Pediatric emergency medicine trisk 2711 2711
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rhabdomyosarcoma tend to have characteristic presentations. Botryoid tumors tend
to grow in potential spaces such as the bladder and vagina. Embryonal tumors often
occur in the GU tract, orbit and head, neck, and parameningeal locations. Alveolar
tumors often present in the extremities and have a worse prognosis.
Rhabdomyosarcoma can metastasize to local lymph nodes, lungs, bone, and rarely
bone marrow.
There are many benign causes of soft tissue masses in children but the emergency
clinician needs to consider cancer as a possible cause. Diagnostic evaluation should
include a thorough history and physical examination. The history should focus on
symptoms caused by the mass and other systemic or constitutional symptoms that
may be present. When a reasonable suspicion for cancer exists, laboratory
evaluation should include a CBC, renal and liver function tests, and serum LDH. A
plain radiograph of the affected area can be useful to look for bone destruction or
fracture from an underlying bone lesion. A true soft tissue mass, however, is best
imaged with an MRI. Often patients can be discharged with follow-up securely
arranged with a pediatric oncologist for further diagnostic workup and initiation of
appropriate therapy. Inpatient management may be needed for pain control or if cord
compression complicates the presentation.
CANCERS OF THE SKIN
Primary cancers of the skin, such as squamous or basal cell carcinoma or melanoma,
are seen in the adult practice setting but rarely occur in children. Melanoma
accounts for less than 3% of all childhood malignancies but occurs occasionally in
adolescents 15 to 19 years old. There may be increased risk in the setting of
immunosuppression, immunodeficiencies, history of radiation therapy or stem cell
transplant, giant congenital nevi, giant congenital melanocytic nevi, or xeroderma
pigmentosum. Other pediatric cancers may involve the skin, such as leukemia,
which may produce leukemia cutis (particularly in infant ALL or in AML). A rash
may be part of the presentation of histiocytic disorders, such as HLH or LCH.
Neuroblastoma does not affect the skin but may present with subcutaneous
pigmented nodules visible through the skin.
Management in the ED should begin with a thorough history and physical
examination. The examination should be used to screen for other skin lesions,
lymphadenopathy, hepatosplenomegaly, masses, or other signs of malignancy that
might be related to the skin findings. If the history and physical examination suggest
a particular diagnosis, then further laboratory or radiographic evaluation may be
helpful. If not, and if the patient appears to be stable without signs or symptoms of
systemic illness, then the patient can be discharged to home with follow-up secured
with either oncology or dermatology. When cancer is suspected, a biopsy will aid in
the diagnosis and involvement from a dermatopathologist with pediatric experience
