Haematological (lymphatic and bone marrow) Flashcards
How do we treat Hodgkin’s lymphoma?
MDT agrees an individual treatment plan:
Haematologist, specialist nurse, clinical oncologist, radiologist and specialist radiologist
Stages 1A, 2A (<3 areas affected) are treated with radiotherapy with short courses of chemotherapy
Stages 2A (>3 areas affected) and all others have radiotherapy and longer courses of chemotherapy
Chemotherapy is four drugs; ABVD Adriamycin Bleomycin Vinblastine Dacarbazine
Stop smoking support - particularly important because chemotherapy causes cardiovascular problems, and smoking increases this risk by 20 times.
How do we treat non-Hodgkin’s lymphoma?
Asymptomatic and low grade = no treatment
Low grade (indolent) but diffuse = chlorambucil (chemotherapy) -INCURABLE: MEDIAN SURVIVAL 10 years-
High grade (aggressive) RCHOP chemotherapy:
Rituximab (CD20 B cell targeter)
Cyclophosphamide (dna alkylating antineoplastic)
Oncovin (vincristine; alkaloid, inhibits cell cycle by binding microtubular proteins)
-50% OF CASES CURED-
Prednisalone
In a woman of age 18 to 35, what are the main issues associated with treatment of lymphoma?
In short: post ABVD chemotherapy, six month wait minimum, normally two year wait.
- Chemotherapy drugs used to treat lymphoma are anti-mitotic, they disturb the menstrual cycle and reduce fertility in women.
- Fertility should recover after Hodgkin’s Lymphoma ABVD treatment within 6 months. - The highest risk of relapse from Hodgkin’s Lynn father is in the first two years after treatment.
- Recommendation is to delay pregnancy until after this period has passed to ensure any further treatment has finished
What might we offer older women who require more gonadotoxic chemotherapy?
Fertility hospital referral and egg or embryo storage
Which period following treatment of Hodgkin’s lymphoma is the risk of relapse greatest?
Two years
After 5 years, risk of relapse is very low
Over 80% of people are cured
What are the most common acute side effects of chemotherapy?
Damage to nerves - numbness/pins and needles (usually improves, myeloma drugs)
Arrythmias and heart failure - anthracyclines commonly do this
Fatigue (tiredness) and lethargy (weakness)
Easy bruising, nosebleeds and bleeding gums - drop in platelet number
Increased risk of infection - neutropenic sepsis
Hearing loss (sometimes)
Anemia (paleness and Dyspnoea)
Nausea and vomiting
Reduced appetite
Diarrhoea and mouth ulcers
Increased risk of clots
Reduced fertility
Thinning hair or hair loss (usually temporary)
Dry skin or rashes
Brittle nails or leukonychia
Cognitive dysfunction
What are the most common long term side effects of chemotherapy?
Heart and lung damage
Chemotherapy-induced cancer: especially alkylating chemotherapy (cyclophosphamide, platins, procarbazine etc)
Long term cognitive impairment
Sometimes permanent infertility - all men under 55 are offered sperm banking!
What is the treatment for acute lymphoblastic leukaemia?
- Support - transfusion and fluids
- Immediate IV antibiotics - neutropenia regime
- Prophylactic antivirals, antifungals and antibiotics
- Chemotherapy - cure rate is 70-90% in children but only 40% in adults
What is the treatment for acute myeloid leukaemia?
- Chemotherapy
- Bone marrow transplant
60% long term survivor rate
What is the treatment for chronic myeloid leukaemia?
- Imatinib - Tyrosine kinase inhibitor
- Stem cell transplantation
Median survival is 5-6 years
What is the treatment for chronic lymphocytic leukaemia?
- Radiotherapy
- Stem cell transplantation
- Supportive care
33% never progress
33% progress slowly
33% progress rapidly
Why is stopping smoking so important in patients who have chemotherapy?
Stop smoking support is always offered - particularly important because chemotherapy causes cardiovascular problems, and smoking increases this risk by 20 times.
Smoking is a cardiovascular risk factor in itself!
How does radiotherapy work?
It is targeted at the rapidly dividing tumour cells, and preferentially damages the rapidly dividing cells, causing their death.
Example: linear accelerator
What is the prognosis for:
- Hodgkin’s lymphoma?
- Diffuse large B cell non-Hodgkin’s lymphoma?
- Follicular non-Hodgkin’s lymphoma?
- Multiple Myeloma?
- Hodgkin’s lymphoma = >80% cured
- Diffuse large B cell non-Hodgkin’s lymphoma = 50% cured, relapse after five years is rare
- Follicular non-Hodgkin’s lymphoma = incurable, relapses very common
- Multiple myeloma = incurable (survive 5 years in 50% of patients)
The more indolent, the more incurable.
The more aggressive, the more curable.
What factors are important in choosing chemotherapy drugs for a patient with lymphoma?
PMH:
IHD - some drugs affect the heart more than others
DM - some drugs affect glucose metabolism
Renal impairment - need drugs that aren’t renal,y excreted
Liver impairment - need drugs that don’t damage the liver further
Histological subtype (but not stage of lymphoma, since all stages will be treated in the same way)
Patient wishes
Which haematological malignancies can’t be cured?
Advanced stage follicular lymphoma (NH lymphoma)
Multiple myeloma
Chronic myeloid leukaemia
What is the treatment for hereditary spherocytosis?
Regular folic acid and splenectomy (if necessary)
What is the treatment for sickle cell crisis? I.e.acute treatment for sickle cell anaemia
IV opiates, fluids and oxygen by mask
Also:
Blood cultures and midstream urine If signs of infection are present
Give transfusion if Hb or reticulocytes drop sharply
What is the long term management for sickle cell disease?
Stay warm and hydrated
Keep to regular hours to reduce stress
Eat well
Take penicillin regularly - due to hyposplenism and subsequent immunocompromise
Transcranial doppler (USS on temporal bone) - for any change in blood flow, which means partial obstruction, and indicates increased likelihood of stroke.
If regular crises occur: take hydroxycarbamide or hydroxyurea (induces HbF production).
What is the treatment for all types of thalassemia?
Life-long transfusions, to suppress extramedullary haematopoiesis
Stem cell transplantation
Iron chelation - prevent iron overload (causes hypothyoidism, hypocalcemia and hypogonadism)
Splenectomy
Hormonal replacement/treat endocrine complications
What is the treatment for autoimmune haemolytic anaemia?
Steroids and treatment of the underlying cause of the autoimmune haemolytic anemia.
