Childhood malignancy

1
???? ?????? ?????? ????? ???? ???? ?????

• ?"? ???? ????
• ???? ????? ?????????? ??????????? ?????
• ???? ?????? ?????? ????? ??????
• ??????? ?????? ?"? ?????, ?????????? ?? ????

2
Childhood malignancy
3
????? ????? ???? ??????

• ?????
• ?????
• CF
• ????? ??????
• AIDS
  ????

4
ALL outcome
5
????? ???? ??????

• ????????? Index of suspicion ?????
  ??????
• ????? ??????? ???? ????????.
• ???? ?????? ????. ???? ????? ????? ???? ???? ????
  ??? ?-10 ???? ?????.
• ??? ??????? ????? ?????? ?? ???? ???? ???????
  ??????? ??? (????? ?????? ???? ???? ???? ??? ???
  ??????).

6
????? ???? ??????

• ??????? ?????? ???? ??????? ?? ?????????
  ????????.
• ?-50 ??????? ????? ????????? ???????? ???????
  ?????? ??? ???? ?????? ?????? ???? ?????
  ????????? ?? ???? ?????? ??????? ??????.
• ????? ??????? ????? ?????? ?? ??? ?????? ?????
  ???????? ?? ????.

7
???? ?? ??????

• 25th 25th
• Diagnosis n mean median
  percentile percentile
• Brain 194 211 93
  38 237
• Ewings 82 182 127
  79 255
• Hodgkins 143 223 136
  49 270
• Leukemia 908 109 52
  20 129
• Non-Hodgkins 184 117 62
  25 141
• lymphoma
• Neuroblastoma 237 120 58
  15 164
• Osteosarcoma 67 127 98
  40 191
• Rhabdomyo- 126 127 55
  25 161
• Sarcoma
• Wilms 223 101 31
  9 120

8

• Diagnosis Time to
  Commentary
• diagnosis
• Nasopharyngeal carcinoma 4 months Earache
  appointment within 2 month
• Non-Hodgkins lymphoma 6 months Vomiting and
  lethargy. Not referred to secondary
  care diagnosed emergency department
• Hodgkins disease 7-8 months Lump in neck. Not
  referred to secondary care ?
  diagnosed while being investigated for
  another problem
• Ewings sarcoma 5 months Backache and
  appointment 5 months after symptoms first
  appeared. MRI not scheduled for
  further 6 months. Diagnosed after emergency
  MRI.
• Osteosarcoma 6 months Sore back referred for
  physiotherapy. Did not obtain referral
• ?
  for 5 months and
  was diagnosed via private consultation
• Acoustic schwannoma 4
  months Numbness in face. Appointment in secondary
  care was 4 months after
  symptoms first appeared. Diagnosed very
  shortly after appointment.
• Astrocytoma 2-5 months Squint and poor
  coordination. Appointment in secondary
• (brain low grade) care for 5 months after
  first presentation but was
  diagnosed in emergency department.
• ALL 3 weeks Weakness and lethargy. Blood test
  done after 3 weeks
• ALL 3 weeks Fever and influenza-like symptoms.
  Blood test done after 3 weeks
• ALL 1 month Lethargy, poor appetite. Blood
  test done after 3-4 weeks

9
????? ??????

• ????? ????? ????? ??????, ??? ?????? ?????? ??
  ??? 12 ???? ????? ??? ???????.
• ????? ????? ??????? ????? ??????
• ????? ???????? - ???? gt 1 ?"? ?? gt 1.5 ?"?
  ??????
• - ????? ???????????? ?? ?? ?????
• ????? ?????? ????? Vs ??????.

10
(No Transcript)
11

• ????? ?????????? ?? ??????? ????? ????? ?????
  ?????? ???? ?? ??? ???? ?? ?? ??? ???????? ?????
  ?????? ??? ??????.
• ?????? ??????? ????? ?? ???? ???? ???????????? ??
  ????, ?? ??????, ??? ???? ???? ??????
• ???? ????? ??? ?????? ?? ???
• ????? ??? 2.5 ?"? ????? ???? ???? ?????

12
?????? ????? ??? ?????

• ???? ?????? ???? ??????? ?????? ?? ??????
  ?????
• Persistent
• Progressive
• Painless
• gt 13y 7-13y lt6y
• Hodgkins Hodgkins NBL
• NH Lymphoma RMS
• Thyroid Lymphoma
• RMS Leukemia
• Mediastinal mass
• ???? ?????? ?????? ??? ????? ????
• 78-41 ?????? ???????
• ???? ????? ????? ??? ?? ?? ?????? ?? ?????? ??
  ?????

13
(No Transcript)
14
????????? ???????? ?? ?????

• ????? ????? ??? ???? ????????? ??? 3-2 ??????
• ?????? ??????? ??? ???? ??? 6 ?????? ?? ??? ????
  ???? ?-1 ?"? ??? 12 ?????? ????? ?? ????? ???,
  ????? ????? ?? ????? ??? ?????.
• ????? ?????? ?????? ????? ?? ?? ???????
• ????? ?????? ???? ?????
• ??????? ????? ?? ????????

15
????? ?????? ???????

• ??? ???? ??????? ???? ???? ?????? ??? ????????
  ????? ??? ???.
• ??? ?????? ????? ?
• ???????
• ???? ??????? ??? ???? ?? ???? (????????????)
• ????? ???

16
???? ????? ?????? ???

• Osteogenic Ewings
• ??? ???????? ????? 79 89
• ??? ?????? ?? ?????? 3 ?????? 4 ??????
• ???? ???? ????? ???????????? ?????? ???? ?????
  ???? ?? ?????? ??????? ???? ????? ??????.

17
???? ??? ?????? ???????

• ?????? ???????
• ??? ???? ????? ??????
• ???? ????? ?????
• ?????? ??????, ???, ????? ?????? ??? ???? ??
  ?????? ????????
• ???? ???? ????? ??????? ?"? ????????? ?????.
• ?? ?? ???? ?? ?? ??????? ?????? ?? ????? ????
  ?????? ?? ?????? ?????.
• ????? ?????? ?????? ?????? ???? ??? MRI.

18
???? ???? ?? ??? ????

• ???? ??? ???? ??? ??? ??????? ??????? ?????? ????
  ??????.
• ????? ???? ???? ???? ?????? ?"? ????? ???? ??
  ???? ??? ???? ???? ?????.
• ???????? ????? ?????? ????? ??? ????? ?"? Wilms
  ?? ????????????.
• ?????? ?????? ???? ??????? ???????? ?? ?????
  ??? ?????.
• ???? ????? ????? ??????? ???? ?????? (???? ???,
  ?????)
• ?? ????? ?? ?????? ?????? ???? ????? ???? ???,
  ????, ????, ??????? ????, ????? ?? ???? ?????
  ?????? ?? ??????? ????? ?????.
• ?? ????? ??? ????? ?? ???? ????? ?????? ??????
  ????????? ??????.

19
??? ????....???? ???? ?????? ??????? ???????
???????????? ?????? ??????? ??

• ???? ?? ???? ?????
• ???? ??? ????
• ?????? C.T. ?? MRI ????? ???????

20

• Retroperitoneal tumors (442 cases) Number of
  patients
• Kidney
• Wilms tumor 202
• Other malignant tumors 10
• Benign tumors 18
• Sympathetic tumors
• Neuroblastoma with metastases at presentation
  125
• Neuroblastoma without metastases
  60
• Neuroblastoma
  15
• Ganglioneuroma 5
• Adrenocortical tumors 7
• Malignant lymphomas 65
• Liver
• Benign tumors 9
• Malignant tumors 14
• Ovary
• Dysgerminoma 4
• Teratoma 27
• Embryonic sarcomas 22

21
???? ???

• ???? ??? ??? ???????? ?????
• ???? ??? ?????!!, ????? ????????????, ??????? ???
  ???, ???? ??? ??????? ?????, ????? ???????
  ?????!!, ??? ??? ?????? ?? ???? ??? ?????? ????
  ?????, ???? ??? ??????? ?????? ?? ??????
• ????? ?? ??? ??? (?? Paraparesis ???????? ?"?)
• ???? ????? ?????????
• ????? ?????
• 
  ????? ?????????? !!!
• 95 ??????? ?? ?????? ?? ????????? ????? ??? ????
  ??? ??? ???
• ?????? ??????????? ?????? ??????!!

22
??????????

• ?????, ????????? ??????????????? ?????? ???
  ?????? ?? ???????.
• ???? 936 ????? ?? ALL
• 51 Hb ???? ?-7.5
• 73 PLT ???? ?-150,0000
• 30 WBC ???? ?-5000
• ?? ??????? ?????? ?? ?? ???? ????? ?????
  ??????????
• ??????? ???? ???????
• ????????????
• ???????
• Ewings
• Rhabdomyosarcoma

23
????????????

• ???????????? ??? 100,000 ?????? ?-10 ????? ?-ALL
  ?-21 ????? AML ??????.
• ????? ????? ?-Leukemoid reaction ?? ????? ????
  ??? 50,000 ?????? ?????? ?- Sepsis (Staph, H.
  Influenzae, Meningococcus, Salmonella).
• ??????? ???????? ???? ????????? ????? ?????
  ???????????? ?? ??? 100,000.
• Lymphoid Leukemoid reaction ????? ?????? ?-EBV,
  Mumps
• Pertusis, CMV, Adeno, Varicella
• ???????????? 100,000-20 ?? ???????????? ???? ????
  ????? ???????? ????????? ???? ???
• Hypereosinophillic synd., Larva migrans,
  Allergy, Periarteritis
• ????? ???? ??? 100,000 ??? ????? ???? ????
  ????????.

24
???? ?????????? ?????????????

• ???? ????? ???????? ?? ??????????
• ????? ?????? ????????
• ????? ?? ???
• ?????????? ?????? ?? ???
• ???? ??????? ?? ?????? ????? ?????
• ???????? ?? ???? ??? ????? ??? ????
• ?????? ???????????, ????? ??? ????? ?? ?????
  ????, ??? ???? ????
• ???? ???? ?????? ?????? ?????? ???

25
????? ????

• ???? ???? ??? ???? ????? ???????? ??????. ????
  ????? ??? ?????????????? ?? ??? ????? ?? ???.
• DIC ???? ????? ????? ?? APML ?? AML ??????
  ????????????? ??????? ?????? ?? ?????? ?????.
• ????? ????? ??????- ????, ITP.
• ????? ???? ?? ?????, ????? ?? ???, ?????? ?????
  ????? ???? Di-dimers.
• DIC PT ? PTT ? Fib. ? ? PET
  FDP ?

26
???? ????? ????????? ??????

• ?????? ????? ?? ????????
• ?????? ???????? ??????? ?? ????
• ????? ???????
• ?????? ?????? ?? ????? ????? ?? ??????? ?? ????
  ?? ?????? !
• ????? ?? ?????? ?????? ????? ???? ????? ??????.
• ????? ?? ????? ??????? ????? ????? 7-5 ???? ?? ??
  ???? ??????? ???????.
• ??? ?????? ?? ??? ????.
• ?????? ?????? (????????? ???? ?????) ?????? ????
  ????????

27
???? ????

• ??? ?? ??????, ????? ??????. ??? ?????? ?? ?????
  ????????, ?? ?????? ????? ???? ??? ???? ??????.
• ???? 96 ????? ???????, ???? ????.
• ???? ?????? ????? ????? ?????? ?? U.S. ???? ???
  ???? ?????? ????? ?????? ?? stage IV
  Neuroblastoma.
• ????? ????? ??????? ?????, ????? ?????? ????
  ????? ???? ???? ?-10 ????? ???? ???? ?????.
• "????? ????? ?? ?? ????? ???? ???????? ????
  ?????? ?? ??? ?? ??? ????".
• "?????? ???????? ????? ?? ??????? ???? ?????
  ???????. ?????? ????? ???? ???? ???? ???????,
  ?????? ??? ???? ?????? ??????, ?????? ???? ?????
  ????????? ????????? ?? ???? ????? ?? ?????? ??
  ???????? ???? ????? ????".

28

• "?????? ????? ?????? ???? ??? ??
• ?????? ????? ?????? ??????? ?????? ???? ??? ???
  ????? ????? ?????? ?????? ?????? ????? ?????? ???
  ???????.
• ????? ?? ????? ?? ???? ?? ???? ?????? ????? ???
  ???? ????? ????? ?? ???? ?? ?? ?????? ??????
  ?????.
• ??? ?? ???? ?????? ?? ????? ????? ??? ????? ?????
  ????? ???? ???? ?? ??????? ???????.
• ???? ????? ????? ??? ???? ?? ??????? ???? ??????
  ?? ????? ????? ???? ????".

29

• ????? ???? ??????
• "??????, ?????? ??? ???? ????? ???? ???? ??????
  ???? ?? ????? ?? ??????".
• "????? ?????? ???? ???? ?????? ?????? ???? ???".
• "????? ????? ????? ??????? ?? ????? ???? ??? ???
  ???? ??????".

30

• ???? ??????... ?????????...
• ???? ?? ???? ??????? ????? ??? ??
  ????
• ??? ??? ????? ?? ????
• ???? ?? ???? ??????? ???? ?????? ?????????
  ??????
• ??????????, ???? ????? ???? ?????"...
• the primary physician should serve as the
  patients advocate

31
???? ???? ?????? ????? ??????

• ????? ????? ????? ??????.
• ?????? ????? ???? ??? ???? ?????? ?????? ?????
• ?? ???? ???? ??????.
• ????? ????? ?????? ?????? ????? ?????.
• ???? ????? ?????? ???? ?????? ????? ?????.

32
??????? ?-Clinical trials

• ???? ?????? ?????? ?????? ??????? ????? ??????
  ?????? ?????.
• ????? ???? ?????? ???? ?? ????? ???????????
  ??????? ???????.
• ??????? ???????? ??????? ?????????, ?????????
  ???? ???? ???? ???? ???????? ??????? ???????????
  ?? ?????????? ?? ???????.

33
Should Adolescents (15-20 Years) with Acute
Lymphoblastic Leukemia Be Treated as Old Children
or Young Adults ? Comparison of the French
FRALLE-93 and LALA-94 Trials.
?????? ????? ?- ALL ???????? ??? ???? ?????????
????? ????? ????????.  177 ??????? ??? ???????
20-15 FRALLE-93 adult LALA-94
77 n 100 15.9 m age 17.9 18 WBC 16.1 5
4/23 B/T 72/28 13 CD10 neg 15 6 922,
411, hypodpl. 5 94 CR 83
p0.04 67 5y EFS 35 p lt
0.0001 Univariate Trial, WBC at Dx.,
cytogenetics, T-lineage Multivariate Trial,
WBC. (p lt 0.0001, p lt 0.0005) ?????? ?????
????? ??????? ??????????? ?????????
???????????.
34
????? ?????

• ???? ??? ?????? ??? ????? ????????
• Compliance
• ???? ???? ???? ????????? ????/ ?????

35
???? ??? ????? ???? ?????? ???? ????

• ???? ??? ??????
• ??????????? ??? ?????? ?- Low risk patients
• ???????? ?? ????? ?? ??? ??????

36
??????? ????? ?????

• ????? ?? ???? ???? ??????
• ?????????? ???? ???? ??? ????? ???? ??? ??????
  (?????)
• ??????? ???? ?????? ???? ?????
• ???? ????? ??????? ?????? ?????
• ????? ??????
• ????? ????? ???? ??????
• ????? ?????? ??????? ??

37
???? ????????

• ???? ????? ???????? ????. ??????, ????, ???? ???
  ?????
• ??? ????? ????? ?????, ??"?, ????????, ????????
• ???? ?????? ?? ????? ??? ????? ???????
• ????? ????? ?????? ??? ???? ?????.

38
??? ?????

• ????????? ?????? ???? ???? ???????? 3.3 ?-15
  ???? (?? 14 ?????????? ??????)
• ????? ?-10 ???? ????? ?? ???.
• ?????? ???????????
• ?????
• ?????
• ???????
• ??????
• ????? ????
• Osteoporosis
• Avascular necrosis
• ????????????
• ?????? ????????????????
• ?????? ?????? (??????, ????? ???????)

39
???? ?? ???? ??????

• ???? ????? Compliance ????? ????
• ???? ????? ????? ?????? !!
• ???? ?????? ????? ????? ?? ????? ??????????
• ?????? ?????? ????? ??????? ?? ??????? ???????
  ?????
• ???? ?????? ?????? ???????? ?????? ?????
• ???? ????? ???? ????
• ?????? ?????? ????? ??? ??????
• ??????? ?????? ?????? ???? ??????? ??????
  ??????? ?????
• ???????? ????? ??????? ???????
• ??????? ?????? 86 76
• ????? ?????? ????? 81 69
• ??????? ????? ???? ???? ??????? ?? ???????
  ????? ????? ????? ????? ????

40
????? ?? ????? ?????? ????? ?

• ??? ?? 12,000 ??????? ??????? ?????
• 67 ???? ????? ?????? ?????
• 46 ????? ??????? ?????? ????? ?? ????? ?????
• 72 ???? ????? ????? ?? ??? ????? ???? ????
• 6 ?? ????? ???? ???? ????? ??? ???? ????????
• 11 ?? ????? ???? ???? ????? ??? ???? ?????
• 70 ?????? ?????? ?? ????? ???? ?? ???? ??????
• ????? ???? ???? ?????? ??

41
????? ???? ?????? ?????? ???????

• 5 ????? ????? ?????? ?????? ?????? ??????
• ????? ?? ??????? ??????? ?????
• ?????? ?? ????? ????? (P-53)
• ????? ?????? ?????????
• ???? ???? ???? - ?????
• ?????
• ????? ????
• ??? ???? ????? ????? ????"? ???? ?-50 ?????????
• ?????? ???? ???????.
• ???? ???? ?????? ?????? ?????? ?????? ?????.

42
???? ????? ??????? ?????? ???? ????

• ??? ??? 3 ????? ???? ???? ????? ????
• ???? ??? ???? ????? ??? ???? ????? ????? ?????
  ??????? ???
• ?? ???? ?????? ?-5 ???? ???? ??????
• ????? ????? ????? ????? ?? ?????? ???? ???? ??
  ?????? ??????? ???????
• ????? ?????? ??????????

43

• ???? ?????? ?????????
• ???? ????
• ???? ?????
  ???????

44
????? ???????? ???? ????? ?????

• ??? ???? ??? ???? ?????? ??????????
• ????? ???? ????? ?? ???? ????? ??????????
• Pediatric total care policy

45
Dr. John Holliday

• ???? ???? ???? ????? ?? ????
• ?? ???? ???? ??? ?? ???? ?"??? ???? ????" ???
  ????? ???? ??? ?????? ???? ????? ??? ?? ???????
  ??????
• ???? ?????? ??????? ??? ?????? ?????? ?"????
  ????? ?? ?? ????" ???? ?? ?"???? ??? ?? ????"
• ?? ?????? ???????? ?? ???? ????? ??? ???? ?????
  ????? ?"? ???? ????, ???? ???? ????? ???? ?????
  ???? ?? ???? ?? ????

46
??? ?????? ????? ?????? ???????

• ?????? ?- Tumor Board
• ????? ???? ????? ??????
• ???? ??? ????? ??? ????? ?????? ??????
• ????? ????? ???? ?????
• ????? ???? ?????? ????? ????? ???????
• ???? ????? ?? ???? ?????
• ????? ??? ?? ??? ???? ???? ????? ???? ??