You are on page 1of 44

What should the General P. know about malignancy? Early diagnosis!

Prof dr Anjo J.P. Veerman VU University Medical Centre Amsterdam, NL

29 april 09

prof dr Anjo J.P. Veerman, SOVUmc, VU University Medical Centre, Amsterdam

2

29 april 09

prof dr Anjo J.P. Veerman, SOVUmc, VU University Medical Centre, Amsterdam

3

VUmc Cancer Centre Amsterdam 2005 Expected (2010): ACTA and R&D

Educational Institute for Health Care and Welfare 2006

Medical block 1966

Outpatients 1986 Prof Veerman Room Expected (2011): Psychiatry clinic
29 april 09

Medical Faculty 1950 Ward block 2003
4 4

Intensive Care tower prof dr Anjo J.P. Veerman, SOVUmc, VU University Medical 1995Centre, Amsterdam

VU University Medical Center Knowledge makes us better From our management…… We doctors would rather make our patients better .

Amsterdam 6 6 . SOVUmc.250 104 300 Trainee Research Assistants (PhD researchers formally employed by the Faculty) 29 april 09 813 prof dr Anjo J. VU University Medical Centre. Veerman.Number of 1st year medical students enrolled Medical students Professors Lecturers 2006 350 2.P.

VU University Medical Center. SOVUmc. Amsterdam 7 7 .P. the Faculty of Human Movement Sciences and the Academic Centre for Dentistry Amsterdam (ACTA) EMGO: Institute for Research in Extramural Medicine. Veerman. Body@work prof dr Anjo J. VU University Medical Centre.Pivotal points Pivotal point Cancer and immunology Brain Vital functions Movement Science Extramural/ transmural care 29 april 09 Research Institute CCA/V-ICI: Institute for Cancer and Immunology ICEN: Institute for Clinical and Experimental Neurosciences ICaRVU: Institute for Cardiovascular Research MOVE: inter-faculty .

Veerman. VU University Medical Centre. Amsterdam .100 Approx.Scientific research Total in 2006 PhDs awarded Publications in professional journals Scientific publications Patent applications 29 april 09 >100 Approx.000 11 (current) 8 8 prof dr Anjo J. 2.P. SOVUmc.

• about 1/600 adults will be a survivor of childhood cancer. impact high • Malignant disease is quite rare in the age group below 18 years.P. SOVUmc. Veerman.Childhood Cancer: Incidence low.!!) • A paediatrician will see. again on average. 29 april 09 prof dr Anjo J. 1 or 2 new cases every year. incidence 40-160/106 • Second cause of death in children over 1 year of age. Amsterdam 9 . after accidents (in western c. VU University Medical Centre.

P. SOVUmc. VU University Medical Centre. Veerman. Amsterdam 10 .Causes of Death in the America’s 29 april 09 prof dr Anjo J.

SOVUmc. VU University Medical Centre.Frequency distribution of childhood cancers bone 5% leukemias 30% nephroblastoma 6% soft tissue tumors 7% others 4% neuroblastoma 8% lymphomas 11% liver 1% 29 april 09 retinoblastoma 3% braintumors 25% 11 prof dr Anjo J.P. Amsterdam . Veerman.

P. VU University Medical Centre.5-year survival 1960-2000 29 april 09 prof dr Anjo J. Amsterdam 12 . Veerman. SOVUmc.

St Jude. VU University Medical Centre.P. Veerman. Amsterdam 13 29 april 09 . Memphis) Event-free survival (%) 80 70 60 50 40 30 20 10 0 High-income countries Survival gap Low-income countries 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 prof dr Anjo J.Pediatric cancer survival gap is widening (with gratitude. from Scott Howard. SOVUmc.

VU University Medical Centre. The longer the diagnostic delay. • symptoms are often very similar to symptoms of more common diseases. Amsterdam 14 . • In many cases. Veerman. • Paediatric text books rarely give a note on early signs and symptoms. the worse the prognosis.Is early diagnosis important? • Yes. symptoms have been present in retrospect for a period of months. • Especially in brain tumours (the most common solid tumour in children!) the median delay is long: in the order of 6-9 months. SOVUmc.P. 29 april 09 prof dr Anjo J.

enlarging head 29 april 09 prof dr Anjo J. new squint. loss of weight and appetite. balance. fatigue. limbs. blindness. bulging eyeball L: Lump: Abdomen and pelvis. Amsterdam 15 .Saint Siluan Signs • S: Seek: Medical help early for persistent symptoms I: Eye: White spot in the eye. glands U: Unexplained: Fever. Veerman. head and neck. and milestones. and easy fractures N: Neurological signs: Change in behaviour. testes. SOVUmc. gait. back. pallor. easy bruising or bleeding A: Aching: Bones. VU University Medical Centre. headache.P. joints.

SOVUmc. persistent bone pain Lump Development of excessive bruises Constant infections A whitish color behind the pupil Nausea with persistent vomiting Constant tiredness Eye or vision changes Recurrent fevers of unknown origin 29 april 09 prof dr Anjo J. VU University Medical Centre. Amsterdam 16 . Veerman.From the Gold Ribbon Website • • • • • • • • • • • Continued unexplained weight loss Headaches.P. vomiting Increased swellings.

battering? • Check for other signs and symptoms • It is rewarding to make a diagnosis ‘bare-handed’! 29 april 09 prof dr Anjo J. Amsterdam 17 . VU University Medical Centre.P.Petechiae. SOVUmc. Veerman. bruises • Always an alarm sign: – – – – – – Hemorrhagic fever? Thrombocytopenia? Aplastic anemia? Leukaemia? Coagulation defect? Child abuse.

VU University Medical Centre.P. arthralgia – Look for: • Pallor • Lymph node swelling • Hepato. what to check? – Ask for: • General malaise • Fever • Bone pain.Bruises.and/or splenomegaly 29 april 09 prof dr Anjo J. SOVUmc. Amsterdam 18 . limp. Veerman.

VU University Medical Centre.P.Leukaemia & Lymphoma • • • • • Are 40% of all childhood malignancies Painless lymphadenopathy Often hepatosplenomegaly (NHL) Weight loss Night sweats (Hodgkin’s disease. Amsterdam 19 . HD) 29 april 09 prof dr Anjo J. SOVUmc. Veerman.

P.000 • in Africa association with Epstein-Barr Virus • Jaw. Veerman. VU University Medical Centre. SOVUmc.Burkitt’s lymfoma • Endemic in Africa 10:100. eye/orbit. Amsterdam 20 . CNS 29 april 09 prof dr Anjo J. abdominal.

Veerman.14) 29 april 09 prof dr Anjo J.P.Burkitt cell: morfology (ALL-L3) typical karyotype t(8. SOVUmc. VU University Medical Centre. Amsterdam 21 .

VU University Medical Centre. SOVUmc. Amsterdam 22 .P. Veerman.Mediastinal mass • Urgent! • Can cause sudden death by blocking airways • Anesthesia and biopsy are risky 29 april 09 prof dr Anjo J.

germ cell tumor • Posterior: • Neuroblastoma • Ganglioneuroma 29 april 09 prof dr Anjo J. VU University Medical Centre.Mediastinal mass anterior or posterior? • Anterior • Non-Hodgkins Lymphoma/ALL • Hodgkins Disease • Teratoma. SOVUmc.P. Amsterdam 23 . Veerman.

P. VU University Medical Centre. Veerman. Amsterdam 24 .Hodgkin ‘s Disease. SOVUmc. PET scan • Chemotherapy more important • Aim at less radiotherapy • Because: • Secundary malignancies! Anterior-----PET scan----Posterior 29 april 09 prof dr Anjo J.

Ewing’s sarcoma X-ray.P. Amsterdam 25 . Technetium bone scan 29 april 09 prof dr Anjo J. SOVUmc. VU University Medical Centre. Veerman.

ataxia • papilledema 29 april 09 prof dr Anjo J. VU University Medical Centre. SOVUmc.Emesis. • Declining school performance • Look for: • Gait. vision.P. think of? • Especially without nausea • And in the morning • Ask for: Brain Tumor! • Altered behaviour. Amsterdam 26 . Veerman.

VU University Medical Centre.Medulloblastoma 29 april 09 prof dr Anjo J. Amsterdam 27 . Veerman.P. SOVUmc.

Amsterdam 28 .Diffuse brain stem glioma Surgery impossible/dangerous Biopsy not necessary Radiotherapy? Temozolamide? Prognosis < 10% survival >Supportive care……. VU University Medical Centre.P. SOVUmc. 29 april 09 prof dr Anjo J. Veerman.

VU University Medical Centre. Veerman.P. Amsterdam 29 .Stereotactic radiotherapy 29 april 09 prof dr Anjo J. SOVUmc.

P. But this is the Textbook patient 29 april 09 prof dr Anjo J. often long delay. Veerman. SOVUmc. Amsterdam 30 .Leucocoria. VU University Medical Centre..

The real patient: diagnosis? Take care. picture taken in bright light: Miosis. SOVUmc.P.. VU University Medical Centre. no reflex (but squint. Veerman.) 29 april 09 prof dr Anjo J. Amsterdam 31 .

P. VU University Medical Centre. Amsterdam 32 .A little darker: Bilateral retinoblastoma! 29 april 09 prof dr Anjo J. Veerman. SOVUmc.

SOVUmc. VU University Medical Centre. blind spot) in a perfectly healthy 1 year old child……… 29 april 09 prof dr Anjo J. Amsterdam 33 .P. Veerman.And this is the reflex of the fovea (papilla.

P. SOVUmc. VU University Medical Centre. Veerman. Amsterdam 34 .And than this? Enucleation right eye Prosthesis in operated retinoblastoma patient 29 april 09 prof dr Anjo J.

Veerman. VU University Medical Centre.P. Amsterdam 35 . SOVUmc.Intra-ocular retinoblastoma: the fundus of the eye 29 april 09 prof dr Anjo J.

P. SOVUmc. VU University Medical Centre. Veerman. Amsterdam 36 .Retinoblastoma MRI 29 april 09 prof dr Anjo J.

VU University Medical Centre.P.Soft tissue masses • Should raise suspicion immediately • Of course • But it is still amazing to see how long the patient delay • And the doctors delay • Can be in case of HD in the supra clavicular region 29 april 09 prof dr Anjo J. Veerman. Amsterdam 37 . SOVUmc.

Amsterdam 38 . VU University Medical Centre. SOVUmc.Abdominal masses • Long delays! • Ask for • Diarrhea • Bone pain • Peri-orbital ecchymoses • Look for • Hypertension • Hemi-hypertrophy • Aniridia • Chromosome 11p13 • Urinary malformations 29 april 09 prof dr Anjo J. Veerman.P.

SOVUmc. Amsterdam 39 . VU University Medical Centre.P.Neuroblastoma 29 april 09 prof dr Anjo J. Veerman.

Wilms tumor 29 april 09 prof dr Anjo J. Veerman. Amsterdam 40 .P. SOVUmc. VU University Medical Centre.

Amsterdam 41 . Veerman.Age distribution Neuroblastoma 29 april 09 prof dr Anjo J.P. VU University Medical Centre. SOVUmc.

P. SOVUmc. VU University Medical Centre. Veerman. Amsterdam 42 .Early diagnosis: Screening for Neuroblastoma? • • • • NO More tumors found But no improvement in deaths Conclusion: spontaneous involution in many cases (maybe as many as 3 out of 4) 29 april 09 prof dr Anjo J.

Amsterdam 43 . Veerman. VU University Medical Centre. SOVUmc.Malignancies have most mundane symptoms • The a priori chance of finding one is low • A high degree of suspicion can help • Nothing compares to – Intelligent history taking – Thorough physical examination 29 april 09 prof dr Anjo J.P.

SOVUmc.P. VU University Medical Centre. Veerman.Few things are as rewarding as • Finding a malignancy early • Referring promptly • See the patient back a few years later • CURED 29 april 09 prof dr Anjo J. Amsterdam 44 .