Cancers from Oxford handbook Flashcards
what is chronic lymphocytic leukaemia?
Accumulation of mature B cells that have escaped programmed cell death and undergone cell cycle arrest in G0/G1 phase.
What symptoms and signs may be present with CLL?
Usually coincidental finding on FBC.
If symptoms are present- may be anaemic, weight loss, sweats and anorexia.
Signs- enlarged rubbery non-tender lymph nodes, hepatosplenomegaly.
What test findings will be present in CLL?
FBC- increased lymphocytes
Later signs- marrow infiltration causes neutropenia, anaemia and thrombocytopenia.
May have autoimmune haemolysis.
What can complicate CLL?
Autoimmune heamolysis (IgM mediated cold autoimmune haemolytic anaemia. Autoantibodies targeted against cells causing extravascular haemolysis and spherocytes) Infection- bacterial, viral esp herpes zoster. Marrow failure
What often causes death in CLL?
Commonly caused by infection (pneumococcus, haemophillus, meningococcus)
How do you treat CLL?
Consider drugs if symptomatic- 1st line- fludarabine + cyclophosphamide + ritixumab
Steroids will help with autoimmune heamolysis Radiotherapy- helps treat lymphadenopathy and splenomegaly
IV immunoglobulin if recurrent infection
What is chronic myeloid leukaemia?
Proliferation of myeloid cells (type of myeloproliferative disorder).
How does chronic myeloid leukaemia present?
Mostly chronic and insidious symptoms- weight loss, tiredness, fever, sweats.
May be features of gout (due to purine breakdown), bleeding (platelet dysfunction), abdominal discomfort (splenic enlargement)
Signs of CML?
Splenomegaly, anaemia, easy bruising
On testing, what will the bloods show in CML?
High WCC with whole spectrum of myeloid cells- increased neutrophils, myelocytes, basophils, eosinophils. Hb will be decreased or normal Platelets are variable.
Describe the bone marrow in CML?
Hypercellular
Describe the progression of CML?
Three stages- chronic, accelerated and blast transformation.
Chronic phase- Few if any symptoms- lasts months or years
Accelerated phase- increasing symptoms, spleen size increasing, difficulty in controlling counts
Blast transformation- acute leukaemia features +/- death.
How do you treat CML?
Drug- imatinib- BCR-ABL tyrosine kinase inhibitor. Allogenic stem cell transplantation- 1st line in young patients
What is a lymphoma?
Disorder caused by malignant proliferations of lymphocytes.
These accumulate in the lymph nodes causing lymphadenopathy but may also be found in the peripheral blood or infiltrate organs.
How are lymphomas divided?
Histologically into Hodgkins and non-Hodgkins lymphoma.
Describe Hodgkins lymphoma?
Characteristic cells with mirror image nuclei are found- called Reed Sternberg cells.
Symptoms of Hodgkins lymphoma?
Often presents with enlarged, painless, non-tender, ‘rubbery’ superficial lymph nodes- typically cervical but also axillary and inguinal.
25% have constitutional upset- e.g. fever, weight loss, night sweats, priuritis and lethargy.
Alcohol induced lymph node pain
Mediastinal lymph node involvement can cause features due to mass effect e.g. bronchial or SVC obstruction or direct extension causing pleural effusions
Signs of Hodgkins lymphoma?
Hepatosplenomegaly
Lymph node enlargement
Cachexia
Anaemia
How do you diagnose Hodgkins lymphoma?
Tissue diagnosis- excision biopsy of lymph nodes
Bloods- Increased ESR or decreased Hb indicate a worse prognosis.
LDH is raised as it is released during cell turnover.
How do you stage Hodgkins?
Done by CXR, CT, PET of thorax, abdominen and pelvis + marrow biopsy if B symptoms
I- confined to single lymph node region
II- involvement of two or more nodal areas on the same side of the diaphragm
III- Involvement of nodes on both sides of the diaphragm
IV- Spread beyond the lymph nodes.
NOTE-
The stage is accompanied by the letter A or B. The letter A means no B symptoms are present. The letter B means B symptoms are present (>10% weight loss in last 6 months, unexplained fever >38, night sweats (needing a change of clothing).
How do you treat Hodgkins lymphoma?
IA and IIA- radiotherapy +/- short doses of chemo
Longer courses of chemo in IIA- IVB with >3 areas involved.
In younger patients ABVD- Adriamycin, Bleomycin, Vinblastine and Dacarbazine + radiotherapy cures about 80%.
What is Non-Hodgkins lymphoma?
This is a category of lymphoma without Reed Sternberg cells. Most are derived from B cell lines- commonest being diffuse large B cell granuloma. (NOTE- not all centre around nodes)
How does a patient with Non-Hodgkins disease present?
75% present with nodal disease- causing superficial lymphadenopathy
25% present with extranodal disease
- Oropharynx- Walders ring lymphoma causing sore throat/obstructed breathing
- Gut- Gastric MALT is caused by H pylori and may regress with its eradication. Symptoms of gastric carcinoma with systemic symptoms (fever,sweats). Non MALT ones are high grade tumours that dont respond to H pylori eradication therapy.
- Small bowel lymphomas- IPSID- presents with diarhoea, vomiting, abdominal pain and weight loss
Systemic symptoms of non-hodgkins lymphoma?
Fever, night sweats, weight loss (less common that in Hodgkins)
Pancytopenia from marrow involvement- anaemia, infection, bleeding.
Tests on non-Hodgkins lymphoma?
FBC, LDH (increased in worse prognosis)
Marrow and node biopsy for classification
Staged the same as Hodgkins.
Describe the characteristics of low and high grade non-Hodgkins lymphoma?
Low grade lymphomas are often indolent, incurable and widely dissemianted. Generally include- follicular lymphoma, marginal zone lymphoma, lymphoplasmoid lymphoma.
High grade lymphomas are more aggressive but often curable. There is often rapidly enlarging lymph nodes with systemic symptoms. Includes- Burkitts lymphoma, diffuse large B cell lymphoma.
How do you treat low grade non-Hodgkins lymphoma?
Low grade- symptomless- may not need treatment
Radiotherapy may be curative in local disease.
Chlorambucil is used in diffuse disease.
How do you treat high grade Non Hodgkin lymphoma?
R-CHOP regimen
R-rituximab
C-cyclophosphamide
H-Hydroxydaunorubicin
O-vincristine (known as oncovin)
P- prednisolone
