Most early signs of pediatric cancer are vague and typical of viral infections, injuries and other common conditions. So how do you spot potential early signs of cancer, do the appropriate workup and know when to refer?
The Pauline Allen Gill Center for Cancer and Blood Disorders at Children’s Health℠ is the largest childhood cancer and blood center in North Texas, treating 1,000 new patients every year. Kathleen Ludwig, M.D., Pediatric Hematologist/Oncologist at Children’s Health and Assistant Professor at UT Southwestern, answers top questions from primary care providers about the most common pediatric cancers: leukemia, lymphoma and brain and nervous system cancers.
Q: How do I distinguish between the early signs of pediatric cancer and common conditions?
The symptoms vary based on the type of cancer, but in general, you’re looking for symptoms that are:
- Persistent and worsening over at least a week, despite treatment
- Out of proportion to what’s considered normal for the child at their age
- Occurring in combination with other associated symptoms
This helps distinguish an infection or injury from the possible early signs of cancer that warrant further evaluation.
Common early symptoms of leukemia
Leukemia typically presents with all three of these symptoms:
- Easy bruising
- A new limp that isn’t associated with an injury
- Unexplained, persistent fever
The child may also have:
- Increased fatigue
- Paleness
- Newly enlarged spleen or liver
- Sudden weight loss
Because bruises are common for kids, particularly at a young age and/or if they play sports, like soccer, we encourage providers to take note of bruising in abnormal places, like their back or stomach. When the bruising is associated with the other typical symptoms described above, consider a leukemia evaluation.
Common early symptoms of lymphoma
Lymphoma presents with large lymph nodes that are very hard, matted and immobile, and progressively worsening over weeks despite antibiotics. If there are lymph nodes in the supraclavicular area, it should be an immediate red flag. These lymph nodes are generally considered malignant unless proven otherwise.
Like leukemia, lymphoma patients typically present with a constellation of symptoms, including:
- Increased fatigue
- Unexplained, persistent fever
- Newly enlarged spleen or liver
- Paleness
- Weight loss
Lymphoma can occur with a large mediastinal tumor. These patients typically are unable to lay flat on their back and have a persistent cough.
Lymphoma is much more common in teenagers than in younger children, although it can occur at any age.
Common early symptoms of brain and nervous system cancers
Brain and nervous system cancers present with neurological changes, such as:
- New unsteady gait or balance problems
- Vomiting in the middle of the night or early morning several times per week with headaches
- Sudden vision changes
Posterior fossa tumors, or skull base tumors, are the most common type of pediatric brain tumor. These usually cause obstructive hydrocephalus, which presents with chronic vomiting and headaches, particularly at night.
Q: What’s the appropriate workup if I suspect cancer?
A physical exam is an important first step to evaluate symptoms that point toward potential cancer.
Labs for leukemia and lymphoma
If you suspect leukemia or lymphoma after the physical exam, the workup should include:
- Complete blood count (CBC) test with differential
- Renal function tests that measure creatinine, uric acid and potassium levels
If the patient has symptoms of lymphoma and an associated mediastinal tumor, you can also do a chest X-ray if that’s accessible at your practice.
Labs and imaging for brain and nervous system cancer
If you suspect a brain or nervous system tumor after the physical exam, the next step should be a CT scan. The workup should also include renal function tests that measure creatinine, uric acid and potassium levels. When you refer to our clinic, we’ll do further imaging, such as an MRI of the brain and spine.
What if labs and imaging are normal?
Then it’s likely the child’s symptoms are caused by a persistent viral infection or another condition.
Q: When should I refer patients to the emergency room?
The patient should go directly to the ER if tests show:
- The white blood cell count is greater than 50,000 per microliter
- Creatinine, uric acid and/or potassium levels aren’t in normal range, which can indicate tumor lysis syndrome and places the patient at risk for renal failure and cardiac arrest
- A mediastinal tumor, either confirmed by a chest X-ray or strongly suspected after a physical exam with or without abnormal CBC lab results
Q: When should I refer to your clinic and how quickly will you see my patient?
If the patient is clinically stable and has normal electrolytes but you suspect cancer based on the physical exam and any labs or imaging, then refer to our clinic for further evaluation. An oncologist on our team is always available to review referrals and lab work. If we highly suspect cancer based on the labs and associated symptoms, we will see these patients within 24-48 hours. If the concern is less suspicious, we see these patients within 14 days.
If you’re concerned and unsure if the child should be referred to the ER or to our clinic, you can reach our oncologists directly by phone at 214-456-2978.
Q: What can my patients expect next when referred to Children's Health?
We perform all evaluations required to confirm a diagnosis, such as a biopsy. If the child has cancer, we begin treatment right away.
At Children’s Health, our nationally recognized program offers the latest innovative treatments and access to clinical trials, some of which aren’t available anywhere else in the region. Our comprehensive care team includes pediatric oncologists/hematologists, surgeons, care coordinators, social workers, child life specialists and more. Our program is offered at both our Dallas and Plano locations to make treatment as convenient as possible.
Learn more about pediatric cancer care at Children’s Health and refer a patient >>