slide 24

E (evolving) - the appearance of any external changes in the mole, which are most often

Change in color (reduction or sharp increase in pigmentation); - violation or complete absence of a skin pattern in the nevus area, a "varnish" surface or peeling; - the appearance of an inflammatory areola around the mole (redness in the form of a corolla); - change in the configuration along the periphery, blurring of the contour of the nevus; - an increase in the size of the nevus (especially over the age of 30 years) and its compaction; - itching, burning, tingling in the area of ​​the mole; - the appearance of cracks, ulceration in the area of ​​the mole, bleeding; - loss of hairs on the mole; - sudden disappearance of a mole (especially after sunbathing in the sun or in a solarium).

Slide 25

Rhabdomyosarcoma.

Rhabdomyosarcomas develop from rhabdomyoblasts, cells that mature into skeletal muscle. Rhabdomyosarcoma accounts for approximately 4% of the total number of tumors in children. About 85% of rhabdomyosarcomas are diagnosed in infants, children and adolescents. There are two main peaks of incidence - early (at the age of about 2 years) and late - (from 15 to 19 years). Males get sick more often than females in a ratio of 1.4-1.7:1. Most often, these tumors occur in the head and neck (40%), in the genitourinary organs (27%), on the upper and lower extremities (18%), and the trunk (7%). Rhabdomyosarcomas are divided into three types: - Embryonic - Alveolar - Pleomorphic

slide 26

Rhabdomyosarcoma. Diagnostics. Treatment.

Diagnosis is based on examination, palpation and biopsy data. Treatment: - The first step in the treatment of rhabdomyosarcoma, if possible, should be complete surgical removal of the tumor. - All patients with rhabdomyosarcoma usually receive chemotherapy. - Radiation therapy is usually given 6-9 weeks after completion of chemotherapy to the area of ​​the remaining tumor. Prognosis: Overall, more than 70% of patients with rhabdomyosarcoma are cured. With the localization of rhabdomyosarcoma in the head and neck, in the vagina and testicles, the prognosis of the disease is favorable. In patients with alveolar rhabdomyosarcoma, the prognosis of the disease is worse than with embryonic.

Slide 27

Nephroblastoma in children.

Nephroblastoma (Greek nephros kidney + blastos germ, germ + -ōma; synonym: Wilms tumor, kidney adenosarcoma, embryonic nephroma) is a dysontogenetic malignant tumor of the kidneys in children, it is a three-component embryonic tumor containing epithelial, blastic and stromal elements (adenomyosarcoma). The tumor occurs equally often in children of both sexes, mainly at the age of 2-3 years, although cases of nephroblastoma in newborns and adults have been described. Macroscopically, the tumor is a node, sometimes very large, clearly demarcated from the renal parenchyma.

Slide 28

Classification of nephroblastoma

Stage I - the tumor is localized inside the kidney and does not germinate its capsule; Stage II - the tumor goes beyond the kidney, but does not germinate its own capsule, there are no metastases; Stage III - the tumor sprouts its own capsule, perirenal tissue or lumbar muscles and adjacent organs, there is damage to regional lymph nodes, tumor rupture before or during surgery; Stage IV - the presence of distant metastases (to the lungs, liver, bones and other organs). Some authors call bilateral nephroblastoma stage V

Slide 29

Diagnostics.

Methods of early diagnosis are examination and palpation of the abdomen, which allow to detect its enlargement or asymmetry, as well as to identify the tumor. Leading in making the correct diagnosis is imaging: echography, traditional radiography (including excretory urography, X-ray computed tomography (RCT), magnetic resonance imaging (MRI), angiography.

slide 30

Treatment of nephroblastoma

surgical (transperitoneal nephrectomy) radiation (preoperative and postoperative irradiation of the tumor bed) chemotherapeutic (preoperative and postoperative)

Slide 31

Neuroblastoma

It is the most common extracranial solid blastoma in children and accounts for 14% of all childhood neoplasms. In the structure of all cancer incidence, neuroblastoma accounts for 7-11% of the total number of malignant tumors in children, ranking fourth after acute leukemia, CNS tumors, and malignant lymphomas. The frequency of neuroblastoma is 0.85-1.1 per 100,000 children under 15 years of age. In children of the first year of life, neuroblastoma is the most common malignant tumor; its incidence at this age is 6.1 per 100,000 children under one year old. The incidence of neuroblastoma at the age of 1 to 5 years is 1.7 per 100,000 children, and at the age of 5 to 10 years - 0.2 per 100,000 children of this age. Neuroblastoma belongs to the group of embryonic tumors such as hepatoblastoma, nephroblastoma, embryonic rhabdomyosarcoma. All of them are characterized by manifestation at an early age, have similar cytomorphological characteristics characteristic of embryonic tumors.

slide 32

Neuroblastoma belongs to the group of embryonic tumors such as hepatoblastoma, nephroblastoma, embryonic rhabdomyosarcoma. All of them are characterized by manifestation at an early age, have similar cytomorphological characteristics characteristic of embryonic tumors. A number of specific, unique features of its biological behavior, not characteristic of other malignant tumors: 1. The ability to spontaneous regression. 2. Ability to differentiate ("maturation"). 3. Ability for rapid aggressive development and rapid metastasis.

Slide 33

International classification of the stage of neuroblastoma (Brouderetal ., 1988).

I Localized tumor located in the area of ​​initial development; the neoplasm is completely removed with or without microscopic evidence of its remnants; macroscopically confirmed absence of lymph node involvement on both sides of the spine IIA Unilateral tumor with possible removal of most of it; microscopically - there are no lesions of the lymph nodes on both sides IIB Unilateral tumor that can be removed completely or most of it; microscopically - there is involvement of unilateral lymph nodes III Tumor extends to the opposite side with or without metastatic involvement of regional lymph nodes; unilateral tumor with metastases to opposite lymph nodes; median tumor with lymph node metastases on both sides IV Disseminated tumor with metastases in distant lymph nodes, skeletal bones, lungs and other organs IVS Localized primary tumor, defined in stages I and II with liver, skin and/or bone marrow metastases

slide 34

Clinical picture

There are symptoms of the primary tumor, parneoplastic syndrome (associated with hyperproduction of catecholamines) and metastatic disease. In principle, neuroblastoma can occur in any organ with sympathetic innervation, but the typical sources of tumor growth in neuroblastoma are the sympathetic nerve trunk along its entire length and the adrenal medulla. Approximately 40% of tumors originate in the adrenal glands, 30% originate from the lumbar sympathetic trunk, 15% from the thoracic region, 3% from the pelvic paraganglia, and 1% from the cervical region. Stage 4S in the American literature is called the “blueberry pie” syndrome due to the characteristic appearance of the patient associated with metastases to the skin, bones, and subcutaneous tissue.

Slide 35

Diagnostics

According to international criteria, the diagnosis of neuroblastoma can be established by histological examination of biopsy material obtained from the primary tumor (or from metastases), or if a bone marrow lesion is detected in combination with an increased content of catecholamines or their derivatives. Imaging methods: extractor urography, computed tomography (CT), MRI, bone or skeletal scintigraphy, chest x-ray, liver scintigraphy, angiography.

slide 36

tumor markers.

The metabolites of catecholamines are highly specific and easily determined: vanillylmandelic acid (VMA) or homovanillic acid (HVA) and dopamine (DA). In the case of false-negative results of the determination of catecholamine metabolites, the determination of the serum content of neuron-specific enolase (NSE), an enzyme determined in neurons, will help in the diagnosis. Another biochemical marker of neuroblastoma is ferritin. The enzyme lactate dehydrogenase (LDH) does not belong to neuroblastoma-specific markers, but its serum level is of prognostic value in these patients. Other markers of neuroblastoma are Ganglioside GD2, neuropeptide Y, and Chromogranin A.

Slide 37

. Scheme for determining the degree of spread of the tumor process

1. Place of the primary tumor - ultrasound, CT, MRI. 2. Chest - radiography, CT. 3. Abdomen - ultrasound, CT. 4. Bone scintigraphy with Te 99 and subsequent radiography of the identified foci of hyperfixation of the isotope.5. Scintigraphy with 131 J metaiodobenzylguanidine (MJBG) .6. Aspiration biopsy of the bone marrow (from 4-8 places) .7. Trepanbiopsy of the bone marrow with histological and immunohistochemical studies.8. Biopsy of lesions suspected of tumor metastases.

Slide 38

Treatment

surgery, radiation therapy, chemotherapy, bone marrow transplantation. According to different authors, the survival rate of patients with neuroblastoma as a whole is about 50% (49-55%), by stages: stage 1 - 100%, stage 2 - 94%, stage 3 60% (67-57%), stage 4 - 10-20%. 4S stage - 75%.

Slide 39

Tumors of the mediastinum

Tumors of the mediastinum are observed equally often in men and women, they occur mainly at a young and mature age. Most of them are congenital neoplasms. Benign tumors of the mediastinum significantly predominate over malignant ones. There are two main syndromes in mediastinal pathology: compression and neuroendocrine.

Slide 40

There are three types of compression symptoms

organ (displacement and compression of the heart, trachea, main bronchi, esophagus) vascular (compression of the brachiocephalic and superior vena cava, thoracic duct, displacement of the aorta) neurogenic (compression with impaired conduction of the vagus, phrenic and intercostal nerves, sympathetic trunk) Neuroendocrine syndrome is also noted, which is manifested by damage to the joints (resembling rheumatoid arthritis), large and tubular bones. There are various changes in heart rate, angina pectoris.

Slide 41

Primary neoplasms of the mediastinum

Thymomas Disembryogenetic tumors: dermoid cysts and teratomas Mesenchymal tumors: lipomas, fibromas, hemangiomas, lymphangiomas. Neurogenic tumors: neurofibromas, neuroblastomas, Cysts: coelomic pericardial cysts, bronchogenic and enterogenic mediastinal cysts. Lymphadenopathy Lymphoma

Slide 42

Secondary mediastinal tumors

These are metastases of malignant tumors of the organs of the chest or abdominal cavity in the lymph nodes of the mediastinum. Most often occur in cancer of the lung, esophagus, proximal stomach. Clinically, they are most often asymptomatic. Only when metastases reach large sizes, various compression syndromes occur - most often the syndrome of the superior vena cava, Horner's syndrome.

slide 43

TUMORS AND TUMOR-LIKE BONE LESIONS

Classification of primary tumors and bone dysplasia in children (according to the WHO classification, Geneva 1972): Benign Malignant By histogenesis: Bone-forming: (osteoma, osteoid osteoma, osteoblastoma, osteosarcoma); Cartilaginous: (chondroma, osteochondroma, chondroblastoma, chondromyxoid fibroma, chondrosarcoma); Giant cell: (osteoclastoma); Bone marrow: (Ewing's sarcoma, reticulosarcoma, myeloma); Vascular: (hemangioma, lymphangioma, angiosarcoma); Connective tissue: (desmoplastic fibroma, lipoma, fibrosarcoma, liposarcoma); Tumor-like lesions: (aneurysmal or solitary cyst, fibrous dysplasia, fibrous metaphyseal defect, eosinophilic granuloma).

Slide 44

Comparative characteristics of benign and malignant bone tumors.

Clinical picture of benign bone tumors Clinical picture of malignant bone tumors Characterized by slow progression of the process and the absence of a “common tumor symptom complex” Absence of metastases Differs in scarcity of manifestations Absence of pathognomonic signs in intraosseous foci Varies depending on the nature of the pathology, its duration and the presence of complications In 50% of children with intraossal a pathological fracture occurs in case of extraosseous neoplasms (osteoma, osteochondroma) there is a symptom of a palpable tumor The main clinical sign is pain The characteristic symptom is night pain A soft tissue component may be present By the time the diagnosis is established, 10%-20% of patients already have macrometastases in the lungs Increase body temperature of the patient There are dysfunctions of the affected limb There are signs of general intoxication

Slide 45

Benign bone tumors.

Osteoma is one of the most morphologically mature benign skeletal tumors originating from osteoblasts. Types: compact and spongy. Surgical treatment - removal of the tumor with an area of ​​healthy bone tissue and periosteum.

Slide 46

Osteoblastoclastoma

Osteoblastoclastoma (giant cell tumor) - characterized by a change in periods of active growth and destruction of bone tissue, periods of stabilization with reparative processes in the bone. Forms: lytic, active cystic and passive cystic. Phases: There are cellular-trabecular and lytic osteoblastoclastomas. In long tubular bones, the tumor is localized in children - in the metaphysis

Slide 47

Differential diagnosis of osteoblastoclastoma.

Aneurysmal cyst A monoosseous form of fibrous osteodysplasia of a long tubular bone.

Slide 48

Other benign tumors and tumor-like diseases of the bones.

Osteoid osteoma. Chondroma Enchondroma Echondroma Hemangioma Eosinophilic granuloma

Slide 49

Malignant bone tumors.

Osteogenic sarcoma is the most common primary bone tumor in children and ranks 6th in frequency among all childhood malignant tumors. The peak incidence occurs in the 2nd decade of life. The tumor originates from primitive bone-forming mesenchyme, characterized by osteoid production during malignant proliferation of the spindle cell stroma. Characterized by the defeat of the metaphyses of long tubular bones. The most common localization (approximately 50% of cases) is the area of ​​the knee joint - the distal part of the thigh and the proximal part of the tibia. Osteosarcoma has a huge tendency to develop hematogenous metastases. The main clinical sign of osteosarcoma is pain over the affected area.

Slide 50

Diagnostics

X-ray examination: X-ray signs of osteosarcoma (Fig. 2): - metaphyseal localization in long tubular bones; - the presence of sclerotic and lytic foci in the bone, the presence of vascularization; - foci of pathological osteogenesis in soft tissues; - violation of the integrity of the periosteum with the formation of a "visor" - needle periostitis - "spicules" (growth of the periosteum in the form of needles located perpendicular to the surface of the bone); X-ray of the lungs reveals macrometastases.

Slide 51

Morphological study of the tumor. Bone scintigraphy (OSG) with Te-99 Computed tomography (CT) of the focus Magnetic resonance imaging (MRI). Angiography Treatment Preoperative chemotherapy is always the first step in treatment. Surgery is the second mandatory stage of treatment. Postoperative chemotherapy - is carried out taking into account the histological response of the tumor to chemotherapy (continuation of treatment, or changing the therapy regimen, or stopping therapy).

Slide 52

Ewing's sarcoma

Ewing's sarcoma ranks second in frequency among malignant bone tumors in children. Most often, this tumor occurs in adolescents aged 10 to 15 years. Several risk factors for Ewing's sarcoma: Gender. Ewing's sarcoma is slightly more common among boys than girls. Age. In 64% of cases, Ewing's sarcoma occurs between the ages of 10 and 20 years. Race. Most often, Ewing's sarcoma is observed in the white population.

Slide 53

Clinic:

Pain An increase in the patient's body temperature Presence of a tumor formation Possible dysfunction of the affected limb Sometimes fever occurs Diagnosis. X-ray diagnosis Tumor biopsy. Aspiration biopsy or bone marrow from several sites Bone scintigraphy Computed tomography of the focus Angiography Ultrasound

Slide 54

X-ray diagnostics

Foci of destruction (small-focal, lamellar, large-focal) Endosteal reaction. Periostitis (The shape of the visor of periosteal growths can be linear, layered, tuberous, fringed, needle-like (spiky).

Slide 55

Treatment

Multicomponent chemotherapy. In modern treatment programs, preoperative and postoperative polychemotherapy is used, while also taking into account the histological response of the tumor to treatment - Radiotherapy to the focus in high doses. - If possible, radical removal of the tumor (including bone and soft tissue component). Radical resection is possible with a focus in the fibula, bones of the forearm, ribs, collarbone, scapula.

Slide 56

Thank you for your attention!

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Compiled by Ph.D. I.P. Kireeva
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INTRODUCTION

Oncological diseases occupy a central place among the problems of clinical medicine. The achievements of modern therapy have led to the fact that an increasing number of patients are experiencing long periods after the start of treatment, and a significant contingent can be classified as recovered. This is especially true of the main variant of the tumor process in childhood - leukemia: every year the number of children with remissions for more than five years is growing; medicine and society as a whole are confronted with cases of practical recovery from acute leukemia that did not exist before. At the same time, it turned out that antitumor treatment alone with the appointment of disability, which is given to all children with cancer, does not completely solve the problems that have arisen. The results of treatment of disabled children with cancer, the so-called "level of quality of life" are determined not only by the severity of the underlying disease, but also by the psychological state, possible mental disorders both in the patient himself and in his family members, which is neither in scientific research nor practically no attention is paid to practical health care in our country. The problem of seriously chronically ill children includes the following main aspects:

Mental disorders associated with a long and severe course of somatic illness;
the impact of the disease on the mental development of the child;
the impact of stress and psychotherapy on the development of the disease;
the influence of the family on the condition of a sick child and the influence of a chronically ill child on the psychological climate in the family.

L.S.Sagidullina (1973) revealed syndromes of damage to the nervous system in 38.8% of children with acute leukemia. I.K.Shats (1989), who studied children with acute leukemia, found mental disorders in all: in 82.6% of children they manifested themselves at the borderline level and were represented by asthenic, dysthymic, anxious, depressive and psycho-organic syndromes. Psychotic disorders were observed in 17.4% of patients. With age and duration of the disease, the proportion of depressive states increased, psychotic disorders predominated in adolescents. We (I.P. Kireeva, T.E. Lukyanenko, 1992) summarized examination data of 65 children aged 2-15 years with acute leukemia. Mental disorders in the form of asthenia were detected in all patients. 46 children (70.8%) had more complex mental disorders requiring special correction. What is the clinic of the most frequent mental disorders in children with cancer?

WHAT IS ASTHENIA IN A CHILD WITH A CANCER DISEASE

Common to all patients is an asthenic symptom complex, which, being one of the least specific forms of response to exogeny, can accompany the disease throughout its entire course, can manifest itself only during periods of deterioration in the somatic condition, during intensive chemotherapy, with concomitant infections. The severity of the asthenic symptom complex is proportional to the severity of the somatic condition; in remission, its manifestations are smoothed out.

Often, asthenic syndrome precedes the first manifestations of the underlying disease. In these cases, when taking an anamnesis, it is revealed that a few weeks, months before the manifestation of an oncological disease, the child became more lethargic, tired, capricious, touchy, tearful, was sleepy during the day, slept restlessly at night. These mental disorders in the prodromal period often do not attract attention or are erroneously interpreted by parents and doctors as a psychogenic provocation of the underlying disease (“he fell ill due to trouble at school”, “because of what he was experiencing”), although in fact he had a place that arose in the prodromal period of the disease, an increased aggravated response to everyday events.

Let us examine in detail the manifestations of asthenic syndrome. The main symptom, without which it is impossible to diagnose asthenia, is physical fatigue, which increases in the evening. This is expressed in complaints of patients about the inability to complete tasks in physical education classes, the need to lie down after a short walk, in complaints of weakness: "hands, legs are weak." Mental fatigue is less pronounced or absent.

In addition to asthenia proper (i.e., "lack of strength"), functional somatovegetative disorders are necessarily present in asthenic syndrome. These include sleep disturbances (prolonged falling asleep with an influx of painful memories of the past or disturbing ideas about the future, an increase in the need for sleep), a decrease in appetite, the appearance of sweating, persistent dermographism, etc.

The third obligate manifestation of asthenic syndrome is emotional (irritable) weakness. This is a pronounced lability of mood with sharp drops: either high or low. Elevated mood often has the character of sentimentality with irritability and anger, low - tearfulness with capriciousness, dissatisfaction with others. The change of such states has an insignificant reason, and the decrease in mood prevails. Increased sensitivity to all external stimuli (the so-called "psychic hyperesthesia"): a loud voice is deafening, it seems to the child that the mother or health workers "shout" at him all the time, the knock of a slamming door is perceived as a shot, the seams on the clothes seem rough, the bright light of the lamp blinding in the dressing room. Reduced pain threshold: injections are felt more painful than in a healthy state.

Other neurotic and behavioral disorders may join the asthenic syndrome. For example, on the eve of or during medical procedures, "tantrums", vomiting, refusal to eat, loss of skills of neatness, speech, behavioral disorders up to the refusal of vital medical procedures. This forces doctors to delay procedures or perform them under anesthesia, which has side effects that are not indifferent to frail children.

We present below (I.K. Shats, 1991). The questionnaire is intended for children from 8 years of age. With younger children and with children of any age who do not have the physical ability to independently complete the questionnaire, an interview form is used, during which the questionnaire is filled out by a doctor (sometimes with the help of parents). When answering on scales I-VI, one, the most appropriate answer is selected, the scores on scales I-VI are summed up, giving a quantitative characteristic of the severity of asthenia: 18-13 points - severe asthenia, 12-7 points - moderate asthenia, 6-1 - fatigue reaction . Point characteristics allow to evaluate the dynamics of the state before and after treatment. Responses on scales VII-IX are not quantified, and when answering one question, several points can be marked. These disorders can be symptoms of both asthenia and somatic suffering itself, but their consideration is important for the general characterization of the child's condition.

CHILD DEPRESSIONS

More than a third of children with oncological diseases are diagnosed with neurotic and depressive states with an almost constant decrease in mood. These children are always whiny or gloomy, lose interest in games and communication with peers. Often there is an increased interest in their illness - patients are not age-oriented in medical terminology, treatment-related events, are interested in the course of treatment, listen to the conversations of others about the disease, express concern for their health. Often, patients are in a very difficult relationship with their parents: they are waiting for their arrival, but all the time they are unhappy with how they fulfill their requests, conflict with their parents, blame them or themselves for their illness. These conditions are characterized by functional dysfunctions of internal organs that are not explained by the underlying disease, persistent disturbances in appetite and sleep, night terrors, "tantrums" like affect-respiratory attacks, and hysterical seizures.

Below we present , (I.K. Shatz, 1991). The scale is filled in by the doctor based on clinical observation of the child. For each of the subscales, the most appropriate description of impairments for the given child and the corresponding score are recorded. Additionally, content characteristics of anxiety and fear are recorded. The scale makes it possible to obtain standard qualitative descriptions of the emotional state and their quantitative assessments for individual subscales and in general. The latter is expressed as a quotient from dividing the algebraic (taking into account the sign) sum of the points scored by the number of subscales (8).

Along with assessing the dynamics of the individual state, the scale makes it possible to control the effectiveness of psychotropic drugs and psychotherapy used in treatment, to compare the emotional state in different clinical groups, taking into account not only the severity, but also the characteristics of emotional disorders.

OTHER MENTAL DISORDERS

In some patients (about a tenth of cases), with a sharp deterioration in the somatic condition, transient psychoses develop with clouding of consciousness. Stunning and delirium are mostly encountered.

In cases of mild stunning (obnubilation), the child has difficulty comprehending, slowness of all reactions, emotional indifference, limited perception. The child looks lethargic, as if "stupid, stupid", absent-minded. With a sharp irritation (raising the voice when asked, pain), consciousness clears up for a while. As the stupor deepens, its next stage develops - drowsiness, in which the child becomes, as it were, drowsy, and being taken out of this state by an external stimulus (loud voice, bright light, pain) can give an answer to a simple question and again falls into a pathological slumber. In a severe general condition, stunning can reach the degree of stupor with the absence of speech contact and with the preservation of the reaction only to very strong stimuli (flash of light, loud sound, pain), in response to which unarticulated vocal and undifferentiated protective motor reactions appear. Finally, with a progressive deterioration in the general condition, a coma (turning off consciousness) occurs with a weakening, and then with the disappearance of unconditioned reflexes, respiratory and cardiac disorders. Each subsequent stage of stunning is about half the previous one, and the doctors have less and less time for resuscitation, if any.

Delirious disorders occur against the background of severe asthenia or shallow stunning, mainly in the evening and at night. During delirious episodes, the child becomes restless, fearful, he has perceptual deceptions, more often in the form of visual illusions, especially such as pareidolia, when fabulous creatures, people's faces, a wolf's muzzle grinning teeth appear in the pattern of wallpaper, cracks on the wall. Visual hallucinations may occur, auditory hallucinations are frequent (ringing, roaring, calling by name, voices of familiar children). Evening delirious episodes are often erroneously assessed - they are mistaken for children's fears of the dark.

In patients with a hereditary burden of epilepsy and in patients with organic brain damage, epileptiform disorders are possible: convulsive seizures, twilight confusion, dysphoria. The organic psychosyndrome develops as a result of an organic lesion of the substance of the brain (cerebral hemorrhage, tumor, or as a consequence of severe intoxication, hypoxia) and is characterized by an irreversible weakening of memory, a decrease in intelligence of varying degrees (up to acquired dementia).

The occurrence, form and severity of mental disorders are influenced by a whole range of exogenous and endogenous factors. The most powerful causative factor is psychological. The sudden onset of a serious illness is perceived by children as a "tragic deprivation of everything", as it leads to many months of hospitalization with separation from school, friends, separation from home, severe treatment, which is accompanied not only by frequent painful procedures, but also by a change in appearance with the advent of obesity, baldness. Psychotraumatic for sick children is the fact that they observe the suffering of other patients, learn about their death. It should be noted that if earlier it was believed that the concept of death was available only to children of school age, then recent studies (D.N. Isaev, 1992) show that this concept can arise already between 2-3 years and even very young children may experience with him anxiety, which, due to the inability to verbally express his fear, is manifested by changes in behavior, fears of physical damage, loneliness.

In addition to the psychological factor in the occurrence of mental disorders, the endogenous factor of predisposition to mental illness, the somatic factor associated with the underlying disease and its complications, and the iatrogenic factor due to side effects of drug and radiation therapy of the underlying disease are important. In the foreign literature, quite a lot of publications are devoted to the psychoorganic syndrome, which manifests itself months and years after radiation therapy, psychoorganic syndromes are also considered during cytostatic treatment.

Mental disorders in blood diseases, therefore, are of mixed: psychogenic, exogenous-symptomatic, exogenous-organic origin. The pathogenesis of mental disorders is poorly understood and is associated with disorders of brain metabolism, dyscirculatory changes in the brain, and edema of the brain tissue.

The question arises of how to treat mental disorders that make it difficult to treat the underlying disease, have an adverse effect on the "lifestyle", and, according to some data, possibly on its duration. Both according to the literature and according to our data, the isolated use of psychotherapy is not effective enough. The use of psychotropic drugs proved to be difficult. IK Shats (1989) recommends using mezepam, sibazon, phenazepam and azafen in the treatment of patients with acute leukemia. Literature data on the interaction of psychotropic drugs with antitumor, hormonal drugs, the effect of psychotropic drugs on hematopoiesis are either absent or contradictory. When we used psychotropic drugs, even at low doses, side and perverse reactions often occurred. In some patients, a positive effect was observed with the use of tranquilizers, nootropics, herbal medicine.

Psychotherapeutic tactics remain underdeveloped. One example is the issue of patient orientation in the diagnosis of cancer. Foreign authors emphasize that the patient should know everything he wants about his present and future, that he needs to know the diagnosis. Severe psychological stress that occurs when reporting an oncological disease is prevented with the help of targeted psychotherapeutic work carried out by both doctors and psychologists, social workers. Abroad, there is special literature for patients with leukemia, breast tumors, etc., and educational work is being carried out among the population. In our country, almost no literature for patients is published, and there is no special training for psychotherapists and social workers to work in oncological institutions. Domestic doctors believe that an oncological diagnosis should not be reported, as this will only increase fear and uncertainty.

Meanwhile, it turned out that many children suffering from cancer, especially adolescents, already know their diagnosis at the first stages of treatment. In this case, children find themselves in a particularly traumatic situation due to the fact that they do not discuss the diagnosis they know with parents or doctors who are convinced that they managed to hide it from the child. And the point here is not only in the "leakage of information" about the diagnosis. C.M.Binger et al. (1969) believe that despite attempts to protect a hopelessly ill child from knowing about the prognosis of his disease, adult anxiety is transmitted to children due to a violation of the emotional climate and mutual understanding in the family.

A long-term illness changes not only the mental state, but also the development of the child, leading to the appearance of pseudo-compensatory formations of the type "conditional desirability of the disease" or "escape to the disease" with fixation on it, which in the end can lead to a break in character within the pathocharacterological or neurotic personality development. Children who have already had cancer develop "post-traumatic stress disorder": recurring nightmares and flashes of memories of illness, treatment, increased sensitivity to trauma, irritability, aggressive behavior, lifelong overdependence on parents in violation of contacts with peers. Loneliness is often the result of an illness.

In the course of our attempts to conduct play psychotherapy in the department, we constantly observed the consequences of mental deprivation: the development of social and communication skills was delayed in children. They did not know how to express their own wishes, they were not familiar with games appropriate for their age, there was reduced or no interest in communicating with peers, the circle of interests narrowed. To the question "what would you like to play?" they either could not answer, or the list of games was limited to lotto and drawing. This made it difficult to use traditional techniques adopted in our country in psychotherapeutic work.

The use of psychotherapeutic techniques developed abroad is even more difficult. This is partly due to the fact that in our country psychotherapy was developed by psychiatrists within the framework of the "medical model" (V.N. Tsapkin, 1992), in which the treatment process is understood as the elimination of "target symptoms". Abroad, however, psychotherapy is developed mainly not by doctors, but by humanitarians, psychologists within the framework of a “psychological model”, which is based on psychoanalytic or other religious and philosophical concepts that require either “faith” or many years of study and are not truly familiar to domestic specialists. In addition, these techniques are not always accepted by patients, since work in the "psychological model" includes work with negative experiences with their temporary intensification and requires a certain psychological education of the patient, the availability of a request for psychological help. Hence the need to develop effective psychotherapeutic tactics is clear. The possibility of creating effective psychotherapeutic methods is indirectly confirmed by thirty years of research by the Washington Institute of Mental Health (1988), which led to the conclusion that "psychotherapeutic intervention usually brings benefits, and that different types of psychotherapy are almost equally effective" (M.B. Parloff, 1988).

FAMILY OF A CANCER CHILD

The next aspect of our conversation concerns the family. It is known that the mental well-being of the child, his behavior may be even more dependent on the mental state of loved ones than on his physical state. Starting from school age, and sometimes even earlier, children are aware that their illness has become a blow to their loved ones, and react to the situation in accordance with the attitude of their parents. In sick children, in addition to high levels of anxiety, internal conflicts associated with misunderstanding by adults are revealed. Children feel abandoned, pathological relationships with the family are formed: either the despotic behavior of a sick child with a complete disregard for the interests of the family, or an indifferent attitude to the environment with care for their own problems, or, finally, complete dependence on parents with a sense of guilt in front of them, the perception of the disease as "punishment" for their "bad" behavior. Children whose families lead a normal lifestyle maintain habitual social contacts, feel more confident and maintain emotional ties with their family members (J.J. Spinetta., L. Maloney, 1978).

However, most of the parents whose children suffer from life-threatening diseases are diagnosed with mental disorders (Kireeva I.P., Lukyanenko T.E., 1994). Mental disorders in parents are primarily due to a chronic psycho-traumatic situation, overwork, financial, housing and other domestic problems, in particular because oncology departments are usually removed from their place of residence, and a sick child needs constant care of loved ones, especially in our conditions of shortage junior and middle medical personnel.

Mental disorders in parents are manifested by the drop in working capacity that occurs in most of them, lack of appetite, sleep disturbances and the functions of internal organs. Psychological testing of parents reveals a high level of "situational anxiety", indicating the dominance of anxiety and dissatisfaction in the state of mind. Decreased mood often reaches despair, sometimes with a refusal to treat a child with doctors, with attempts to seek help from healers, psychics, which sharply worsens the prognosis of the disease. Correction of mental disorders in parents, therefore, is necessary not only to restore their well-being and working capacity, but also because without psychocorrectional assistance to the family it is impossible to form an adequate attitude towards the illness and treatment of the child.

CONCLUSION

The data presented indicate the need for:
1) organization of interdisciplinary scientific research on the problem of mental and personality disorders in children suffering from life-threatening diseases and in their families;
2) conducting scientific research aimed at developing the most effective drug tactics in the treatment of mental disorders in children with cancer;
3) organization of psychosocial assistance to children with cancer and their families.

At the same time, only psychologists and psychiatrists working in the health care system will not be able to solve all problems. They need help, the participation of teachers, social workers, cultural and religious figures, the search for cooperation not only with the sick, but also with their families, relatives and the society in which these people live.

LITERATURE

Adjuvant psychological therapy for cancer//Medical Market. - 1992, No. 8.-S. 22-23.

Gindikin V.Ya. Review of the book "Psychosomatics in clinical medicine. Psychiatric and psychotherapeutic experience in severe somatic diseases." Ed. E. Benish and I.E. Meyer. Zap. Berlin-Heidelberg-New York, 1983//Journal of neuropathology and psychiatry. S.S.Korsakov. - 1987, Issue. 2. - C, 297-299.

Guskova A.K., Shakirova I.N. The reaction of the nervous system to damaging ionizing radiation (Reviews / Journal of neuropathology and psychiatry named after S.S. Korsakov. - 1989, Issue 2.- P. 138-142.

Isaev D.N. Formation of the concept of death in childhood and the reaction of children to the process of dying / / Review of Psychiatry and Medical Psychology. V.M. Bekhterev. - 1992, No. 2.- C.17-28.

Kireeva I.P., Lukyanenko T.E. Psychosocial assistance in pediatric oncohematology//Rehabilitation of children with disabilities in the Russian Federation. - Dubna, 1992. - S. 76-77.

Kireeva I.P., Lukyanenko T.E. Psychiatric aspects in pediatric somatology//Scientific conference of young scientists of Russia dedicated to the 50th anniversary of the Academy of Medical Sciences: abstracts. Moscow, 1994. - S. 287-288.

Psychodiagnostic methods in pediatrics and child psychoneurology. Tutorial. Ed. D.N. Isaev and V.E. Kagan. - S.-Ptb. PMI, 1991.- 80 p.

Sagidullina L.S. Damage to the nervous system in acute leukemia in children: Abstract of the thesis. dis. cand. honey. Sciences. - M., 1973. - 21 p.

Shats I.K. Mental disorders in children with acute leukemia: Abstract of the thesis. dis. cand. honey. Sciences. - L., 1989. - 26 p.

Tsapkin V.N. Unity and diversity of psychotherapeutic experience//Moscow Journal of Psychotherapy. - 1992. - S. 5-40.

Binger S.M., Ablin A.R., Feurste R.C. et al. Childhood leukemia: emotional impact on patients and family//New Engl.J.Med. - 1969, Vol. 280.-P. 414-418.

Parloff M.B. Psychotherapy and research: an anaclitic depression// Psychiatry. - 1988, Vol. 43. - P. 279-293.

Spinetta J.J., Maloney U. The child with cancer: patterns of communication and denial//J.Consult.Clin.Psychol. - 1978, Vol. 46., No. 6.- P. 1540-1541.

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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 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 biopsies, intravenous injections, etc.) - these are some of the external factors that "put pressure" on the child's psyche, making him withdrawn, gone into 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, the caring and attentive attitude of others 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 a child has 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 personal authority of the doctor in such patients, which is further strengthened 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 the 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 doctor already knows the final diagnosis), 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, and 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 very 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 also has 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 - is 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 measures.

Children with a high degree of experience 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 the best 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 goal 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.

When discharging a child from a hospital, the doctor must have a conversation with the parents, and preferably with the teachers of the school or kindergarten, so that in the presence of certain defects caused by the disease and treatment (amputation, enucleation, alopecia, etc.), the teachers find the most reasonable manner behavior and treatment of a schoolchild or 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 the prostheses have to be changed several times as the patient grows, however, it is impossible to leave children 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 a favorable psychological factor for the surrounding children. 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 component is 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 of various types of therapy (scoliosis, chest deformity, etc.). Dosed physical therapy 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

The material was prepared by the doctor of the highest category Shcheglov A.A.
Thanks to the possibilities of modern medicine, most children with early-stage cancer can be completely cured. And who, if not the parents who communicate with the child every day, will be able to notice changes in his condition in time and turn to specialists?
According to pediatric oncologists, parental attention plays a huge role in the early detection of malignant tumors in children. Of course, here we are not talking about the fact that parents need to examine and feel the child every day in search of a tumor. They just have to follow the advice of the famous American oncologist C. Cameron: "Don't be too careless about getting cancer in children, nor too worried, but be on the lookout!"

Principles of "cancer alertness"

General practitioners and parents should be aware of some of the principles that form the concept of "cancer alertness", which may be useful for the timely diagnosis of a tumor in a child.

Knowledge of the first signs and course of the main types of malignant tumors in children.

Knowledge of the organization of the pediatric oncology service and the rapid referral of the child, if necessary, to the appropriate specialized department.

Thorough examination of the child at any visit of the parents to the doctor.

With an unusual course of any disease, inexplicable symptoms and an unclear clinical picture, it is necessary to remember the theoretical possibility of developing a malignant tumor.

Examination of a child with a suspected malignant tumor should be carried out as soon as possible with the involvement of the necessary specialists.

The principle, long promoted in adult practice: "When in doubt about the diagnosis, think about cancer," should be unconditionally accepted in pediatric practice.

Common symptoms of cancer

General provisions that are useful to pay attention to both pediatricians and parents:

Certain types of malignant tumors are inherent in each period of childhood, as will be indicated below;

Boys get sick twice as often as girls;

Tumors are somewhat more common in children born to women over the age of 40.

Loss of appetite and associated weight loss;

Paleness of the skin;

Unexplained rise in temperature.

For an attentive parent, changes in the usual behavior of the child will also be noticeable:

He becomes moody;

Begins to tire faster than usual;

Often forgets about his favorite games.

brain tumors

The second most common malignant disease in children are brain tumors.

Symptoms of the disease

In cases where a developing tumor is located far from the vital centers of the brain, it can grow asymptomatically for a long time, and acute, suddenly developed symptoms are characteristic of tumors located near life-supporting centers. One way or another, the first clinical manifestations of brain tumors are associated with an increase (due to tumor growth) of intracranial pressure. At first, this is manifested by signs of a general tumor symptom complex, and with the further development of the disease, signs such as headache are added, which occurs most often in the morning and is aggravated by tilting the head, coughing.

If an older child can complain, then in younger children the symptoms of the disease are manifested by anxiety, in which the baby begins to cry, clutch his head, and rub his face.

A very common symptom is causeless vomiting, which, like a headache, is usually noted in the morning.

Other signs that accompany tumor growth include changes in vision, gait disorders (in older children, handwriting disorders may manifest as a change in handwriting).

Some patients have seizures.

The appearance of the above symptoms is not at all necessarily due to the occurrence of a brain tumor (perhaps this is due to other diseases of childhood), but if they are detected, it is certainly necessary to consult a specialist in this field - a neurosurgeon.

Malignant diseases of the lymph nodes

In the third most common place are malignant diseases of the lymph nodes, among which, first of all, we should mention lymphogranulomatosis - a disease, or lymphoma, Hodgkin's and lymphosarcoma - non-Hodgkin's lymphoma. Despite the similarity of these diseases in terms of the substrate of the lesion - lymphatic tissue - there are many differences between them in terms of the clinical course, methods of treatment and prognosis.

Lymphogranulomatosis

With lymphogranulomatosis, the cervical lymph nodes are most often (90%) primarily affected.

Since in childhood the cervical lymph nodes increase with many diseases, as a rule, neither doctors nor parents worry about their increase. Naturally, thermal procedures and antibiotics are prescribed. Sometimes after this, the nodes may temporarily decrease in size, which further complicates the situation, since a decrease in the nodes for parents and even for doctors, as it were, indicates the absence of a malignant tumor.

In most cases, without special treatment, the lymph nodes again slowly but steadily increase in size, sometimes solder with each other, forming the so-called conglomerates. Since the general condition of the child does not suffer at the first stages of the disease, even in a large city, the child is observed for a long time (sometimes up to a year) by various specialists without receiving the necessary treatment. Meanwhile, the disease progresses, other groups of lymph nodes are involved in the process, and the so-called symptoms of intoxication may join: causeless rises in temperature, increased sweating (especially at night), weight loss, less often - skin itching.

In a routine blood test, an increase in ESR and the number of leukocytes and a decrease in the number of lymphocytes may be detected.

As a rule, a child enters a specialized clinic when the disease is already in stages II-IV. The number of patients admitted to the clinic with stage I of the disease does not exceed 10%, and it is at this stage that the most gentle treatment methods for the child's body are used and almost all patients can be cured.

If, with an increase in the lymph nodes in the neck, the doctor examining the child remembers that there is such a disease as lymphogranulomatosis, the diagnosis will be more timely.

There are several points, the knowledge of which can help to suspect Hodgkin's disease.

Most often, lymphogranulomatosis affects children aged 4-6 and 9-10 years, since during these periods of childhood the most serious physiological changes occur in the child's lymphatic system, and the lymph nodes become vulnerable to the effects of some disease-causing factor. There are many theories, but as with most malignant tumors in children, the cause is unknown.

Boys get sick three times more often than girls.

Unlike inflammatory diseases of the lymph nodes, the node (or nodes) enlarged with lymphogranulomatosis is completely painless when palpated, the skin covering it is absolutely not changed, there is no increase in local temperature above the node.

Currently, the following tactic has been adopted: if the enlargement of the lymph nodes persists for more than a month, and the child does not have any diseases that explain this enlargement of the nodes (tonsillitis, dental caries, inflammatory foci such as boils near the enlarged node), parents are offered a diagnostic puncture of this node .

The puncture is performed on an outpatient basis, without hospitalization, with a conventional intramuscular needle, so it is no more painful than any injection, and does not bring any harm to the child. An experienced cytologist will either suspect the diagnosis or reject it. In case of suspicion, an examination in a specialized department is required for the final diagnosis and necessary treatment.

If the puncture is performed by an experienced physician, and the material obtained during the puncture is examined by a qualified cytologist, the frequency of diagnostic errors is minimal. In inexperienced hands, this procedure is pointless, since the diagnosis will not be established, and time, precious for the timely start of treatment, will be lost further.

Lymphosarcoma

Lymphosarcoma occurs in the lymphatic tissues and, in its course, growth rate, and prognosis, is closer to acute leukemia than to lymphogranulomatosis. There are no favorite age peaks in lymphosarcoma. Boys get sick more often than girls. The first manifestations of the disease depend on the primary location of the tumor.

Conventionally, four most frequent localizations of the process are distinguished:

Lymphosarcoma of the abdominal cavity;

Lymphosarcoma of the lymph nodes of the chest cavity (mediastinum);

Lymphosarcoma of the nasopharynx;

Lymphosarcoma of peripheral (cervical, axillary, inguinal) lymph nodes.

Less common is an isolated lesion of lymphosarcoma of bones, soft tissues, skin, and internal organs. In principle, lymphatic tissue is present throughout the human body, so it is possible to develop lymphosarcoma in any organ or tissue.

When a tumor occurs in the abdominal cavity, two variants of the clinical picture are possible:

If the intestines are affected, the growth of the tumor leads to its obstruction, and the child is admitted to the hospital for urgent indications;

When the tumor is located outside the intestine, its growth leads to an increase in the volume of the abdomen, and children are admitted for treatment only in advanced stages of the process.

Upon careful questioning of the parents, it turns out that the tumor did not develop asymptomatically. Parents indicate subtle signs at the beginning of the disease: some children had some kind of vague abdominal pain, changes in appetite, diarrhea, alternating with constipation. Since these phenomena were not very pronounced, parents, and often medical workers, believed that all this was due to errors in the diet, the presence of worms, etc.

In the primary lesion of lymphosarcoma of the lymphatic tissues of the chest, the first manifestations of the disease are most often signs characteristic of viral and inflammatory diseases: fever, cough, malaise. Shortness of breath, swelling of the face, expansion of the saphenous veins of the skin of the chest wall, as a rule, are detected with an advanced tumor process. Mediastinal lymphosarcoma is characterized by a very aggressive course, and the rapidly developing clinical picture requires urgent special treatment.

The most informative diagnostic method in polyclinic conditions is chest X-ray, which is not very readily prescribed due to the exaggerated risk of harm from radiation.

Oddly enough, lymphosarcoma of the glands of the pharyngeal ring is diagnosed quite late, because the existing pathological changes in the soft palate and tonsils are interpreted as a manifestation of the inflammatory process. The appearance of metastases in the cervical lymph nodes, which is expressed by their increase, forces a more thorough examination of the child by an ENT specialist. Of the clinical signs that parents should pay attention to, it is necessary to indicate voice changes, nasal discharge, nasal discharge without obvious signs of viral diseases such as SARS or influenza.

Lymphosarcoma of the peripheral lymph nodes (often the cervical nodes are primarily affected) in its clinical manifestations practically does not differ from the one we described earlier in the section on lymphogranulomatosis. Of course, a specialist, examining a child, will already notice the difference between these diseases during palpation, but there is not much point in presenting these medical subtleties here. According to the clinical course, lymphosarcoma, of course, is characterized by a more rapid course than lymphogranulomatosis, and the pre-treatment period is determined by weeks, not months. In the presence of lymphosarcoma, the use of thermal procedures (especially physiotherapy) is very harmful to the course of the disease, under the influence of which tumor growth is accelerated. In connection with this circumstance, I would like to warn against prescribing any methods of treating enlarged lymph nodes if the diagnosis is not exactly established.

Tumors of the kidneys

Kidney tumors in children are undoubtedly congenital and are usually diagnosed at an early age. The peak of detection of these tumors falls on the age of 2-5 years. Boys and girls get sick equally often.

The manifestations of the tumor symptom complex described above, as a rule, are not noticed by the parents, and only an increase in the tumor to the size when it begins to be palpated or becomes visible "by eye" makes the parents consult a doctor. If parents are carefully questioned, it turns out that some symptoms did occur: some children complained of pain in the abdomen or lower back, most had changes in appetite and normal behavior, some had unexplained rises in body temperature. Unfortunately, these signs are not noticed by the parents, since the general condition of the child with a kidney tumor remains quite satisfactory for a long time. It is much worse that parents, having noticed an increase in the abdomen or felt a tumor, do not pay attention to it, believing that the child has rickets or simply an enlarged liver or spleen. More rarely, the first sign of a kidney tumor is an admixture of blood in the urine (sometimes so insignificant that it is detected only by microscopic examination).

Neuroblastoma

Even more rare is neuroblastoma, a tumor that develops from nervous tissue. The favorite sites of these tumors are the retroperitoneum and mediastinum. This tumor also has a congenital character and is detected at a fairly early age.

Unlike kidney tumors, with neuroblastoma of the retroperitoneal space, one of the first clinical signs may be pain in the legs (most often in the knee joints) and changes in the blood test (decrease in hemoglobin) appear quite early.

In a child, earlier than with a kidney tumor, pallor of the skin occurs, small hemorrhages on the skin may appear. In a later period, the tumor becomes visible to the eye or palpable in the upper abdomen.

Since neuroblastoma develops very quickly, situations are possible when the first sign that parents will pay attention to is not the tumor itself, but its metastases - in the skull bone (dense tubercles appear on the scalp), in the orbital bone (appears near the eye " bruising" or marked protrusion of the eyeball).

When mediastinal neuroblastoma is affected in the early stages, the disease is asymptomatic, and the tumor is detected only during an X-ray examination performed for some other disease. In later stages, neuroblastoma can grow into the spinal canal, which is accompanied by a characteristic clinic: paralysis of the lower or upper extremities, disorders of the functions of the pelvic organs in the form of urinary and stool incontinence.

bone tumors

Of the numerous malignant bone tumors in childhood, two types are most often diagnosed - osteogenic sarcoma and Ewing's tumor. The first, as a rule, affects round bones (femur, tibia, humerus), the second - flat bones (scapula, pelvic bones, ribs). Both tumors can affect any bone.

The most characteristic sign of bone tumors in children is pain that occurs without obvious indications of injury. A little later, a swelling appears over the lesion.

Ewing's tumor is also characterized by an element of inflammation, that is, the appearance of pain and swelling may be accompanied by an increase in body temperature and skin over the pathological focus. In the blood test, changes characteristic of inflammatory diseases are revealed - an increase in ESR and the number of leukocytes.
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