknown.
Rhabdomyosarcoma Congenital anomalies and Li-Fraumeni syndrome and neurofibromatosis 1 are associated with increased genetic conditions risk.
Hepatocellular carcinoma Infections Hepatitis B virus infection increases risk.
Malignant germ cell tumors Cryptorchidism Cryptorchidism is a risk factor for testicular germ cell tumors.
Modified from Kliegman RM, Stanton BF, St. Geme JW III, editors: Nelson Textbook of Pediatrics, ed 19, Philadelphia, 2011, Saunders.
patient with leukemia may also have a normal CBC. Lactate dehydrogenase and uric acid are often elevated in fast-growing tumors (leukemia or lymphoma) and occasionally in sarcomas or neuroblastoma. In many cases, it is appropriate to assess electrolytes and renal and hepatic function in the screening process. Elevated blood pressure, if confirmed by repeat measurements, should prompt a urine analysis, as should the palpation of an abdominal mass.
A chest x-ray (CXR) (posteroanterior and lateral) is the bestscreening radiographic study for a patient with suspiciouscervical lymphadenopathy, fever, and weight loss. Mediastinalmasses and pleural effusions can often be detected on CXR.
Abdominal signs or symptoms warrant an ultrasound or CT.Persistent headache, vomiting, or abnormal neurologic findings should lead to a head CT or MRI. For suspected bonetumors, plain radiographs are indicated and will usuallyreveal the lesion(s), if present. Radiographs may be normalwhen a bony pelvic lesion is suspected; a CT or MRI shouldbe obtained. Other imaging studies to delineate a mass and tosearch for suspected metastases are often indicated, but thesedecisions are usually best left to the pediatric oncology team.Table 153-3 shows the general use of diagnostic imaging following confirmation of a diagnosis of cancer, assessing the primary tumor and for metastases. Positron emission tomography(PET) has proved useful for staging and assessing response forsome pediatric cancers, especially lymphomas. Metaiodobenzylguanidine (mIBG) scans are useful for neuroblastoma.
Table 153-2 Common Manifestations of Childhood Malignancies SIGN/SYMPTOM SIGNIFICANCE EXAMPLE Hematologic Pallor, anemia Bone marrow infiltration Leukemia, neuroblastoma
Petechiae, thrombocytopenia Bone marrow infiltration Leukemia, neuroblastoma
Fever, neutropenia Bone marrow infiltration Leukemia, neuroblastoma Systemic
Bone pain, limp, arthralgia Primary bone tumor, metastasis Osteosarcoma, Ewing sarcoma, leukemia, to bone neuroblastoma