Back to basics

 Diagnosing cancer, leukaemia and brain tumours in children. The view of two shared care paediatricians

Drs Shahid Ali and Andrew Cowley are Consultant Paediatricians at Northampton and Shrewsbury. They share care for children with malignant disease with Birmingham Children’s Hospital, but are also general paediatricians.

 

Dr Cowley begins:
Common things are common. In Shrewsbury we see 5,000 emergency admissions and 7,000 new outpatients each year, but only about 10 turn out to be cancer. Children present with common complaints such as headaches and swollen glands. I’ll use these as examples to demonstrate some of the difficulties of distinguishing what is and isn’t cancer. Most patients go to their GP and get referred to hospital in three ways:- 

1. Emergency Admission – This route is common if the child is unwell.
2. General Out-Patient Appointment – for which patients can wait up to 5 weeks.
3. An urgent appointment under the 2 week wait rule for suspected cancer.

Headaches:
• A 9 year old girl presents to her GP with a history of an intermittent headache for 2 months. A family history of migraine is noted and she is being bullied at school.
• Examination is normal so she and her family are reassured and sent home to return if the headache worsens.
• After 4 weeks she returns to her GP at 11 am with a different headache, causing her to cry at night. The GP refers her up to the hospital as an acute admission with the possible diagnosis of viral meningitis, or an intracranial space-occupying lesion.

In hospital – arrives 2.30pm, seen by junior doctor at 3pm and then reviewed by a registrar at 4pm. A consultant is then called. No mention of the possible diagnosis. A CT scan is done – it’s not meningitis after all, it’s a brain tumour. They waited all day then their life is turned upside down in a minute.

She could have been referred to clinic with the initial headache. As a doctor you have to decide what could this headache be? A tension headache, migraine, sinusitis, behavioural problems, or is it just due to her home work? Common things are common – a tension headache occurs in up to 40% of children. A brain tumour occurs in only 0.03% of children.

A lump in the neck:
Parents see a lump and worry about leukaemia or cancer. Some may have a personal history or know of someone with cancer (adult cancer occurs in up to 1 in 3 adults). They want a blood test to rule it out, however there isn’t a single cancer test. Tests are done and are all normal (often falsely reassuring), although those looking for infections such as glandular fever, or bacterial infections, eg tonsillitis, can take longer. Antibiotics are given and the child sent home with a review in 2 weeks. The lump shrinks slightly so antibiotics are continued. Another week goes by. The parents now can’t decide whether it’s bigger or smaller after all they’ve been feeling their child’s neck 3 times a day for the last 3 weeks! Now what? Watch and wait, another type of antibiotic, or do we ask a surgeon to remove it? Anxious times. The diagnosis finally comes from a blood test weeks later – cat scratch fever. The parents are relieved and welcome the diagnosis even though they don’t have a cat!

In summary a district general hospital is a stepping stone from GP to a Principal Treatment Centre. Out of the 12,000 patients we see, only 10 will be diagnosed with cancer this year.

Dr Ali continues:
Cancer in children is generally rare with around 1700 cases being diagnosed in the UK every year in children under 15 years of age. Acute childhood leukaemiais the most common type of cancer in children, accounting for about one third Back to Basics: Diagnosing cancer, leukaemia and brain tumours in children. The view of two shared care paediatricians Drs Shahid Ali and Andrew Cowley are Consultant Paediatricians at Northampton and Shrewsbury. They share care for children withmalignant disease with Birmingham Children’s Hospital, but are also general paediatricians. 7 of all children’s cancers. Leukaemia is a cancer of white blood cells. Normal healthy people have two types of white blood cells, neutrophils that help to fight bacterial infections and lymphocytes that help to fight viral infections. About 83% of acute leukaemias arise from lymphocytes and these are called acute lymphoblastic leukaemia (ALL). The remainder arise from neutrophils and these are called acute myeloid leukaemia (AML).



Most children who present with acute leukaemias have a short history of symptoms, usually 2-3 weeks. The symptoms of leukaemias can be easily understood if one knows some basic facts about blood. Blood cells are made in bone marrow and are of three types: red blood cells that carry oxygen, white cells that help fight infections and platelets that help make blood clot in case of injury. Acute leukaemia develops from one single abnormal cell that multiplies and eventually replaces normal healthy cells in bone marrow. So children may present looking pale with anaemia due to decreased red cells, or they may have fever from infections due to a reduced number of healthy white cells. One very important symptom that usually prompts urgent referral is bruising due to low platelet count. Most children, therefore, will present with a varying combination of symptoms like fever, paleness, tiredness, sore throat, bruising and bone pain. Some patients may also have swollen abdomens due to enlarged liver and spleen, or they may have large lymph glands in their neck, armpits or groins.

Not every child who gets these symptoms and signs will have leukaemia. Iron deficiency is relatively common in toddlers and vitamin deficiencies causing anaemia occur more rarely. Bruising may have other causes including ordinary rough and tumble. Sometimes there are concerns that a child may have been subjected to harm to cause bruising or there may be acquired conditions that cause the platelets to drop and present with bruising or bleeding. Glandular fever and related viral infections can result in signs and symptoms that are suggestive of leukaemia. Usually the diagnosis is straightforward, but sometimes there is a need to do more invasive tests such as bone marrow biopsy to reach the diagnosis.