From the case files

Brain cancer accounts for quarter of all childhood cancers, yet many GPs may still not have experience of the condition. Dr Rachel Birch outlines a case where diagnosis could have been made earlier

Top tip - Early diagnosis is important for the best outcome so maintain a high index of suspicion for this condition when reviewing children with unexplained symptoms.

Childhood brain cancer

At presentation, Peter was 14 years old and had presented with migraines since the age of 8. He was taking Pizotifen and his headaches were well controlled. Over the past four weeks he had started getting headaches again. They were in a similar location to his migraines, but were different in nature – he couldn’t put his finger on exactly how.

His mother took him to see Dr G who attributed his increased headaches to puberty and the fact that he had a new job doing a morning paper round. He advised better sleep hygiene and suggested that Peter use Sumatriptan when the headaches were severe.

Four weeks later the headaches were no different. In addition, Peter had started to feel sick a lot in the mornings and occasionally vomited. His mother told Dr G she was worried he had a brain tumour. In the consultation Peter admitted to feeling stressed about upcoming exams and was tearful, stating that he couldn’t cope with the headaches any more. Examination was normal and Dr G felt that Peter was anxious. He arranged a CAMHS referral and agreed to see him again in two weeks.

After two weeks his mother attended with him and they saw the GP registrar, Dr W. Peter’s mother was concerned that Peter was sleeping every evening for an hour after school and seemed lethargic and disinterested most of the time. She wondered whether Peter might be depressed.

Dr W questioned Peter further and found that the headaches were present on wakening most mornings and that he had been sick on occasions at school break time. Neurological examination was normal.

Dr W was concerned about Peter’s symptoms and arranged same day referral to paediatrics. The next day, following an MRI scan, Peter was diagnosed with a brain tumour. Subsequently this turned out to be a low grade astrocytoma and Peter underwent surgery a few days later.

Fortunately after six months, Peter is doing well, and the surgery is believed to be curative at this stage.

Peter’s mother made a complaint to the practice about the six-week delay in his diagnosis. Dr G undertook a SEA with the practice team to review the case. He met with Peter and his mother, offered an apology and shared with them what they had learnt from the incident and what steps the GPs would take to raise their awareness of childhood brain tumours. Peter’s mother was satisfied with this approach and no further action was taken.

Learning point

• Always reassess a child with a history of migraine or tension headaches if the headache changes.
• Suspect a brain tumour if there is a history of persistent headaches on wakening for more than four weeks.
• Persistent vomiting on wakening for more than two weeks should be considered a red flag.
• Lethargy is the most common behavioural change associated with brain tumors.
• Listen to the parents' concerns as they know their children well and can pick up subtle changes in their behaviour and health. 

Guidance

All GPs should be familiar with Brain Pathways Guideline developed by the Children’s Brain Tumour research centre in Nottingham and is endorsed by the Royal College of Paediatrics and Child Health (RCPCH) and NICE*.

It advises that doctors should consider a brain tumour in any child presenting with:

• Headache
• New, persistent headache, for more than four weeks, occurring at any time (children under four may not be able to complain of headache – observe behaviour)
• Nausea and/or vomiting
• Persistent nausea and/or vomiting for more than two weeks
• Visual symptoms and signs
• Reduced visual acuity or fields
• Abnormal eye movements
• Abnormal fundoscopy
• Motor symptoms and signs
• Abnormal gait or coordination
• Focal motor weakness
• Growth and development abnormalities
• Growth failure
• Delayed, arrested or precocious puberty
• Behavioural change. Most commonly lethargy
• Diabetes insipidus
• Seizures
• Altered consciousness

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