eMedicine Specialties > Pediatrics: General Medicine > Oncology

Rhabdomyosarcoma: Follow-up

Author: Timothy P Cripe, MD, PhD, Professor of Pediatric Hematology/Oncology, University of Cincinnati; Director, Translational Research Trials Office, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
Contributor Information and Disclosures

Updated: Dec 2, 2008

Follow-up

Further Inpatient Care

  • Chemotherapy: Chemotherapy cycles are usually administered every 3 weeks (although vincristine is periodically given weekly) in patients with rhabdomyosarcoma (RMS), depending on recovery of the bone marrow. Patients receiving cycles that include cyclophosphamide, ifosfamide, and etoposide generally require inpatient admission for drug administration and monitoring.
  • Fever and neutropenia: Admission is required to administer intravenous (IV) antibiotics and to monitor patients.
  • Other reasons for inpatient care: Patients may require admission for a multitude of other medical problems during the chemotherapy phase of treatment, including varicella infection (to administer IV acyclovir and to monitor), mucositis (resulting from narcotics use), dehydration, meningitis, constipation, fungal pneumonia, and cystitis, among others.

Further Outpatient Care

  • CBC count: Perform a CBC count twice each week in patients receiving therapy by using granulocyte-colony stimulating factor (G-CSF) so that G-CSF can be discontinued when the absolute neutrophil count has reached a predetermined level (usually 1 or 5 X 109/L [1000 or 5000/µL]).
  • Blood chemistry: Monitor blood chemistry results and liver function in patients receiving parenteral nutrition or in those who have a history of toxicity, especially if the patient continues to receive nephrotoxic or hepatotoxic antibiotics or other drugs.
  • Chemotherapy: Depending on the protocol, some chemotherapy regimens (eg, vincristine, dactinomycin in particular) can be administered on an outpatient basis.
  • Monitoring for recurrence: Continue to perform blood tests and radiographic scans on an outpatient basis, with the frequency decreasing over time. In general, patients should be examined every 3 months for the first year, every 6 months for the second and third years, and yearly thereafter.
  • Long-term follow-up care: At 5 or longer after the end of therapy, patients are considered to be long-term survivors. Patients should be examined annually at a late-effects clinic and monitored with appropriate studies depending on the type of therapy they received. Visits may include hormonal, psychosocial, and neurologic evaluations, as well as follow-up examinations by the radiotherapist.

Inpatient & Outpatient Medications

  • Trimethoprim-sulfamethoxazole: Prophylaxis against pneumocystic pneumonia should continue until 6 months after the end of chemotherapy.
  • Fluconazole: Systemic fungal prophylaxis is not necessary.
  • Clotrimazole: Prophylactic therapy for thrush may be discontinued after chemotherapy is completed.
  • Chlorhexidine mouth rinse: Prophylaxis against gingivitis and other mouth infections may be discontinued after chemotherapy is completed.

Transfer

  • Although major cancer therapy should take place at a center with pediatric oncologists, the child's referring pediatrician or general practitioner should continue to play an important role in the child's care throughout treatment.
  • The referring physician can be critical in performing the first evaluation of an illness, particularly if the child lives far from an oncology center.

Deterrence/Prevention

  • No preventive measures are known for childhood cancers.

Complications

The treatment of rhabdomyosarcoma results in a multitude of potential long-term adverse effects.19 The most common findings include the following:

  • Cardiomyopathy
    • In patients who receive an anthracycline, cardiac function must be monitored to assess for the development of cardiomyopathy.
    • Cardiomyopathy may also from cyclophosphamide use.
  • Pulmonary failure
  • Metabolic derangements: Ifosfamide use, in particular, can lead to renal electrolyte wasting (Fanconi syndrome).
  • Secondary malignant neoplasms
    • Secondary malignant neoplasms may arise as a result of radiotherapy and chemotherapy, particularly with alkylating agents.
    • Etoposide markedly increases the risk for acute myelogenous leukemia, particularly when regimens with frequent dosing schedules are used.
    • Radiation therapy increases the risk of second malignancies, including skin and bone tumors.

Patient Education

  • Chemotherapy: Parents and patients (if appropriate) must undergo formal training to learn about the adverse effects of chemotherapy. They must know what is expected to happen as a result of the therapy and are encouraged to ask questions.
  • Central venous catheters
    • When patients have central venous catheters that exit the skin (eg, Hickman or Broviac catheters), the parents or the patient must learn to properly care for the line. This care usually involves daily heparin flushes.
    • Patients and parents must understand the limitations on activities because of central venous catheters. For example, swimming is not permitted.
    • Patients with subcutaneous catheters (eg, Mediport catheters) do not need to perform daily care, but they should learn to apply a topical anesthetic (eg, EMLA cream, or lidocaine-prilocaine cream) at least 1 hour before an anticipated needle stick.

Miscellaneous

Medicolegal Pitfalls

  • Although uncommon, legal issues associated with delayed diagnosis of rhabdomyosarcoma (RMS) are becoming more important, especially to primary care providers.
  • Therefore, rhabdomyosarcoma must be considered in the differential diagnosis in any patient with symptoms suggestive of cancer or a palpable mass.
 


More on Rhabdomyosarcoma

Overview: Rhabdomyosarcoma
Differential Diagnoses & Workup: Rhabdomyosarcoma
Treatment & Medication: Rhabdomyosarcoma
Follow-up: Rhabdomyosarcoma
References
[ CLOSE WINDOW ]

References

  1. Arndt CA, Crist WM. Common musculoskeletal tumors of childhood and adolescence. N Engl J Med. Jul 29 1999;341(5):342-52. [Medline].

  2. Stout AP. Rhabdomyosarcoma of the skeletal muscles. Ann Surg. 1946;123:447-72.

  3. Pappo AS, Shapiro DN, Crist WM, Maurer HM. Biology and therapy of pediatric rhabdomyosarcoma. J Clin Oncol. Aug 1995;13(8):2123-39. [Medline].

  4. Barr FG. Molecular genetics and pathogenesis of rhabdomyosarcoma. J Pediatr Hematol Oncol. Nov-Dec 1997;19(6):483-91. [Medline].

  5. Merlino G, Helman LJ. Rhabdomyosarcoma--working out the pathways. Oncogene. Sep 20 1999;18(38):5340-8. [Medline].

  6. Punyko JA, Mertens AC, Baker KS, et al. Long-term survival probabilities for childhood rhabdomyosarcoma. A population-based evaluation. Cancer. Apr 1 2005;103(7):1475-83. [Medline].

  7. Oberlin O, Rey A, Lyden E, et al. Prognostic factors in metastatic rhabdomyosarcomas: results of a pooled analysis from United States and European cooperative groups. J Clin Oncol. May 10 2008;26(14):2384-9. [Medline].

  8. Mazzoleni S, Bisogno G, Garaventa A, et al. Outcomes and prognostic factors after recurrence in children and adolescents with nonmetastatic rhabdomyosarcoma. Cancer. Jul 1 2005;104(1):183-90. [Medline].

  9. Gripp KW. Tumor predisposition in Costello syndrome. Am J Med Genet C Semin Med Genet. Aug 15 2005;137C(1):72-7. [Medline].

  10. Qualman SJ, Coffin CM, Newton WA, et al. Intergroup Rhabdomyosarcoma Study: update for pathologists. Pediatr Dev Pathol. Nov-Dec 1998;1(6):550-61. [Medline].

  11. Wolden SL, Wexler LH, Kraus DH, et al. Intensity-modulated radiotherapy for head-and-neck rhabdomyosarcoma. Int J Radiat Oncol Biol Phys. Apr 1 2005;61(5):1432-8. [Medline].

  12. Yock T, Schneider R, Friedmann A, et al. Proton radiotherapy for orbital rhabdomyosarcoma: clinical outcome and a dosimetric comparison with photons. Int J Radiat Oncol Biol Phys. Nov 15 2005;63(4):1161-8. [Medline].

  13. Currier MA, Adams LC, Mahller YY, et al. Widespread intratumoral virus distribution with fractionated injection enables local control of large human rhabdomyosarcoma xenografts by oncolytic herpes simplex viruses. Cancer Gene Ther. Apr 2005;12(4):407-16. [Medline].

  14. Modak S, Guo HF, Humm JL, et al. Radioimmunotargeting of human rhabdomyosarcoma using monoclonal antibody 8H9. Cancer Biother Radiopharm. Oct 2005;20(5):534-46. [Medline].

  15. Bersani F, Taulli R, Accornero P, et al. Bortezomib-mediated proteasome inhibition as a potential strategy for the treatment of rhabdomyosarcoma. Eur J Cancer. Apr 2008;44(6):876-84. [Medline].

  16. Cao L, Yu Y, Darko I, et al. Addiction to elevated insulin-like growth factor i receptor and initial modulation of the AKT pathway define the responsiveness of rhabdomyosarcoma to the targeting antibody. Cancer Res. Oct 1 2008;68(19):8039-48. [Medline].

  17. Klingebiel T, Boos J, Beske F, et al. Treatment of children with metastatic soft tissue sarcoma with oral maintenance compared to high dose chemotherapy: report of the HD CWS-96 trial. Pediatr Blood Cancer. Apr 2008;50(4):739-45. [Medline].

  18. Pappo AS, Lyden E, Breitfeld P, et al. Two consecutive phase II window trials of irinotecan alone or in combination with vincristine for the treatment of metastatic rhabdomyosarcoma: the Children's Oncology Group. J Clin Oncol. Feb 1 2007;25(4):362-9. [Medline].

  19. Punyko JA, Mertens AC, Gurney JG, et al. Long-term medical effects of childhood and adolescent rhabdomyosarcoma: a report from the childhood cancer survivor study. Pediatr Blood Cancer. Jun 15 2005;44(7):643-53. [Medline].

  20. Pappo AS, Shapiro DN, Crist WM. Rhabdomyosarcoma. Biology and treatment. Pediatr Clin North Am. Aug 1997;44(4):953-72. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

rhabdomyosarcoma, RMS, alveolar rhabdomyosarcoma, botryoid rhabdomyosarcoma, embryonal rhabdomyosarcoma, spindle cell rhabdomyosarcoma, pleomorphic rhabdomyosarcoma, soft tissue sarcoma, rhabdomyoblasts, pediatric sarcoma, sarcoma, respiratory difficulty, lung nodules, pleural effusion, anemia, thrombocytopenia, neutropenia, menorrhagia, metrorrhagia, neurofibromatosis, Li-Fraumeni syndrome, Rubinstein-Taybi syndrome, Gorlin basal cell nevus syndrome, Beckwith-Wiedemann syndrome, Costello syndrome, Arnold-Chiari malformation

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Timothy P Cripe, MD, PhD, Professor of Pediatric Hematology/Oncology, University of Cincinnati; Director, Translational Research Trials Office, Department of Pediatrics, Cincinnati Children's Hospital Medical Center
Timothy P Cripe, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American Pediatric Society, American Society of Hematology, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Samuel Gross, MD, Professor Emeritus, Department of Pediatrics, University of Florida, Clinical Professor, Department of Pediatrics, UNC, Adjunct Professor, Department of Pediatrics, Duke University
Samuel Gross, MD is a member of the following medical societies: American Association for Cancer Research, American Society for Blood and Marrow Transplantation, American Society of Clinical Oncology, American Society of Hematology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Steven K Bergstrom, MD, Assistant to the Chairman, Department of Pediatrics, Division of Hematology-Oncology, Kaiser Permanente Medical Center of Oakland
Steven K Bergstrom, MD is a member of the following medical societies: Alpha Omega Alpha, American Society of Clinical Oncology, American Society of Hematology, American Society of Pediatric Hematology/Oncology, Children's Oncology Group, and International Society for Experimental Hematology
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Max J Coppes, MD, PhD, MBA, Executive Director, Center for Cancer and Blood Disorders, Children's National Medical Center; Professor of Medicine, Oncology, and Pediatrics, Georgetown University
Max J Coppes, MD, PhD, MBA is a member of the following medical societies: American Association for Cancer Research, American Society of Pediatric Hematology/Oncology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.