Treatment in Pediatric Cancer

Department of Child Health

Faculty of Medicine
University of HKBP Nommensen
Leukemia
Chemotherapy
 Chemotherapy (chemo) is the main treatment for nearly all
childhood leukemias
 This is treatment with anti-cancer drugs that are given into a
vein, into a muscle, into the cerebrospinal fluid (CSF), or
taken as pills
 Except when given into the CSF, chemo drugs enter the
bloodstream and reach all areas of the body, making this
treatment very useful for cancers such as leukemia
Chemotherapy
 The treatment of leukemia uses combinations of several
chemo drugs
 Doctors give chemo in cycles, with each period of treatment
followed by a rest period to give the body time to recover
 In general, treatment for acute myeloid leukemia (AML) uses
higher doses of chemo over a shorter period of time (usually
less than a year), and acute lymphocytic leukemia (ALL)
treatment uses lower doses of chemo over a longer period of
time (usually 2 to 3 years)
Chemotherapy
 Readiness for patient will get chemotherapy :
 Clinically good
 Laboratory findings
 Nutritional state
 Pshycological state
Chemotherapy
Some of the drugs used to treat childhood leukemia include:
 Vincristine
 Daunorubicin, also known as daunomycin
 Doxorubicin
 Cytarabine, also known as cytosine arabinoside or ara-C
 L-asparaginase , PEG-L-asparaginase
 Etoposide
 Teniposide
 6-mercaptopurine
 6-thioguanine
 Methotrexate
 Mitoxantrone
 Cyclophosphamide
 Prednisone
 Dexamethasone
Chemotherapy
The side effect of chemo depend on the type and dose of drugs given
and the length of treatment. These side effects can include:
 Hair loss
 Mouth sores
 Loss of appetite
 Diarrhea
 Nausea and vomiting
 Increased risk of infections (because of low white blood cell
counts)
 Bruising and bleeding easily (from low platelet counts)
 Fatigue (caused by low red blood cell counts)
Chemotherapy
 The side effects above usually go away when treatment is finished.
There are often ways to reduce these side effects  drugs can be
given to help prevent or reduce nausea and vomiting
 Tumor lysis syndrome
 another possible side effect of chemotherapy
 patients who had large numbers of leukemia cells in the body
 When chemo kills these cells, they break open and release their
contents into the bloodstream  kidneys, which aren’t able to get rid
of all of these substances at once
 Making sure the child gets lots of fluids during treatment and by
giving certain drugs, such as bicarbonate, allopurinol, and
rasburicase, which help the body get rid of these substances
Surgery
 Surgery has a very limited role in treating childhood
leukemia
 Because leukemia cells spread throughout the bone marrow
and to many other organs through the blood, it’s not possible
to cure this type of cancer by surgery
 Surgery rarely has any role even in the diagnosis, since a bone
marrow aspirate and biopsy can usually diagnose leukemia
 State After Treatment
Remission
 A remission (or complete remission) is usually defined as having no
evidence of leukemia after the 4 to 6 weeks of induction
treatment. This means:
 The bone marrow contains fewer than 5% blast cells,
 The blood cell counts are within normal limits, and
 There are no signs or symptoms of the disease
 A molecular complete remission means there is no evidence of
leukemia cells in the bone marrow, even when using very
sensitive lab tests, such as polymerase chain reaction (PCR).
Even when leukemia is in remission, this does not always mean
that it has been cured
Minimal residual disease
 Minimal residual disease (MRD) is a term used after treatment when
leukemia cells can’t be found in the bone marrow using standard lab
tests (such as looking at cells under a microscope), but they can still be
detected with more sensitive tests (such as flow cytometry or PCR). In
general, children with MRD during or after induction chemotherapy are
more likely to have the leukemia relapse (come back) and therefore may
need more intense treatment. Children with more MRD have a greater
risk of relapse than those with less MRD.
Active disease
 Active disease means that either there is evidence that the leukemia is
still present during treatment or that the disease has relapsed (come
back) after treatment. For a patient to have relapsed, more than 5% of
the marrow must be made up of blast cells
Retinoblastoma
Children with retinoblastoma are treated by a team of doctors
that often includes:
 A pediatric ophthalmologist: a doctor who treats eye
diseases in children
 An ocular oncologist: a doctor (usually an
ophthalmologist) who treats cancers of the eye
 A pediatric oncologist: a doctor who treats children with
cancer
 A radiation oncologist: a doctor who treats cancer with
radiation therapy
The goals of treatment for retinoblastoma are:
 To get rid of the cancer and save the child’s life
 To save the eye if possible
 To preserve as much vision as possible
 To limit the risk of second cancers later in life, which can be
caused by treatment, particularly in children with hereditary
retinoblastoma

The most important factors that help determine treatment are:

 Whether the tumor is just in one eye or both
 How good the vision in the eye is
 Whether the tumor has extended outside the eye
The main types of treatment for retinoblastoma are:
 Surgery
 Radiation therapy
 Photocoagulation (using lasers to kill small tumors or the
blood vessels that feed them)
 Cryotherapy (using cold to freeze and kill small tumors)
 Thermotherapy (using a type of laser to apply heat to kill
small tumors)
 Chemotherapy
 High-dose chemotherapy and stem cell transplant
Chemotherapy
Chemo can be given in different ways :
 Systemic chemotherapy
 Periocular (subtenon) chemotherapy
 Intra-arterial chemotherapy
doctors can use much smaller doses of chemo drugs (less
than 10% of the doses used for systemic chemo)
 Intravitreal chemotherapy
Chemotherapy
Some of the drugs used to treat children with retinoblastoma
include:
 Carboplatin
 Cisplatin
 Vincristine
 Etoposide
 Cyclophosphamide
 Topotecan
 Doxorubicin
 Most often, 2 or 3 drugs are given at the same time. A standard
combination used to shrink intraocular retinoblastomas is
carboplatin, vincristine, and etoposide, although for very small
tumors, only carboplatin and vincristine may be enough
Chemotherapy
Along with those listed above, certain chemo drugs can cause specific side
effects
 Cisplatin and carboplatin can affect the kidneys. Giving the child plenty
of fluids during treatment can help reduce this risk. These drugs can also
cause hearing loss in young children, especially in babies younger than 6
months.Your child’s doctor may check your child’s hearing with tests
during or after treatment. When carboplatin is injected directly into the
tissues near the eye (periocular chemotherapy), it can cause redness and
swelling in the area.
 Vincristine can damage nerves. Some children may feel tingling and
numbness, particularly in their hands and feet.
 Some drugs, such as etoposide, doxorubicin, and cyclophosphamide, can
increase the risk of developing a cancer of white blood cells known
as acute myeloid leukemia (AML) later in life. Fortunately, this is not
common.
Chemotherapy
 Doxorubicin can damage the heart. The risk of this happening
goes up with the total amount of the drug given. Doctors try
to limit this risk as much as possible by not giving more than
the recommended doses and by checking the heart with an
echocardiogram (an ultrasound of the heart) during
treatment.
 Cyclophosphamide can damage the bladder, which can cause
blood in the urine. This risk can be lowered by giving this
drug along with plenty of fluids and with a drug called
mesna, which helps protect the bladder.
Surgery ( Enucleation )
 Surgery is not needed for all retinoblastomas, especially for
smaller tumors. But if a tumor gets quite large before it is
found, vision in the eye has often already been destroyed,
with no hope of getting it back
 The most obvious side effect of enucleation is the loss of
vision in that eye, although most often the vision has already
been lost because of the cancer.
 Removing the eye also can affect the future growth of bone
and other tissues around the eye socket, which can make the
area look somewhat sunken. Using an orbital implant can
sometimes lessen this effect
Lymphoma
Chemotherapy
 Chemotherapy (chemo) is the main treatment for non-
Hodgkin lymphoma (NHL) in children. Chemo uses anti-
cancer drugs that are usually given into a vein or taken by
mouth
 These drugs enter the bloodstream and reach all areas of the
body, making this treatment very useful for cancers that tend
to spread widely, such as NHL
 In some cases where the lymphoma may have reached the
brain or spinal cord, chemo may also be given into the
cerebrospinal fluid (known as intrathecal chemo)
Chemotherapy
 Children with NHL get a combination of several chemo drugs
over a period of time
 The number of drugs, their doses, and the length of treatment
depend on the type and stage of the lymphoma
 Doctors give chemo in cycles. Each chemo cycle generally lasts
for several weeks
 A period of treatment is followed by a rest period to allow the
body time to recover
 Most chemo treatments are given on an outpatient basis (in the
doctor’s office or clinic or hospital outpatient department), but
some – especially at the start of treatment – may need to be given
while the child stays in the hospital
Some of the drugs commonly used to treat
childhood lymphoma include:
 Cyclophosphamide
 Vincristine
 Doxorubicin
 Prednisone
 Dexamethasone
 Cytarabine
 Methotrexate
 L-asparaginase, PEG-L-asparaginase
 Etoposide
 6-mercaptopurine
 Ifosfamide
Surgery
 Surgery often has a limited role in treating lymphoma since it’s
unlikely to cure it by itself, and normal organs might be damaged
in the process
 Surgery is sometimes used as the first treatment for early-stage
Burkitt lymphoma that is in only one area (such as part of the
intestine) to try to remove as much of the tumor as possible
before chemotherapy.
 If the lymphoma can be removed completely, doctors might be
able to give a less intensive chemotherapy regimen
 Other uses of surgery include: To get biopsy samples for lab tests
to determine the exact type of lymphoma if non-surgical
procedures (needle biopsy, bone marrow biopsy, etc.) could not
get enough tissue
Radiation Therapy
 Sequential nodal spread of disease, usually from neck to
pelvis, allows for cure with radiation therapy to the involved
and contiguous nodal regions but requires accurate staging of
the disease
 Radiation therapy was the first curative modality used for
Hodgkin lymphoma (HL) in the early 1960s. However, the
doses and fields used for the treatment of adult Hodgkin
lymphoma caused profound musculoskeletal retardation,
cardiac toxicity, and increased incidence of secondary
malignancies in the radiation field
Radiation Therapy
 Radiation protocols are used as an adjuvant treatment after
chemotherapy
 To reduce complications, risk-adapted or response-based, low-
dose, involved-field, or extended-field radiation is administered
 In current pediatric trials, the use of nodal conformal radiation is
being evaluated to further decrease the burden of radiation to
other tissues
 In addition, in some protocols the field for radiation has changed,
from the involved areas at the time of diagnosis to the residual
disease present at the time of response to therapy evaluation
Palliative Care
 Pediatric Palliative care (pronounced pal-lee-uh-tiv) is
specialized medical care for children with serious illnesses. It
focuses on providing relief from the symptoms, pain, and
stress of a serious illness—whatever the diagnosis. The goal is
to improve quality of life for both the child and the family.
 Pediatric palliative care is provided by a team of doctors,
nurses and other specialists who work together with a child’s
other doctors as an extra layer of support. It is appropriate at
any age and at any stage of an illness and can be provided
along with treatment meant to cure.
 Pediatric palliative care addresses a serious medical
conditions, including genetic disorders, cancer, prematurity,
neurologic disorders, heart and lung conditions and others.
 It relieves the symptoms of these diseases, such as pain,
shortness of breath, fatigue, constipation, nausea, loss of
appetite and difficulty sleeping. In short, it helps the child
and the family gain the strength to carry on with daily
life.
 Pediatric palliative care is family-centered. Families are
better able to choose options that are in line with their
values, traditions and culture. This improves the well-being of
the entire family
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THANK YOU