Types and causes of pediatric oncology. Varieties and causes of the development of childhood oncology The development of oncology in childhood is good

Pediatric oncology differs significantly from adult oncology both in terms of the nature of tumors (almost no cancerous tumors), and by their localization (extremely rare tumors of the lungs, gastrointestinal tract, breast, genitals). In children, mesenchymal tumors predominate: sarcomas, embryomas, and mixed ones.

In the first place are tumors of the hematopoietic organs (leukemia, lymphogranulomatosis), then the head and neck (retinoblastoma, rhabdomyosarcoma), retroperitoneal space (neuroblastoma and Wilms tumors) and, finally, bones and skin (sarcoma, melanoma).

Despite the fact that in children, as in adults, the division of tumors into benign and malignant remains, such a distinction, as well as the isolation of true tumors from tumor-like processes and malformations, is extremely difficult due to their biological commonality and the presence of transitional forms.

One of possible causes development of tumors in children is the existence of ectopic embryonic cells that have the potential for malignant transformation.

It is also impossible to exclude the significance of a long-term focus of inflammation, viruses, as well as mutations that change the biochemical structure of the cell. An important place belongs to ionizing radiation, and the influence of trauma, which apparently plays the role of not a causal, but a provoking factor, is also not completely excluded.

The age of children suffering from tumors gives a sharp rise in the curve to 3-6 years in a graphical representation, although observations of malignant tumors in newborns are known. There is an opinion that each age of the child has its own type of tumor. Thus, dysoitogenetic formations (Wilms tumor) are characteristic of children under the age of 2 years. Lymphogranulomatosis, brain tumors occur in children from 2 to 12 years old, bone tumors often appear by the age of 13-14. This is due to the peculiarity of metabolism and physiological functions that change with age.

An important endogenous factor is hormonal influences, which determine the different frequency of individual forms of tumors in boys and girls. In boys, malignant tumors of the lymphatic apparatus are more often noted, and from benign forms - angiofibroma; girls are more likely to develop teratomas and hemangiomas.

A special feature for some neoplasms (hemangioma, juvenile papilloma, neuroblastoma, retinoblastoma) is their ability to spontaneous regression, which is explained by the fact that these tumors are the last stage of prenatal disorders, after the removal of which regression begins in the postnatal period.

One of the most important features of childhood tumors is the existence of a family predisposition to certain neoplasms (retinoblastoma, chondromatosis, intestinal polyposis). Establishing a history of such burdened heredity facilitates the timely recognition of these tumors and outlines ways to prevent them.

The course of malignant tumors in children is extremely peculiar. Thus, obviously malignant tumors (Wilms' tumor, neuroblastoma) can behave as benign ones for a long time: the capsule and surrounding tissues do not germinate. At the same time, being easily removed, they can metastasize. On the contrary, benign tumors - hemangiomas, which are based on a malformation of peripheral vessels, have infiltrating growth, can germinate neighboring organs, destroying them, and are removed with great difficulty.

The course of malignant tumors in children varies from rapid, with dissemination within a few weeks, to torpid, which is determined by the biological potency of the tumor, its localization and the overall resistance of the organism. A malignant tumor, regardless of the type and nature of the growth of the local focus, at a certain stage of development is manifested by regional or distant metastases. Sometimes the process of metastasis proceeds rapidly, according to the type of generalization.

Although the existence of general or local immunity has not yet been conclusively proven, the presence of certain protective properties of the body is beyond doubt. This is confirmed by the uneven development of the tumor, the detection of emboli in various organs that do not metastasize, and, finally, cases of spontaneous regression of the tumor.

The issues of early diagnosis in pediatric oncology are the most important among all others. The pediatrician must remember that behind the inexplicable symptoms, the atypical course of the disease, a neoplasm may be hidden, and it must be excluded in the first place. Each examination of a child by a doctor should be carried out from the standpoint of oncological alertness.

Oncological alertness of a pediatrician includes the following points:

• 1) knowledge early symptoms tumors most common in childhood(5 main localizations - hematopoietic organs, bones, retroperitoneal space, central nervous system, eyes);
• 2) knowledge of precancerous diseases and their detection;
• 3) prompt referral of the child to a specialized institution;
• 4) a thorough examination of each child who visits a doctor of any specialty to identify a possible oncological disease.

It is known that the cause of neglected cases in pediatric oncology, along with the lack of personal experience of doctors due to the relative rarity of neoplasms in children, is also the atypical course of the initial stage of the disease. So, under the guise of pains in the lower extremities that are typical for the period of growth of a child, pains in the lower extremities can be hidden initial stages leukemia, "enlarged" liver and spleen, upon closer examination, turn out to be a tumor of the retroperitoneal space.

For the purpose of diagnosis, the simplest methods of investigation are used - examination and palpation. Consistently carefully examine the state lymph nodes, renal regions, skull, eyes, tubular bones. Some supporting data can be obtained from a laboratory study (anemia, increased ESR, changes in the concentration of catecholamines). The study is being completed in the clinic using radiological methods (plain radiographs of the bones, excretory urography) and puncture biopsy. If necessary, the study (instrumental methods, angiography) ends in a hospital.

The possibility of malignant degeneration with such defects as a teratoid tumor, xeroderma, intestinal polyposis, and some types of age spots has been proven. Removing them in children is the prevention of neoplasms in adults. In addition to the removal of benign tumors, which are the background for the development of a malignant neoplasm, measures to prevent tumors in children are:

• 1) identification of family predisposition to certain forms of tumors;
• 2) antenatal protection of the fetus (elimination of all kinds of harmful effects on the body of a pregnant woman).

Diagnosis of tumors in children is always closely related to issues of deontology. On the one hand, parents should be well aware of the child's condition and the danger of delaying hospitalization, on the other hand, they should not lose hope of providing real help to their child. When communicating with children, it must be taken into account that sick children are especially observant, they quickly begin to understand the terminology and can realistically assess the threat to their health and even life. This requires a careful, tactful, attentive attitude towards sick children.

The choice of treatment method is determined by the nature and prevalence of the tumor process, the clinical course and the individual characteristics of the child. Surgical intervention, which is the main method of treatment, is carried out in compliance with two principles: the radical nature of the operation and the obligatory histological examination of the removed tumor. It should be noted that the criteria for malignancy of tumors in childhood are relative [Ivanovskaya TI, 1965].

As well as surgical method in pediatric oncology, radiation treatment and chemotherapy are used. The last two methods are prescribed only when an accurate diagnosis is established.

The use of combined treatment, an expanding range of chemotherapy drugs allow a significant part of children (up to 44-60%) to achieve survival for more than 2 years without relapses and metastases, which is equivalent to 5 years in adults and gives hope for a full recovery.

Poor outcomes largely depend on incorrect and late diagnosis, which is explained by the weak oncological alertness of pediatricians and surgeons, insufficient knowledge most neoplasms of childhood and the difficulty of diagnosis. A huge role in the prevention of neglected forms should be played by sanitary and educational work among the adult population, aimed at ensuring the timely appeal of parents with children for advice and treatment.

Isakov Yu. F. Children's surgery, 1983

General issues of pediatric oncology

• Year of issue: 2012
• Ed. M.D. Alieva, V.G. Polyakova, G.L. Mentkevich, S.A. Mayakova
• Genre: Oncology, pediatrics
• Format: PDF

Oncological diseases in childhood are one of the most important problems not only in pediatrics, but also in medicine in general. Mortality of children from malignant diseases in developed countries ranks second, second only to deaths of children from accidents.
At present, both in world practice and in Russia, significant progress has been made in the diagnosis and treatment of children with. Over the past decades, child survival has improved significantly: if in the early 1950s. Since the absolute number of children diagnosed with a malignant neoplasm died, now up to 80% of such patients can be cured.

For more than 35 years of existence, a unique experience has been accumulated in the treatment of pediatric patients with malignant neoplasms. The arsenal of diagnostic possibilities has been significantly expanded when using morphological, immunological, genetic and molecular biological methods for the identification of tumors. Radiation, endoscopic and other modern possibilities are widely used, which contribute to the clarification and specification of the diagnosis, the optimization of surgical approaches, the use of adequate chemotherapy programs and radiation treatments. The use of targeted drugs is being widely introduced.

Based on the experience gained, for the first time in the domestic literature, the National Guide to. It contains data on advanced scientific achievements, provides practical recommendations for the diagnosis and treatment of the most common neoplastic diseases in children, which are based on the extensive clinical experience of leading domestic specialists and on the results of major clinical studies conducted both in our country and abroad. . Separately, information is presented on the use of the most modern drugs, which in some cases allow achieving impressive results, including in patients with refractory diseases. The information presented in the National Guidelines will serve as a standard for providing oncological care to children in Russia and will help doctors in their practical work.

• Chapter 1. History of pediatric oncology.
• Chapter 2 Epidemiology of malignant neoplasms in children:

1. Classification of children's tumors.
2. Morbidity and survival of children with malignant neoplasms in developed countries.
3. Malignant neoplasms in children in Russia.
4. Comparative analysis of child mortality from malignant neoplasms in Russia and developed countries.

• Chapter 3 Features of pediatric oncology:

1. Genetic aspects of pediatric oncology.
2. Morphological studies in pediatric oncology.

• Chapter 4 Diagnosis of tumors:

1. paraneoplastic syndromes.
2. Diagnosis of lymphomas in children.
3. Laboratory diagnostic methods.
4. General clinical research.
5. Biochemical research.
6. Research of system of a hemostasis.
7. Endoscopy in pediatric oncology.
8. Endoscopy of the upper respiratory tract.
9. Bronchoscopy.
10. Esophagogastroduodenoscopy.
11. Fibrogastroscopy.
12. Colonoscopy.
13. Laparoscopy.
14. New endoscopic techniques.
15. Radiation diagnosis of malignant tumors in children.
16. Radionuclide diagnostics in pediatric oncology.
17. tumor markers.

• Chapter 5. Treatment:

1. General principles of surgical interventions for tumors of various localization.
2. Tumors of the head and neck.
3. Thoraco-abdominal oncosurgery.
4. Tumors of the musculoskeletal system.
5. Tumors of the central nervous system.
6. Diagnostic video surgery.
7. malignant tumors.
8. Vaccine therapy.
9. Hematopoietic stem cell transplantation.
10. Modern methods of intravenous administration of anticancer drugs.

• Chapter 6 Accompanying therapy in pediatric oncology and hematology.
• Chapter 7 Features of anesthesia and resuscitation in pediatric oncology:

1. Anesthesiological provision of surgical interventions.
2. Intensive care in the early postoperative period.

• Chapter 8 Principles of nutritional support:

1. Diagnosis and treatment of individual tumors

• Chapter 9 Tumors of the hematopoietic and lymphoid tissues:

1. Acute lymphoblastic leukemia.
2. Acute myeloid leukemias.
3. Chronic myeloid leukemia.
4. Non-Hodgkin's lymphomas.
5. Hodgkin's lymphoma.
6. histiocytic tumors.
7. Langerhans cell histiocytosis.
8. Histiocytic sarcoma.
9. Interdigitating dendritic cell sarcoma.
10. Follicular sarcoma of dendritic cells.
11. Juvenile xanthogranuloma.

• Chapter 10 Tumors of the central nervous system.
• Chapter 26 Second tumors in children cured of malignant neoplasms.
• Chapter 27 Vaccination of children with solid tumors.
• Chapter 28
• Chapter 29 Problems of children's hospices.
• Chapter 30 Postgraduate training for pediatric oncologists.

In recent years, the problem of specialized oncological care for children has attracted great attention. This was reflected in the creation of children's oncology departments in a number of large centers in our country and abroad, and in the appearance of a significant number of works devoted to particular issues of children's oncology.

According to large statistical data, there has been an absolute increase in the incidence of tumors in children, including malignant neoplasms.

Among the various causes of death in children aged 1 to 4 years, malignant tumors are in third place, moving to second place in the older age group, second only to trauma in frequency.

The distribution of malignant tumors according to their histogenetic affiliation and localization is very peculiar. Unlike adults, in whom neoplasms of an epithelial nature predominate - cancers, mesenchymal tumors - sarcomas, embryos or mixed tumors - are immeasurably more common in children. In the first place (a third of all malignant diseases) are tumors of the hematopoietic organs (lympholeukemia - 70-90%, acute myelogenous leukemia 10-30%, rarely - lymphogranulomatosis), blastomas of the head and neck (retinoblastoma, rhabdomyosarcoma), are approximately 2 times less common. , then neoplasms of the retroperitoneal space (neuroblastomas and Wilms' tumor) and, finally, tumors of bones, soft tissues and skin (sarcomas, melanomas). Very rarely in children, lesions of the larynx, lungs, breast, ovaries and gastrointestinal tract are observed.

ETIOLOGY, PATHOGENESIS

In children, as in adults, the division of tumors into malignant and benign is formally preserved. It, like the distinction between true tumors and tumor-like processes, as well as malformations, is very difficult due to their biological commonality and the presence of transitional forms.

Although the causes of blastomatous growth remain completely unknown, there are a number of theories and hypotheses that, according to N.N. Petrov, are united by the polyetiological theory of the origin of malignant neoplasms.

One of the undoubted reasons for the development of childhood tumors is the existence of ectopic cells, germs that have the potential for malignant transformation. This fact is the basis germinal theory of Conheim, which is not comprehensive, but partly explains the mechanism of development of some childhood tumors. Thus, teratomas, neuroblastomas, hamartomas and Wilms tumors do not have a primary blastomatous nature. These are rather malformations, the blastomatous potencies of which arise only at a certain stage, as a result of malignant transformation of cells.

Conheim's theory is supported by the following facts:

a) the existence of multiple lesions not only in systemic diseases (leukemia and lymphosarcoma), but also in cases of primary multiplicity of foci of osteogenic sarcoma and neuroblastoma;

b) malignant transformation of individual rudiments in any area of ​​the body after removal of a clinically detectable neoplasm, which gives the impression of recurrence, although in essence there is a manifestation of the growth of new tumors.

The pathogenesis of some tumors (desmoids, cancer thyroid gland etc.) fit into Ribbert theory, according to which the hearth chronic inflammation serves as a background for the onset of tumor growth. Viruses play a certain role in oncogenesis, as well as mutations that change the biochemical structure of the cell. An important place is occupied by ionizing radiation - multiple X-ray transilluminations or radiation exposures carried out for a therapeutic purpose. In particular, radiation treatment of persistent thymus significantly increased the incidence of thyroid cancer and leukemia in childhood (Duffiet. al., Clark). It has been suggested that exposure of parents to radionuclides is a more likely risk factor for the development of cancer in children than direct external exposure.

A special, specific for some neoplasms of childhood is their ability to spontaneously regress. The latter is characteristic of hemangioma, juvenile papilloma, neuroblastoma and retinoblastoma. The reasons for this phenomenon are unclear.

One of the most important features of childhood tumors is the existence of a family predisposition to some neoplasms, in particular, to retinoblastoma, bone chondromatosis and intestinal polyposis. Establishing a history of such burdened heredity outlines ways of prevention and facilitates the timely recognition of these tumors in children.

SOFT TISSUE TUMORS

Classifications of soft tissue tumors are complex and ambiguous. A variant of the classification of the most common true tumors. Like all tumors, soft tissue neoplasms are classified according to histogenesis, maturity, and clinical course.

Tumors of fibrous tissue:

Mature, benign:

Immature, malignant:

fibrosarcoma.

Adipose tissue tumors:

Mature, benign:

hibernoma;

Immature, malignant:

liposarcoma;

malignant hibernoma.

Tumors of muscle tissue (smooth and striated):

Mature, benign smooth muscle:

leiomyoma.

Mature, benign of transversely striated muscles:

rhabdomyoma.

Immature, malignant smooth muscle:

leiomyosarcoma

Immature, malignant from transversely striated muscles:

rhabdomyosarcoma;

Tumors of the blood and lymph vessels:

Mature, benign:

gem (lymph) angioma;

hemangiopericytoma;

glomus angioma.

Immature, malignant:

gem (lymph) angioendothelioma;

malignant hemangiopericytoma.

Tumors of synovial tissues:

Mature, benign:

benign synovioma.

Immature, malignant:

malignant synovioma.

Tumors of the mesothelial tissue:

Mature, benign:

benign mesothelioma.

Immature, malignant:

malignant mesothelioma.

Tumors of peripheral nerves:

Mature, benign:

neurinoma (schwannoma, neurilemmoma);

neurofibroma.

Immature, malignant:

malignant neuroma;

Tumors of the sympathetic ganglia:

Mature, benign:

ganglioneuroma.

Immature, malignant:

neuroblastoma (sympathoblastoma, sympathogonioma);

ganglioneuroblastoma.

Teratoma.

In addition to soft tissue tumors, non-epithelial tumors include neoplasms from melanin-forming tissue, as well as bone, which are divided into bone-forming and cartilage-forming: of them mature, benign - chondroma, osteoma, immature, malignant - chondrosarcoma, osteosarcoma.

Non-epithelial tumors also include tumors of the central nervous system:

Neuroectodermal

Tumors of the meninges

Mature, benign fibroblast tumors

DIAGNOSTICS Childhood tumors are especially difficult in the early stages. In practice, the diagnosis is made only when it caused certain anatomical and physiological disorders, which is manifested by subjective complaints and objectively determined symptoms. At the beginning of their development, tumors are so latent that it is usually impossible to catch this moment clinically, and a truly early diagnosis in oncology is extremely rare. Recognition of tumors in children is additionally hampered by the absence of clear complaints that the child is not able to formulate.

Detection of malignant tumors in children is more successful when it is carried out in a complex way - by a clinician, radiologist, endoscopist, ultrasound specialist and pathologist. Some value is also noted for other research methods, for example, laboratory, radioisotope research, etc.

The role of the pediatric clinician or pediatric surgeon, who is the first to examine the patient and directs the thought of other specialists along the right or wrong path, is very responsible. The latent course and uncertainty of manifestations of tumor growth at the beginning of the disease make it very difficult to differentiate from other more frequent and typical diseases. To avoid mistakes already at the first clinical trial a sick child, the diagnosis of a malignant tumor should be included in the number of possible suspected diseases and rejected only after reliable evidence of the non-tumor nature of the process.

The clinician usually has two options:

1) when the presence of a tumor is detected immediately and

2) when the tumor cannot be detected by physical methods of examination.

TREATMENT is based on the general biological patterns of the course of tumors in children. This takes into account the localization, histological type, the correspondence of morphological malignancy to the clinical course (the ability of some tumors to develop rapidly, others to become mature benign ones), duration clinical manifestations And general state child.

The main methods of treating tumors in children are surgery, radiation therapy and chemotherapy. The arsenal of therapeutic measures may also include: a general regimen and, if possible, the maximum creation of normal living conditions (study, games, etc.), proper diet, vitamins, antibiotics, antipyretics and restorative therapy. Transfusion of blood products is carried out according to strict indications.

The choice of treatment method is determined by the nature and prevalence of the tumor process, the clinical course and the individual characteristics of the child. Treatment is carried out according to a pre-planned plan by any one method or combined with the definition of the entire course of treatment, i.e. dosages, rhythm, duration and sequence of certain therapeutic measures.

SURGICAL TREATMENT

The main treatment for tumors in children, as in adults, is surgery. The operation is performed without delay, but after all the necessary research and preparation of the child to reduce the risk. Children, in contrast to adults, tolerate operations well, and the so-called inoperability of the child due to a general weakened state rather speaks of the weakness of the surgeon. Surgical interventions for tumors require compliance with two important conditions. The main thing is the radical nature of the operation, the scale of which must be thought out in advance and ablastic. Partial excision of malignant tumors or their "husking" entails the continuation of the growth of the residual tumor at a more rapid pace or the occurrence of a relapse, in which the chances of a radical re-intervention are sharply reduced. To achieve greater ablastics, an electrosurgical method is used to excise malignant tumors.

An important provision is the mandatory histological examination of all removed tumors in relation to their good quality. Rapid biopsy should be widely used during the operation in order to immediately subject to a wide excision of the bed of the removed tumor, if its malignancy is established.

RADIATION THERAPY

The second most important method of treating malignant tumors is radiation therapy (X-ray therapy or remote gamma therapy). According to modern settings, the following principles should be followed in the treatment of tumors in children.

1. Carry out radiation therapy according to very strict indications, trying, if possible, to replace it with another equally effective methods treatment.

2. Choose the method and technique of radiation therapy that are the most gentle for the surrounding normal tissues and organs (the use of hard radiation for the treatment of bone tumors, the protection of the spleen during irradiation of retroperitoneal tumors, etc.).

3. Combine radiation therapy with other drugs that inhibit tumor growth (cytostatic agents, hormones), since most tumors in children are relatively low radiosensitivity.

4. Choose doses of radiation therapy, taking into account the following two points:

a) the effect of irradiation is determined not by the age of the child, but by the biological properties of the tumor, the radiosensitivity of which is directly proportional to the growth rate and inversely proportional to the degree of cell differentiation;

b) radiosensitivity is proportional to the sensitivity of normal cells of the tissue with which the tumor is genetically linked. There are a number of exceptions that require individual selection of doses and irradiation rhythm. So, for example, mature hemangioma is better cured by radiation therapy than angiosarcoma. Effect in the treatment of tumors lymphatic system and neuroblastoma are the same, although lymphocytes are sensitive to radiation, and the nerve cell is not sensitive.

5. Strive to shorten the interval between irradiations as much as possible, since the absorption of rays by the tumor tissue is greater than that of normal tissue, and the latter recovers faster after radiation exposure.

Radiation therapy, usually, causes certain local and general reaction. In childhood, radiation reactions have their own characteristics.

but) Early reactions: local - in the form of erythema, at the same doses of radiation is less pronounced than in an adult, and proceeds more easily. The general reaction at children is observed rather seldom. However, sometimes already at the beginning of radiation therapy there is a danger of blockade of the kidneys due to the rapid absorption of protein decay products in highly radiosensitive tumors.

b) Intermediate reactions clinically little pronounced and latent, although in the future they can lead to severe disorders due to the selective sensitivity of some organs to radiation exposure (lung tissue, intestines, bone marrow and epiphyseal growth foci).

in) Late reactions come in 1-2 years and later, manifested locally by atrophy and induration of the skin up to radiation ulcers. This most often happens with repeated courses of X-ray therapy on areas such as the head, lower leg, and foot. As a result of radiation pneumonia, pneumosclerosis occurs; if the germ layer is damaged, shortening of the bones, etc. Relatively resistant to radiation exposure, endocrine organs, except for the thyroid gland and genital organs. The complexity of the use of radiation methods of treatment and their danger to the child's body require special rigor in compliance with technical conditions, doses and sparing of healthy organs and tissues.

Indications for radiotherapy in children are as follows:

a) the possibility of successful treatment of a neoplasm by a purely radiation method without surgery, provided that a morphological diagnosis is established using a biopsy;

b) a group of tumors prone to recurrence after surgical excision (embryonic rhabdomyosarcoma, liposarcoma);

c) with previously known technical difficulties that prevent radical surgical intervention.

DRUG TREATMENT OF TUMORS- chemotherapy and hormone therapy.

In recent years, chemotherapeutic agents from the group of alkylating agents (ThioTEF, sarcolysin, dopan, etc.) and antitumor antibiotics (chrysomallin, actinomycin D, vincristine, vinblastine) have been successfully used for Wilms tumors, retinoblastoma and rhabdomyosarcoma (L.A. Durnov, Sutow) . Methods of perfusion and intra-arterial infusion have been developed for the direct effect of massive doses of chemotherapy on the tumor. These methods are widely studied. However, long-term results do not confirm their great effectiveness, in particular, in sarcomas. This is mainly due to the lack of a chemotherapy drug that has a directed effect on the cells of mesenchymal tumors.

Most oncologists believe that medicinal treatment it is more expedient to use it as an addition to surgical or radiation treatment to influence not the main mass of the tumor, but individual tumor cells and complexes circulating in the blood - potential sources of metastases.

From hormonal drugs in children, steroid hormones (prednisolone) are used in the treatment of lymphogranulomatosis, leukemia in combination with chemotherapy or radiation therapy.

At the present stage, methods of combined and complex treatment tumors, which equally applies to pediatric oncology. This direction pursues the goal of maximum use of surgical and radiation effects on the local tumor focus, supplemented by general antitumor therapy with cytostatic and hormonal drugs.

PREVENTION tumors of childhood is based on three provisions:

1) identification of family predisposition to certain forms of tumors (retinoblastoma, osteochondroma, neurofibromatosis);

2) antenatal protection of the fetus - the elimination of all kinds of harmful effects (chemical, physical, radiation and others) on the body of a pregnant woman;

3) removal of benign tumors, which are the background for the development of a malignant neoplasm, namely nevi, neurofibromas, osteochondromas, teratomas; elimination of foci of chronic inflammation and scars.

FORECAST

Judgment about the prognosis is possible only if the data of the histological examination of the tumor and its clinical course. Some morphologically malignant tumors are not always fatal. At the same time, the localization of fully mature benign tumors in the brain or other vital organs can be fatal.

Such a seemingly leading factor as early treatment initiation does not always determine a favorable outcome. At the same time, there are observations of good results with very common tumors.

The biological features of tumor growth in childhood - the susceptibility of various age groups to various types of tumors, the role of physiological and metabolic processes and hormonal influences - are important for determining the prognosis. Ewing put forward the thesis that an acute decrease in the frequency of malignant tumors, characteristic of children of 8-10 years of age (“presex”), is a fact of fundamental biological significance, suggesting that the causative factors of early childhood have become obsolete and new conditions for the emergence and development of children should be expected. new types of tumors. Consequently, in children, by all means, life should be extended even in the incurable stage, counting on the inclusion of the biological defenses of the body.

Vascular tumors

The most common benign tumor in children are hemangiomas, which occur, according to some authors, in 10-20% of newborns. Most of them disappear on their own, and some grow rapidly and threaten the child with significant cosmetic defects.

Hemangiomas are often called the whole spectrum of vascular tumors (true hemangiomas) and various vascular dysplasias (false hemangiomas), although sometimes the border between them is really difficult to draw.

Hemangiomas- true vascular benign tumors that develop and grow due to the proliferation of the vascular endothelium, in which mitotically dividing cells are histologically determined. However, these tumors, unlike other benign neoplasms, have locally infiltrating growth, sometimes very fast, although they never metastasize. They are determined already at birth, sometimes appear in the first weeks of life. Their predominant localization is the skin and subcutaneous tissue of the upper parts of the trunk and head. Some of them grow with the child, and some grow much faster and pose a threat of formation of huge cosmetic defects on the face, leading to visual and hearing impairments. Occasionally, hemangiomas of internal organs (liver, spleen) and bones occur.

table Classification of vascular tumors and dysplasias

Capillary hemangiomas are found mainly on the skin, their favorite localization is the face, especially in girls. They are bright crimson (sometimes with a cherry tint) spots with clear boundaries, rising above the surface of the skin. They usually grow without overtaking the growth of the child, over time, whitish spots of fibrous tissue appear in their center, which increase towards the periphery, and gradually the hemangioma disappears, leaving areas of pale atrophic skin, which subsequently cease to differ from the surrounding skin. Self-healing is subject, according to various authors, from 10 to 95% of capillary hemangiomas. It takes place over two or three years. If the hemangioma is rapidly increasing in size, then the question of starting treatment is raised.

The task of the pediatrician and pediatric surgeon is to monitor the growth rate of the hemangioma in size. At the first visit to the child, the doctor makes a contourogram of the tumor on a plastic film and controls the growth dynamics. If the tumor does not outstrip the growth of the child, you can not rush to start treatment. If whitish spots appeared in its center, increasing in size and merging with each other, then this indicates the beginning of the reverse development of the tumor. In the case of a rapid increase in the tumor, the question of its surgical treatment should be raised.

There are many ways to treat hemangiomas. the most radical and fast way- surgical removal. The operation is undertaken with the localization of hemangiomas in the region of the trunk and extremities. With its localization in the area of ​​​​the face, where surgical intervention threatens with cosmetic defects, resort to other methods of treatment.

Method of short-focus X-ray therapy.

Sclerosing therapy is the introduction of 70 ° alcohol into the hemangioma, which causes aseptic inflammation in it and gives rise to scarring. For tumors of a large area, alcohol is injected at several points, sometimes several times.

Cryotherapy - tumor freezing liquid nitrogen using special cryoapplicators of various shapes and sizes. Previously, cryotherapy with carbonic acid snow was used, but at present it has been abandoned, since it leaves rather rough scars after healing.

Electrodestruction and electrocoagulation of tumors.

Laser therapy on the tumor area.

Capillary hemangiomas are sometimes complicated by ulceration, ulcers can suppurate and bleed. Their treatment is usually conservative: the ulcerated surfaces are treated with antiseptic solutions and then ointment antiseptic dressings are applied to them. Ulcer healing usually speeds up the onset of hemangioma scarring.

Cavernous hemangiomas are much less common than capillaries. They consist of blood cavities of various sizes communicating with each other, lined with endothelium. These hemangiomas are located in the subcutaneous tissue and have the appearance of a soft bulging tumor-like formation, which is easily squeezed and immediately after its completion takes the previous shape (a “sponge” symptom). Often they shine through the skin, giving it a bluish color. These hemangiomas are found in internal organs and bones. These hemangiomas rarely self-heal. The most effective way to treat them is surgical excision. If it is not possible to implement it (very large tumor sizes, critical localizations), sclerosing therapy is carried out in combination with cryodestruction, sometimes with microwave cryodestruction. With gigantic sizes of hemangiomas, embolization of the tumor vessels is carried out under angiographic control before carrying out the above therapeutic measures.

Branching hemangiomas are rare. They are a "tangle" of non-dilated vessels, usually located in the muscles that it deforms. Their treatment is only surgical. The diagnosis is usually established on the operation undertaken for a soft tissue tumor.

Capillary and cavernous lymphangiomas occur as tumors of the subcutaneous tissue. They don't disappear on their own. their treatment is only surgical. At the operation, macroscopically, they are difficult to distinguish from adipose tissue, although in the cavernous variant, their release is accompanied by the outflow of a significant amount of lymph. Since it is impossible to pinch or bandage the lymphatic vessels that feed them, lymphatic leakage from the wound continues for some time after the operation. With non-radical removal of the tumor, there may be a relapse. The diagnosis is confirmed by histological examination of the removed preparation.

Cystic lymphangiomas are usually localized on the neck and in the submandibular region and are already present at birth. They sometimes reach a gigantic size, commensurate with the head of a born child, occupy the entire lateral surface of the neck, the submandibular region, and can spread into the mediastinum. Macroscopically, they consist of large and small cysts filled with lymph. Sometimes they cause a violation of the patency of the pharynx and larynx and require an emergency imposition of a tracheostomy and feeding through a tube. Their treatment is only surgical and consists in the possible radical excision of the tumor. This is sometimes very difficult, since it sprouts the bottom of the mouth, and sometimes the tongue, is in a complex relationship with the large vessels of the neck and its organs.

Hemlymphangiomas, which treated only by surgery before surgery are regarded as hemangiomas. Only when histological examination removed preparation, it is established that the tumor is mixed.

Flat angiomas tumors in the exact sense of the word are not. This is one of the types of capillary dysplasia, which is a dark red spot of irregular shape, with clear boundaries, not rising above the surface of the skin. When pressed with a finger, it turns pale under it, but as soon as you remove your finger, it immediately takes on the same color. Flat angiomas are usually located on the face and therefore are a cosmetic defect, they do not pose a threat to life and health. Their treatment is inappropriate since any methods leave a scar that is no less cosmetically flawed in place of the stain.

Medial spots are flat angiomas located in infants along the midline of the head: in front - above the bridge of the nose, behind - in the occipital region. Treatment is not required since they always disappear spontaneously from the front, they almost do not disappear from behind, but are covered by a growing hairline.

"Wine Stains" resemble flat angiomas, but, unlike them, rise above the skin, have an uneven surface, sometimes with warty formations on it. They have developed fibrous tissue and therefore they usually do not completely blanch when pressed. They are sometimes called vascular nevi. Cosmetic damage with them is much more significant than with flat angiomas, because sometimes it is advisable to excise them with the replacement of the defect with a free skin flap.

Telangiectasias sometimes called stellate hemangiomas. They are vascular "asterisks" with a punctate vessel in the center, running perpendicular to the skin, from which thin vessels extend radially in all directions in the form of rays. They are located on the face, sometimes spontaneously disappear. In chronic hepatitis and cirrhosis, they appear on the skin chest and shoulder girdle. Their treatment is carried out only for cosmetic purposes and consists in diathermocoagulation of the central vessel with a needle electrode, after which the entire “asterisk” disappears.

Pyogenic granulomas usually occur at the site of minor skin lesions, on which excess granulation tissue quickly grows with a large number of capillaries. It has a mushroom shape with a narrow stem. They are also called pyococcal granulomas. A purulent exudate is released from the bleeding surface of the granuloma, often with an unpleasant odor. Treatment - operational: removal by excision or electrocoagulation of her legs. With non-radical removal, the granuloma may recur.

The most common venous dysplasia in children is aneurysm of the internal jugular veins. It is often bilateral and looks like an oval-shaped protrusion on the neck, in front of the sternocleidomastoid muscle, which occurs with straining, coughing, physical effort, crying. As soon as the tension stops, the protrusion immediately disappears. Over time, it increases in size and appears even when talking, singing. There are no other complaints. The treatment is surgical and is carried out for cosmetic reasons. It consists in isolating a vein and wrapping it outside with alloplastic material or auto-fabric.

Varicose veins may appear as early as childhood. But in children it never leads to venous insufficiency and trophic disorders on the limbs, because operations on this they have do not produce. It is recommended to constantly wear elastic stockings, use Troxevasin-gel with simultaneous oral administration of Troxevasin capsules.

Angiomatosis are widespread growths of tissue, identical to cavernous hemangiomas, along the superficial veins of the extremities, which are usually also dilated. It is sometimes found on the trunk, it also happens in the internal organs. On the extremities, the defect leads to an increase in venous insufficiency and trophic disorders of soft tissues, which increase after the addition of thrombophlebitis. Treatment consists in the removal of dilated veins along with angiomatous growths, altered skin and soft tissues. mi. Before the operation, it is necessary to verify the patency of deep veins using phlebography.

Common forms of angiomatosis with an increase in the volume of the limbs, multiple hemangiomas and pigment spots on the skin occur when combined with aplasia or hypoplasia of the deep veins of the limb - Klippel-Trenaunay syndrome. Its diagnosis is confirmed by phlebography, in which the absence of segments of the deep veins of the limb or their sharp narrowing is found. Treatment is surgical and is aimed at restoring blood flow through the deep veins. most often by replacing them with an autovenous graft from another limb.

Purely arterial dysplasias do not occur. They can only be combined with venous dysplasia in the form of congenital arteriovenous fistulas (shunts, communications) - parkes-weber syndrome . Through them, arterial blood, bypassing the microcirculatory bed, enters directly into the veins. The severity of clinical manifestations depends on the width of arteriovenous anastomoses. Stealing blood flow in the microvasculature leads to the rapid development of trophic disorders of soft tissues. An increase in pressure in the veins is clinically manifested by pulsation in them and leads to their sharp varicose expansion, and an increase in blood flow through them leads to an overload of the right heart.

Arterialization of venous blood leads to accelerated growth of bones and the limb as a whole. Sometimes the difference in limb length reaches 15 cm or more. On palpation of the limb, an increase in its temperature is noted, and near the shunt, vascular tremor is felt by the hand, which, during auscultation, is heard as a coarse systolic-diastolic murmur. The diagnosis is confirmed by arteriography of the limb, in which there is no capillary phase; from the arteries, the contrast enters immediately into the veins, which are sharply dilated. Functional research methods show an acceleration of arterial blood flow and an increase in the oxygen content in venous blood.

Surgical treatment consists in the skeletonization of arteries and veins and their separation. The operation is extremely traumatic and difficult. Sometimes a limb has to be amputated. Promising is the development of a method for endovascular occlusion of arteriovenous fistulas.

Dysplasia of the lymphatic vessels manifested by the so-called lymphatic edema, which is less in the morning and increases in the evening. In severe forms of dysplasia, edema reaches sizes described as elephantiasis (elephantiasis) of the limbs. More often affected lower limbs, in boys, the genital organs are sometimes involved in the process. Long-term edema leads to development in soft tissues fibrotic changes fiber, as a result of which the volume of the limb ceases to decrease overnight. "Soft" edema turns into "hard". Dystrophic phenomena on the skin contribute to the easy attachment of erysipelas, each of which exacerbates the violations of lymphatic drainage and causes an even greater increase in the volume of the limb.

The increase in the size of the limb occurs mainly due to the thickening of the subcutaneous tissue. Surgical treatment consists in a phased or simultaneous excision of the subcutaneous tissue. In the stage of "soft" edema, the imposition of lymphovenous anastomoses using microsurgical techniques is promising.

Pigmented nevi

Congenital pigmented nevi, relatively often observed in children, are classified as benign tumors. They are formed from special cells containing the pigment melanin. In rare cases, pigmentless nevi occur.

Classification by histological structure:

borderline nevus

intradermal nevus

mixed

The origin of nevi is associated with the vicious development of the neuroectoderm.

Clinical picture. Localization of nevi is different. Most often they are located on the face and neck, less often - on the limbs and torso. Their size can reach gigantic proportions. The color of the spots can vary from light yellow to slate black, which is determined by the level of melanin content.

A special variety is the blue nevus, the color of which is determined by the deep location of the pigment clusters. Nevi usually protrude somewhat above the surface of the skin, are densely covered with hair or are areas of pigmented smooth skin, may have dense rounded inclusions or papillomatous and warty growths.

Congenital pigmented nevi increase gradually, according to the growth of the child. Their course is usually benign and before puberty, malignancy (transition to melanoma) is not observed.

Basically, they bring a cosmetic defect during this period, being located on the face and open areas of the skin. In rare cases, they can be injured, ulcerated, inflamed.

differential diagnosis.

Freckles, unlike nevus, they arise due to congenital excessive deposition of pigment in limited small areas of the skin. They increase and darken under the influence of solar radiation and become hardly noticeable in winter.

moles, appearing during the first 3-5 years of a child's life, they do not have tumor cells and can disappear on their own. The difference from the nevus is established only histologically.

Disseminated nevus also occurs after birth, tends to disappear and never degenerates into a malignant tumor.

Mongolian spots- are rare, characterized by a single localization and a peculiar color.

Indications for surgical removal of a nevus:

cosmetic defect

the location of the nevus in places of increased trauma

the location of the nevus in places of high insolation

prone to inflammation and ulceration

prone to rapid progressive growth

tend to change color to a darker

Absolute indication for surgery- suspicion of malignant degeneration or the inability to differentiate these tumors.

Operation. The choice of methods of surgical treatment is individual. Depends on the size of the nevus, its localization and the condition of the surrounding tissues. In all cases, the pigmented tumor is excised with a skin area with a thin layer of underlying fiber.

Nevuses can be removed simultaneously with the subsequent closure of the defect by one or another method or by multi-stage partial marginal excision with gigantic sizes.

Relapses of nevus in children in the long term are generally not detected. Cosmetic results usually improve with age.

Wilms tumor in children

Nephroblastoma (Wilms' tumor) is a highly malignant embryonic kidney tumor and belongs to congenital neoplasms. This group also includes embryonic rhabdomyosarcoma, hepato-, retino-, neuro- and medulloblastoma. They are united by the fact that they arise as a result of violations of embryonic tissues.

In the structure of oncological morbidity, nephroblastoma makes up 6-7% and occupies the second place among solid neoplasms in children under the age of 14, yielding in frequency only to tumors of the central nervous system. Approximately 25,000 cases of this pathology are registered annually in the world. . In Belarus, the incidence is 7.5 per 1 million people under the age of 15, which is in line with the global average.

The genetic model for the development of Wilms' tumor was proposed by A. Knudson in 1972. Nephroblastoma occurs as a result of two consecutive mutations in regions of homologous chromosomes that are responsible for the normal formation of the urinary system. The first mutation can be inherited from parents with germ cells or arise independently under the influence of adverse factors. The second mutation, which appears during the development of the kidney, leads to the appearance of a neoplasm. This genetic mechanism explains the rare occurrence of Wilms tumor, as well as the reason for its association with congenital anomalies in children. Indeed, with nephroblastoma, aniridia, hemihypertrophy, malformations of the urinary organs (cryptorchism, hypospadias, gonadal dysgenesis, pseudohermaphroditism, horseshoe kidney) are often observed. A. Knudson's theory was confirmed: the most common aberration in nephroblastoma tissue was established - a deletion in the short arm of the 13th pair of chromosomes. The altered region was named the Wilms tumor gene. It is an anti-oncogene, i.e. during its normal functioning, a neoplasm does not occur, and in the case of damage to the gene, the cells, losing control, acquire the ability to divide indefinitely.

The urinary system develops from the intermediate mesoderm of the early embryo. In this case, three kidneys are successively formed: pronephros, mesonephros, metanephros (permanent kidney). Wilms' tumor is formed due to uncontrolled proliferation of a permanent kidney blastema that appears during the 5th week. embryonic development fetus . Metanephrogenic blastoma gives rise to two types of tissue:

mesenchymal and epithelial, from which the glomerular and tubular apparatus of the kidney is subsequently formed. Accordingly, blastema, mesenchymal and epithelial components are distinguished in nephroblastoma. The histological variant of the tumor is determined by the ratio of these tissues. The morphological conclusion is very important for establishing the scope of therapy. The most intensive treatment is indicated for high degree tumor malignancy. In addition to this factor, an important role in predicting the course of the tumor process has its primary distribution - the stage of the disease, which determines the radicalness of the surgical intervention. Nephroblastoma is characterized by all types of dissemination: invasion into surrounding tissues, lymphogenous pathway through the vessels (para-aortic, paracaval lymph nodes), hematogenous pathway through the blood to distant organs (lungs, liver, bones, brain, etc.). The most favorable prognosis occurs when complete removal of the primary focus (stages I-II) is possible. The worst outcome is expected in patients with distant metastases (stage IV).

Currently, worldwide preference is given to an integrated approach, including nephrectomy, chemotherapy and radiation therapy. The concept of complex treatment was formed gradually. Therefore, comparing the results in historical terms allows us to evaluate the contribution of each method. If one nephrectomy allowed to cure 10% of patients, then additional radiation increased this figure to 50%.

The role of chemotherapy is especially great in increasing the effectiveness of exposure. Currently, it is the same mandatory component as the operation. An integrated approach allows to increase the 5-year relapse-free survival up to 60-80%.

The first such programs began to be developed in the early 70s in the United States by the National Wilms Tumor Study (NWTS), whose activities continue to this day.

At the end of the 80s in Western Europe, under the auspices of the International Society of Pediatric Oncology (SIOP), generally accepted protocols for the treatment of Wilms' tumor were created.

In Belarus, the treatment of this pathology is carried out according to the modified NWTS and SIOP protocols. It begins with neoadjuvant chemotherapy (dactinomycin, vincristine). The main step is the operation. Further, dactinomycin, adriamycin, vincristine are used for 28 weeks, and irradiation is carried out according to indications. In stage IV and tumors of a high degree of malignancy, biotherapy, high-dose chemotherapy is prescribed.

The original development of the Research Institute of Oncology and Medical Radiology. N.N. Alexandrova is the use of biotherapy. Supplementation of the main complex with β-interferon made it possible to increase the long-term relapse-free survival of children with Wilms' tumor. In the Republican Scientific and Practical Center for Pediatric Oncology and Hematology, the drug is used for a high degree of malignancy of the neoplasm.

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Deontology

A doctor and a sick child, on the one hand, and that exorbitant grief that suddenly befalls parents who lose their beloved, sometimes only child, on the other. The doctor must understand the dramatic nature of the situation that has arisen, in which the behavior of a child who accepts everything like a child - both good and bad, his experiences that come not only from external influences, but also due to some extent to internal changes that are caused by the course of malignant process.

The smile of a child with cancer- this is not only evidence of an impending improvement in the condition, but also a wordless expression of the mutual contact that has been established between the little patient and the attending physician. And in how quickly such contact will be established, the decisive role belongs to the doctor.

Especially painful for a child of any age are the first days of stay in the hospital. Consciousness that the child is ill with something serious (especially in children of school age), fear of upcoming examinations, which increases significantly when communicating with their peers who have been in the clinic for a long time and are well aware of all therapeutic and diagnostic methods (sternal and spinal puncture , trepanobiopsy, puncture biopsy, intravenous injections etc.) - these are some of the external factors that "put pressure" on the child's psyche, making him withdrawn, lost in his thoughts and experiences.

In addition, the change of a home environment familiar to a child of any age to a hospital environment, separation from parents and close friends leave a certain imprint on the behavior of a sick child. In such a situation, one must not forget for a moment that a child is not a miniature adult, but a complex creature that requires a purely subtle and extremely individual approach.

Nothing causes negativism towards the doctor, like a gross deceit (a promise to be discharged home in a few days, not to conduct complex and sometimes painful studies, etc.), an indifferent attitude that diminishes the child's personality. In this regard, with young children it is even easier. The ability to quickly switch, "underestimate" the environment, caring and Attentive attitude surroundings allow the baby to quickly distract (but not forget it!) From the manipulation that just caused pain. Of course, the physical injury inflicted on a child during a particular study or medical procedure will be the less, the higher the qualifications and practical training of the doctor.

In some cases, with young patients, one has to go to forced deception in order to conduct the necessary research. But even in this situation there can be no template (when conducting repeated examinations), since the child remembers well the previously encountered situation in the treatment room, the preparation and conduct of the examination, even the position of the doctor preparing for this or that manipulation.

The most sparing tactics of the doctor in such a situation, especially if the medical procedure carried out brought significant relief and reduced the suffering of the child, it allows you to erase the line of fear that occurs in a child when crossing the threshold of the treatment room. In the practice of a pediatric oncologist, there were many cases when children with neuroleukemia themselves asked for repeated spinal punctures when the hypertensive syndrome increased and excruciating headaches resumed.

With patients of school age, adolescents, medical tactics change significantly. A school-age child who enters the clinic, "loaded" with his thoughts and experiences, immediately receives a stream of information from his peers, who have experienced all the "hardships" of the treatment room. Sometimes the doctor does not have enough time for the gradual psychological preparation of the student for the upcoming study. The need for the fastest possible diagnosis, the solution of urgent issues of therapeutic tactics do not allow postponing the necessary studies for several days.

In such a situation, a skillful, soothing and encouraging word, saturated with logical content about the need for a particular procedure, is decisive in overcoming fear. The principle of "influence of the personality" of the doctor is very important in establishing full contact with older children. If the child fully trusts the doctor, then he will agree to any procedure with the confidence that it is necessary for a speedy recovery.

Significant difficulties are encountered with repeated admission of a sick child to the clinic. The severity of the patient's condition associated with the progression of the underlying disease, significant "fatigue" from previous procedures, consciousness, and even greater fear (compared with primary studies) of repeated studies dictate the need for thorough "psychological asepsis" in such patients. The doctor's personal authority in such patients, which is further consolidated during systematic conversations with them on a variety of topics (not related, of course, to the discussion of the child's illness), deepens the mutual trust that is created between the doctor and the adolescent who has been observed for years.

We witnessed how the attending physician and the schoolboy who suffered for a long time Hodgkin's disease, played a game of chess "for a sternal puncture", the need for which was extremely burdensome for the child. Having lost the game, the boy, without a moment's hesitation, went to treatment room. Of course, the above example may, at first glance, seem dubious in ethical terms (the puncture would still be done, and in this situation, the doctor, who has unconditional advantages in the practice of the game, who knows the outcome of the game in advance, beats the teenager). Nevertheless, the very fact of such a mutually trusting approach largely characterizes the depth of the relationship that has developed between the doctor and the patient.

The word of a doctor who has authority over a child is of great importance. This is especially evident in clinical rounds. The ability of a doctor to use a word that inspires confidence in a speedy recovery is the best emotional stimulus for a child. At the same time, an inadvertently expressed doubt in the presence of a child, uncertainty of intonation, confusion can cause irreparable damage to the relationship between the child and the attending physician.

A doctor who has been working with cancer patients for a long time, more than once had to marvel at the courage of his little patients. The eye of a child does not miss anything, he notices everything. The transfer of a roommate to an isolated room does not externally affect the child. He continues to play and smile, but he knows very well that his comrade has become worse, and therefore he had to be isolated. With what maternal tenderness and care children treat their comrades, who, due to a number of circumstances, are on bed rest!

The children's oncology clinic is full of tragedies that can happen at any moment. Sometimes it happens that the tragedy is played out suddenly, in front of many children. But in no case did we have to (and did not have a reason to) explain to the teenager the reason for the irrevocable absence of his comrade among the children of the clinic. Such courage of children, like nothing else, helps to maintain vitality, is the incentive to work that an oncologist needs.

The next, no less important section of deontology is This is the relationship between the doctor and the parents of a sick child.. Any of his illness is a "torment of the soul" for parents, not to mention cancer. In this regard, the parents of a sick child should be treated with particular care. We often had to meet with parents who received a direct, disappointing answer from doctors in some medical institutions to the question of the final diagnosis and prognosis of their child's illness. The whole drama of the disease turns into a "pitch hell" for parents.

In such a situation, we see before us people who have already lost faith in the recovery of the child. Unfortunately, as often happens, the constant feeling of the possible loss of a beloved child, which sometimes persists in the minds of parents for many years, causes irreparable harm not only to the parents themselves, but also to the sick person, close relatives and, of course, clinic doctors. In this case, the active assistance necessary for the doctor in the struggle for the life of the child runs into a passive expectation of inspired hopelessness.

Regardless of the level of intellectual development, the degree of awareness in a particular area of ​​medical knowledge, parents from the first days of the child's stay in the clinic are interested in only one question: the final diagnosis and the doctor's frank opinion regarding the prognosis of the disease. The most responsible is the first meeting of the doctor with the parents of a sick child. There is no need to say that the doctor must be in "full readiness" for the upcoming conversation in advance. The doctor's tact, his ability to correctly, in the right direction to conduct a conversation with parents, not allowing hasty conclusions (although the final diagnosis is already known to the doctor), create the favorable background on which relationships are based.

Diagnostics

Follow-up meetings are also no less challenging, as they cover future research and treatment options. The terms "sternal puncture", "lumbar puncture", "puncture biopsy", etc., are associated by many parents with interventions that cause even more harm to an already seriously ill child. A patient explanation of the need for these studies (without which, of course, a modern oncological clinic cannot do) always gives a positive result.

Issues of prognosis of the disease, as a rule, are increasingly discussed already in the process of ongoing treatment. In this regard, time is of great help to the doctor. In the process of conducting modern polychemotherapy for acute leukemia, in most cases there is a rather rapid positive clinical effect, although hematological parameters continue to reflect the acuteness of the leukemic process. Explanation to parents in an accessible form of these provisions allows them to hope that the ongoing therapy is effective, and the prognosis of the disease is favorable.

Significant reinforcement of the parents' hope for a favorable immediate outcome of the disease are also clinical examples from the experience of treating patients with a similar disease. The reference to the possible emergence of new, even more effective anticancer drugs, the improvement of treatment tactics, the successes achieved in recent years in the treatment of such patients make it possible for parents to realize the need to be patient and continue an active struggle for the life of the child.

Despite the apparent success in treatment, parents often have doubts about the correctness of the diagnosis and therapy. They make attempts to organize repeated consultations, consultations, analyzes, etc. The task of a highly qualified doctor who subtly understands the specifics of his profession, and therefore devoid of selfish prejudices, is to fully contribute to this quite understandable desire of parents. Such consultations contribute to an even greater increase in the authority of the attending physician.

The period of discharge of the child home is very responsible in the oncology clinic.

Indeed, in essence, almost the same active therapy should continue at home, where the role of the attending physician largely falls on the shoulders of the parents. If in such a situation the doctor sees a particle of himself in each of the parents, then he can confidently count on strict adherence to all recommendations for further therapy.

The period of the child's stay in the clinic (and it can be quite long) involuntarily contributes to the fact that certain mutual contacts are also established among the parents. If at the very beginning they concern a discussion of the condition of children, treatment, ongoing additional research, then in the future the range of issues discussed by them expands significantly. Such a connection is maintained even after the children are discharged from the hospital and is supported by letters, telephone conversations and personal meetings. Everything that a parent learns about the "new" treatment (from relatives and acquaintances, from popular science literature, radio and television broadcasts, etc.) very quickly becomes common property. At the same time, thoughts involuntarily arise about whether their child was treated correctly, whether they were sufficiently modern methods, and why this treatment regimen was applied to their child, and not another, etc.

All this flow of questions falls on the doctor at the first outpatient appointment, in the first letter or telephone conversation. Undoubtedly, every question asked requires an exhaustive answer. However, in our opinion, there is nothing more convincing than a good example. In this regard, the correct selection of patients invited for a follow-up examination in the clinic is of great importance. Parents of a recently discharged child must certainly get an appointment together with a "long-liver". The emotional psychological charge received at such a reception will serve as a clear illustration of modern possibilities in the field of treatment, as well as a critical review of the doubts that have arisen.

Unfortunately, the close relationship between parents has and negative sides. It often happens that parents learn about the tragic outcome of the disease before doctors. However, properly structured work with parents contributes to the fact that this extremely difficult news is perceived by them more often without connection with their own child. The belief that it is their child who will be among those recovering, and, in addition, the belief that further progress will be made in the treatment of these diseases, is a protective barrier, a protective inhibition in the perception of the news received.

As you know, in some children, an exacerbation of the disease occurs at different times, which introduces new, even greater difficulties in relationships with parents. These difficulties are due to the fact that with the onset of an exacerbation of the disease, the parents lose the main thing that was acquired with such great difficulty - the hope for the complete healing of the child. During this period, more than ever, all the actions of a doctor must obey the principle of humanism. The observance of this principle during the entire period of illness, no matter how long it may be, will allow the parents of the deceased child to realize that they, on their part, and the attending physician on theirs, have done everything in their power in the hardest struggle for the maximum extension of the life of a sick child. . Modern methods of treatment of malignant tumors in children allow the majority of children to recover. However, this is a difficult and long way, even with the use of the most modern treatment programs, where the basic method is the use of combinations of chemotherapy drugs. The real achievement of the ultimate goal - the complete cure of the child from oncological diseases- largely due to the strength and reliability of the connections of a kind of triangle, the top of which is a sick child, and its corners - a highly qualified doctor - a pediatric oncologist, on the one hand, and the parents and relatives of the child - on the other.

Rehabilitation

Psychologically, the patient has no life experience; his worldview has not yet settled down, as well as his attitude to the environment; the psyche is extremely vulnerable. In our age of acceleration, rather early developing anatomical and physiological functions, although far from mature, come into conflict with an even less mature psyche. A child is largely dependent on others, especially parents. All this should be taken into account when carrying out rehabilitation activities.

Children with a high degree of anxiety relate to their appearance and internal state. The presence of visible and significant internal damage can cause mental disorders and even serious mental illness.

Rehabilitation is closely intertwined with deontology. Good relationships between a doctor, a sick child, his parents create Better conditions for rehabilitation. The entire experience of pediatric oncologists teaches that the achievement of good treatment results depends not only on therapeutic measures, but also on the relationship of the child with the doctor, the ability of the latter to inspire hope in the child and his parents.

The principles of rehabilitation in relation to a child suffering from a malignant tumor can be formulated as follows.

1. Rehabilitation should begin when a diagnosis is made, because the doctor's mental influence should be effective already at the first meetings with the child and his parents.
2. It is necessary to carry out rehabilitation measures constantly, ensuring their continuity even in cases where the child is outside the hospital.
3. Rehabilitation should be comprehensive and aimed both at restoring anatomical and physiological functions, and at the psyche of the child and his parents. For this purpose, specialists of various profiles (psychologists, methodologists of physiotherapy exercises, teachers, educators, etc.) should be involved in the work.
4. It is important to ensure a combination of individual and collective in the system of rehabilitation activities. In this case, the proportion of one or another component depends on the personality of the sick child (and his parents).
5. The return of a sick child to the team must be prepared. Educators should be aware of the illness of the child and provided with recommendations for handling it. In any case, it is impossible to single out a child with a tumor in the team, emphasizing his special position among healthy children. The duties of a teacher and educator are to ensure as much as possible a normal attitude towards him from those around him.

Rehabilitation in pediatric oncology should be designed for a much longer period. Unlike adults, a child has a long life ahead of him, in which he must acquire a profession, start a family, raise children, that is, be a full-fledged person. The task of the doctor and the purpose of the rehabilitation measures he takes is to bring the child to a full-blooded life, removing as many obstacles as possible on his difficult and long path.

In the process of treatment, the doctor must choose the most rational methods that, ceteris paribus, can give minimal complications and side effects. The study of programs for the treatment of malignant tumors in children is currently aimed at finding such methods. It should be pointed out that many mutilation operations that are performed in adults are not necessary in some cases in childhood due to the high sensitivity of most neoplasms in children to radiation and drug therapy.

Mental rehabilitation, as we have already indicated, is interconnected with deontology and begins from the moment a diagnosis of a malignant tumor is established. Already during this period, the child (of course, we are talking about children of school age) should be ready for many trials, but at the same time, believe in his recovery. The doctor's task is greatly facilitated by the fact that the child and adolescent are more suggestible and optimistic than adults. However, it should be borne in mind that children have less will and life experience than adults, and many issues have to be resolved for them. Children should not feel even the slightest inferiority. It is necessary to instill in them the confidence that they are no different from their peers and can live life just like their comrades. By the way, the experience of pediatric oncologists teaches that the correct orientation of the child and adolescent allows him to ignore some anatomical and physiological losses.

In no case should a sick child be singled out in a family where there are other children; the attention of the family should be equal for all - the sick and the healthy. This is the art of the educator, parent and doctor.

Discharging a child from a hospital, the doctor should talk with the parents, and preferably with the teachers of the school or kindergarten so that in the presence of certain defects caused by illness and treatment (amputation, enucleation, alopecia, etc.), teachers find the most reasonable manner of behavior and treatment of a schoolchild or a young child. The "invisibility" of this relationship is the most tangible help to the child. The behavior of others should be guided not by pity, but by reasonable support.

In the process of treatment, children should periodically interrupt their studies, attend kindergarten, break away from their families and homes. In such cases, it is necessary to provide teaching at home or in a hospital; this gives them additional strength in the struggle for life. But even in the hospital team, with the help of educators, teachers, psychologists, and, first of all, doctors and nurses, it is necessary to create such an environment so that the child feels as little as possible his isolation from his family, school, and comrades.

The importance of the so-called cosmetic rehabilitation. Many children who receive radiation and drug treatment go bald. Usually they take it very hard, especially girls. It is necessary to convince the child that this phenomenon is temporary (it is even better to cite children whose hair has recovered as an example). In many cases, depression, which often occurs in older bald girls, can be relieved by the temporary use of wigs.

Children are very painful (sometimes stronger than adults, up to the phenomena of dysmorphism) for all defects on the face that occur after various operations for tumors located in the head and neck (resection of the jaw, enucleation). In such cases, it is necessary to carry out prosthetics as early as possible, modern methods of which allow obtaining good cosmetic results.

Mental rehabilitation is closely connected not only with deontology, but also with physical rehabilitation. It should be borne in mind that a pediatric oncologist deals with a growing organism, therefore, if possible, methods of operations and operative approaches should be chosen that take this circumstance into account.

Thus, the operation of replacing a removed bone with an endoprosthesis in children under 10 years of age is difficult, since the intensive growth of a healthy limb leads to a significant difference in their length, severe deformity, and the inability to use the endoprosthesis. True, a special endoprosthesis has now been developed that expands as needed, but it is still not perfect enough, so endoprosthesis replacement for children under 10 years old is not yet recommended. It is best to carry it out when intensive growth ends.

The complexity of prosthetics for children, in addition, is aggravated by the fact that prostheses have to be changed several times as the patient grows, but children cannot be left without a prosthesis, since it is necessary not only for physical rehabilitation, but to a large extent for mental. At the same time, well-executed prosthetics serve as favorable psychological factor and for the children around. They see that a ward mate has a prosthesis, which he easily and successfully uses, and they go for such an operation with less fear. It must be constantly remembered that the most convincing for the child is a good example.

In the system of rehabilitation measures, an important integral part is an physiotherapy , which is applied not only in case of loss of a limb by children, but also for all patients treated for a malignant tumor. In specialized clinics of pediatric oncology (and not only in them), all conditions must be created for this. Physiotherapy exercises, improving the general condition of the child, prevent the development of many complications of the disease and treatment and correct the consequences various kinds therapy (scoliosis, chest deformity, etc.). Dosed physiotherapy exercises should be carried out even before the start of intensive treatment, in the postoperative period (breathing exercises, massage and other procedures) and be a mandatory event for a long time.

Recovered children who have reached reproductive age pose questions to the doctor about the possibility of having a child in the future. Rehabilitation also includes this problem. To prevent radiation castration, not only a rational method of irradiation is necessary, but also surgical protection of the ovaries (for this purpose, the ovaries are surgically moved and marked with tantalum clips), which allows for gentle radiation treatment.

Cured children are capable in the future not only of sexual activity, but also of the birth of normal offspring.

Rehabilitation in pediatric oncology is becoming increasingly important due to the increasing number of recovered children.

L.A. Durnov, G.V. Goldobenko

What is cancer? The human body is made up of trillions of living cells. Normal "good" cells grow, divide and die according to all biological canons. During the years of growing up, these cells divide more intensively, and later, upon reaching adulthood, they only make up for the loss of dead cells or participate in the healing process.

Cancer begins when individual abnormal cells in a particular part of the body begin to grow and multiply uncontrollably. This is the general basis for all cancers.

Childhood Cancer The growth of cancer cells differs from that of normal cells. Instead of dying according to the dictates of time, cancer cells continue to grow and give rise to more and more atypical cells. These cells have another most unpleasant ability: they penetrate into neighboring tissues, literally growing into them with their tumor "pincers".

But what makes cancer cells so aggressive? Damage to DNA - the brain of the cell, which determines its behavior. A normal cell, if something happens to its DNA, either repairs it or dies. In a cancer cell, DNA is not restored, however, the cell does not die, as it should normally. On the contrary, the cell, as if breaking off the chain, begins to produce cells similar to itself, absolutely unnecessary for the body, with exactly the same damaged DNA.

Humans can inherit damaged DNA, but most of the damage is due to a malfunction in the process. cell division or due to exposure to environmental factors. In adults, it may be some trivial factors, such as smoking. But more often than not, the cause of cancer remains unclear.
Cancer cells often "travel" to different parts of the body, where they begin to grow and form new tumors. This process is called metastasis and begins as soon as cancer cells enter the bloodstream or lymphatic system.

Different types of cancer behave differently from each other. Tumors come in different sizes and respond differently to a particular treatment. That is why children with cancer need treatment that is appropriate for their particular case.

How is cancer in children different from cancer in adults?

The types of cancer that develop in children are often different from those in adults. Childhood cancers are often the result of changes in DNA that occur very early, sometimes even before birth. Unlike cancer in adults, childhood cancer is not as strongly associated with lifestyle or environmental factors.

With few exceptions, childhood cancers respond better to chemotherapy. The child's body tolerates it better than an adult. But later, chemotherapy, as well as radiation therapy, can cause delayed side effects, so children who have had cancer must be under close medical supervision for the rest of their lives.

What are the key statistics on childhood cancer?

Cancer in children accounts for less than 1% of all cancer cases diagnosed annually in the world's population. Over the past few decades, the incidence of childhood cancer has increased slightly.

Thanks to the improvement of cancer treatment methods, today more than 80% of childhood cancer patients live 5 years or more. If we take, for example, the 70s of the last century, then the 5-year survival rate was only about 60%.

However, the survival of cancer patients is highly dependent on the type of cancer and a number of other factors. Cancer remains the second most common cause of child death after accidents.

The most common types of cancer in children

Leukemia

The term "leukemia" combines oncological diseases of the bone marrow and blood. It is the most common type of cancer in children, accounting for 34% of all childhood cancers. The most common leukemias are acute lymphocytic leukemia and acute granulocytic leukemia. Among common symptoms These conditions can be noted pain in the bones and joints, weakness, fatigue, bleeding, fever, weight loss.

Brain tumors and other tumors of the nervous system

This cancer accounts for 27% and is the second most common cancer in children. There are many different types of brain tumors, and their treatments and medical prognosis vary widely. Most of them begin in the lower regions of the brain, such as the cerebellum and brain stem. Typical clinical picture includes headaches, nausea, vomiting, blurred vision, double vision, disturbances in gait and fine movements. In adults, cancer often affects the upper parts of the brain.

Neuroblastoma

Neuroblastoma originates in the nerve cells of the embryo or fetus and manifests itself in newborns or infants, less often in children older than 10 years. The tumor can develop anywhere, but most often it occurs in the abdomen and looks like a small swelling. This type of cancer accounts for 7% of all childhood cancers.

Wilms tumor

Wilms tumor affects one or (rarely) both kidneys. It is found, as a rule, in children 3-4 years old. Like neuroblastoma, it manifests itself with the same swelling in the abdomen. May cause symptoms such as fever, pain, nausea and loss of appetite. Among other childhood cancers, Wilms tumor occurs in 5% of cases.

Lymphoma

Lymphoma is a group of cancers that start in specific cells. immune system- lymphocytes. Most often, lymphoma "attacks" the lymph nodes or other collections of lymphoid tissue (tonsils, thymus), as well as the bone marrow, causing weight loss, fever, sweating, weakness, and swelling of the cervical, axillary, and groin lymph nodes.

There are two types of lymphomas, both of which can occur in both children and adults: Hodgkin's lymphoma and non-Hodgkin's lymphoma. Each of them accounts for 4% of the total incidence of cancer in children. Hodgkin's lymphoma is most common in two age groups: 15 to 40 years of age and over 55 years of age. In this sense, non-Hodgkin's lymphoma is more common in children, which is more aggressive but responds well to treatment compared to similar cases in adults.

Rhabdomyosarcoma

Rhabdomyosarcoma affects muscle tissue. It can be found in the neck, groin, abdomen and pelvis, and in the extremities. Among all types of soft tissue sarcomas in children, rhabdomyosarcoma is the most common (3% in the overall picture of childhood cancer).

Retinoblastoma

Retinoblastoma is a cancer of the eye. In children, it occurs in 3% of cases, usually under the age of 2 years. It is detected by parents or an ophthalmologist due to the following feature: normally, when the pupil is illuminated, the eye appears red due to the blood vessels of the back wall of the eye, and with retinoblastoma, the pupil appears white or pink. This can be seen in the photograph as well.

bone cancer

Of this group of oncological diseases, osteosarcoma and Ewing's sarcoma are most common in children.

Osteosarcoma is most common in adolescents and usually develops in places where bone tissue grows most actively: near the ends of the long bones of the limbs. It often causes bone pain that worsens at night or with physical activity, as well as swelling in the affected area.

Ewing's sarcoma develops less frequently than osteosarcoma (1% vs 3%). Its most likely habitat is the bones of the pelvis or chest wall(ribs and shoulder blades), as well as the bones of the lower extremities.

Is it possible to prevent cancer in children?

Unlike adults, for children there are no lifestyle factors (such as smoking) that could contribute to the development of cancer. Scientists have linked only a limited number of environmental factors to childhood cancer that can cause cancer. One of them is radiation. And even then, in most cases, this applies to those cases where exposure to radiation is mandatory, for example, radiation therapy in the treatment of some other type of cancer (it turns out that they treat one cancer, thereby causing another). Therefore, if a child develops cancer, parents should not reproach themselves, because. prevent this disease is not in their power.

Very rarely, a child may inherit certain genetic mutations from their parents that make them susceptible to certain types of cancer. In such cases, an oncologist may recommend the so-called preventive surgery, when an organ in which a tumor is highly likely to develop is removed. Again, this is very, very rare.

Signs of Cancer in Children

Childhood cancer is sometimes very difficult to recognize, mainly because its symptoms overlap with many common illnesses and injuries. Children often get sick, often walk in bumps and bruises, and yet all these manifestations of the “golden childhood” can mask the early signs of cancer.

Parents should be sure that their child is getting regular health check-ups at kindergarten or school, and should carefully monitor for any unusual or persistent symptoms themselves. These symptoms include:

• unusual swelling or lumps;
• unexplained weakness and pallor;
• tendency to form hematomas;
• constant pain in a certain part of the body;
• lameness;
• unexplained and persistent fever and soreness;
• frequent headaches, sometimes with vomiting;
• sudden visual disturbances;
• rapid weight loss.

Most of these symptoms, fortunately, turn out to be a sign of some kind of infectious disease or injury. However, parents should always be on the lookout. And those children who inherited adverse genetic changes from their parents should be under vigilant medical and parental control.

Treatment of cancer in children

The choice of treatments for childhood cancer depends mainly on its type and stage (scale of spread). The treatment program may include chemotherapy, surgery, radiation therapy, and/or other treatments. In most cases, combined treatment is used.

With a few exceptions, childhood cancers respond well to chemotherapy. This is due to its tendency to grow rapidly, and most chemotherapy drugs act specifically on fast-growing cancer cells. Children generally recover better from high doses of chemotherapy than adults. The use of more intensive treatment options gives a greater chance of ultimate success, but at the same time increases the risk of short-term and long-term side effects. In this regard, the oncologist must do everything possible to balance the patient's need for intensive treatment with the possible risk of unwanted side effects.

Survival rates for childhood cancer

So, according to the statistics of the American Cancer Society, based on the information received for the period from 2002 to 2008. The 5-year survival rates in childhood cancer patients for the most common types of cancer are:

• leukemia - 84%;
• cancer of the nervous system, incl. brain - 71%;
• Wilms tumor (kidney cancer) - 89%;
• Hodgkin's lymphoma - 96%;
• non-Hodgkin's lymphoma - 86%;
• rhabdomyosarcoma - 68%;
• neuroblastoma - 75%;
• osteosarcoma (bone cancer) - 71%.

Of course, these indicators are generalized and cannot serve as the only source for estimates and forecasts in each specific case. Much is determined by the type of cancer, as well as factors such as the age of the child, the location and size of the tumor, the treatment received, and the responsiveness of cancer cells to it.

Subsequent side effects

The treatment of childhood cancer requires a special approach based on careful medical monitoring of the patient after treatment. After all, the sooner they are revealed possible problems the easier it will be to eliminate them. A patient who has overcome cancer, in any case, risks getting a number of delayed side effects associated with the transferred treatment. These negative effects may include:

• lung problems (caused by certain chemotherapy drugs or radiation therapy);
• growth retardation and physical development (including the musculoskeletal system);
• deviations in sexual development and possible infertility;
• problems associated with learning;
• increased risk of new cancer.