Case 20 - Haematologcal Malignancies Flashcards
What is normal lymph node anatomy?
200-400 lymph nodes in the neck
Act as filters for the lymphatic fluid
Fluid leaks out of capillaries > interstitial fluid > lymphatic system > jugular vein > SVC
Have a hilum, and an outer cortex (B cells), inner germinal centre is where there is proliferation of lymphocytes
When the lymphocytes in the cortex proliferate upon recognition of a pathogen, it increases the size of the lymph node and causes lymphadenopathy
What is defined at lymphadenopathy in adults and children?
Most children have lymphadenopathy at some point
>2cm width in a lymph node in a child is lymphadenopathy
>1cm is adult lymphadenopathy
But any persistent Sx associated with a swollen node is relevant
How will inflammatory lymphadenopathy present?
The lymph node will be hot, and swollen, fluctuating in size
Often tender too
Associated illness or symptoms often alongside the lymphadenopathy
Could be a head or neck illness
Could be cervical TB (in immunocompromised) - becomes very red around the area and may burst through the skin and seep pus
Why might lymph nodes be malignant?
Could due to metastasis do the lymph nodes e.g. in cervical lymph nodes could be due to head, neck, throat, thyroid cancer etc.
These are fixed and irregular
Could also by lymphoma - cancer of the lymphocytes themselves
How do you test for inflammatory lymph nodes?
Based on history of infection
Can do BTs e.g. WCC and CRP to check for inflammation
CXR for TB or to look at hilar lymph nodes
What is malignant lymphoma?
A cancer of the lymphocytes - does not have to be based at the lymph nodes, can be anywhere that lymphocytes are found - usually non-Hodgkins
More common in B cells than T cells
What are RFs for malignant lymphoma?
FHx EBV HPV Smoker Alcohol Caucasian
But most have unknown cause
What are symptoms of lymphoma?
Non-specific symptoms, like tiredness, lethargy Painless, slow growing lump May have pain Dysphagia Odynophagia
B symptoms are constitutional:
- Night sweats
- Weight loss
- Fever
Assessment of lymphoma?
Will do full history
Reticuloendothelial exam
Head and neck exam including fibreoptic endoscopy in the ENT head and neck lump clinic
Then can either take a USS guided FNA, or do a biopsy
Biopsy is more invasive but gives a more definite diagnosis
USS
CT/MRI
PET
Histology of lymphoma?
In Hodgkins lymphoma, will see the presence of Reed-Sternberg cells ‘owl eyes’ appearance
In non-Hodgkins will just see abnormal cells in an increased number depending on the type of non-Hodgkins
Staging of lymphoma
Using Ann Arbor system:
- Stage 1 = only one group of nodes
- Stage 2 = 2+ groups of nodes but only on one side of the diaphragm
- Stage 3 = on both sides of the diaphragm
- Stage 4 = spread to other organs
What are the types and subtypes of lymphoma?
Hodgkins Non-Hodgkins - high or low grade -Diffuse B cell -T cell -Follicular
What is Hodgkin’s lymphoma?
Presence of Reed-Sternberg cells
Peaks between 15-30y and 50y+
Relapse rare after 5y is rare
Can be:
-Lymphocyte predominant
-Nodular sclerosis - collagen bound nests of Hodgkins –Mixed cellularity
-Lymphocyte depleted
Will see inflammatory cell infiltration too, this is not seen in non-Hodgkins lymphoma
What are the types of non-hodgkins lymphoma?
Diffuse B cell 60y median age Most common type Aggressive but responds well to treatment (high grade) LDH is associated with prognosis
T cell
Can be of the skin and difficult to diagnose
High grade
Follicular
Median age is 60y
Chemo/radiotherapy if there’s symptoms
Seen as incurable due to relapse, but controllable - low grade
Treatment of Hodgkin’s lymphoma?
Assess the stage of Hodgkins lymphoma
1, 2, 3A can be treated with radiotherapy alone
3B and 4 treated with ABVD chemotherapy
