Haematological Malignancies Flashcards
1
Q
What are the differentials for lymphadanopathy?
A
- Infective: Viral, TB, HIV, bacterial
- Inflammatory Sarcoidosis
- Malignant: Lymphoma / mets from other cancers e.g. gastric (virchow’s node)
- Reaction to drugs (allergy e.g. to beta lactam abx)
- Autoimmune e.g. Lupus
2
Q
What does enlarged Virchow’s node suggest (AKA Troisier’s sign)?
A
A malignancy, commonly gastric, also kidney or ovarian/testicular
(supraclavicular nodes could also indicate lung cancer)
3
Q
What are the “B” symptoms for lymphoma?
A
Night sweats, fever, weight loss
4
Q
What is the staging of lymphoma?
A
- Stage 1: single lymph node affected
- Stage 2: 2+ lymph nodes affected above diaphragm
- Stage 3: lymph nodes above AND nodes below diaphragm
- Stage 4: Organ involvement (with or without lymph nodes)
5
Q
What scan is used to stage lymphoma and why?
A
PET scan, needs to assess if nodes are affected above or below diaphragm.
6
Q
What are the 2 most common types of Non-Hodkin’s lymphoma?
A
- Diffuse Large B Cell (high grade)
- aggressive but responds well to aggressive treatment
- 60 years
- cureable
- Follicular (indolent)
- slow onset
- often watched rather than treated
- Good response to treatment but no cure
7
Q
When does lymphadenopathy become clinically relevant?
A
- Adult > 1cm (or 1.5cm at level II)
- Paediatric > 2cm
- Any node with associated head neck symptoms that is persistent
8
Q
Name some common bacterial causes of lymphadenopathy
A
- Strep - group A
- Staph A
- Strep pneumoniae
- Anaerobes
- fusobacterium (teeth)
- TB
Immunocompromised:
- Bartonella (cat scratch disease)
- Toxoplasmosis = parasitic (rare)
9
Q
Name some common viral causes of lymphadenopathy
A
- Adenovirus
- Rhinovirus
- Coxsackie virus A + B
- EBV → glandular fever includes tender, enlarged lymphnodes
10
Q
How can you tell the difference between an inflammatory and a malignant lymphadenopathy?
A
Inflammatory:
- Post-infection (symptomatic)
- Should decrease in size over time, or fluctuate in size
Malignant:
- Not necessarily post-infection
- Increases in size over time; progressive enlargements
- May have associated head and neck symptoms
- e.g. dysphagia, hoarse voice
- Often painless (pain = sign of inflammation)
11
Q
What shape should a lymph node be?
A
Rugby ball shaped!
Football shape = baaad
12
Q
What is TB?
A
- Infection with organism Mycobacterium tuberculosis.
- TB is more common in
- developing countries
- immunocompromised people e.g. HIV patients
- malnourished
- IV drug users
- It is droplet spread - usually needs sustained close contact with an infectious case
- Starts in the alveoli, can become dormant in the lymphatic system and reactivate later at a time of immunocompromise
13
Q
What are the symptoms of TB?
A
Symptoms - 90% present with pulmonary symptoms only:
- Cough +/- haemoptasis
- Shortness of breath
Constitutional symptoms include:
- Fever + chills
- Night sweats
- Lymphadenopathy
- Fatigue
- Weight Loss / loss of appetite
14
Q
Malignant nodes are 1 of 2 types of cancer
A
- Lymphoma
- Hodgkins
- Non-Hodgkins
- Metastatic
- Majority from head/neck primary
- Supraclavicular fossa nodes (Virchow’s) are 2º to lung / GI tract
15
Q
How do you clinically discern between a lymphoma and metastatic lymph node
A
Lymphomas: smooth, firm lumps, can present with B symptoms
Mets: Harder, irregular, skin can be stuck to them - fixed
16
Q
How do you assess a neck lump?
A
- Size – width / height / depth
- Location – can help narrow the differential – anterior triangle / posterior triangle / mid-line
- Shape – well defined?
- Consistency – smooth / rubbery / hard / nodular / irregular
- Fluctuance – if fluctuant, this suggests it is a fluid-filled lesion – cyst
- Trans-illumination – suggests mass is fluid-filled – e.g. cystic hygroma
- Pulsatility – suggests vascular origin – e.g. carotid body tumour/aneurysm
- Temperature – increased warmth may suggest inflammatory / infective cause
- Overlying skin changes – erythema / ulceration / punctum
- Relation to underlying/overlying tissue – tethering/mobility (ask to turn head)
- Auscultation – to assess for bruits – e.g. carotid artery aneurysm
17
Q
Name the lymph nodes of the head and neck
A
18
Q
What investigations should you do on finding a suspected lymphoma?
A
- Core biopsy* (w US guidance)
- [USS - excellent for characterising benign nodes]
- Full body CT scan w contrast / MRI for staging
- PET for lymphoma staging (above / below diaphragm)
*fine needle aspiration is not helpful in lymphoma as sample too small
19
Q
What does this x-ray show? What are your differentials?
A
Bilateral Mediastnal Lympadenopathy
- Sarcoid Lymphoma
- Glandular fever
- Disseminated Malignancy
- Tuberculosis
- Lung cancer
20
Q
What are lymphomas?
A
- Lymphomas are malignancies that involve the lymphocytes.
- Lymphocytes are present in the
- circulation
- bone marrow
- lymph nodes
- other organs that form the reticulo-endothelial system:
- liver
- spleen
- Characteristically, lymphomas are solid tumours involving the lymph nodes and when there is involvement of other organs it is referred to as extra-nodal involvement:
- skin
- brain
- bowels
- bone
- Lymphomas are closely related to lymphoid leukaemias, which originate in the marrow and therefore typically involves circulating lymphocytes.
21
Q
What are the subtypes of malignant lymphomas?
A
- Hodgkins (malignancy of the young, peak incidence 15-30, 2nd peak over 50, 80% are cured)
- characterised by the presence of Reid Sternberg cells
- Non-hodgkins
- High grade (fast growing, symptomatic but curable)
- Diffuse Large B-cell
- Burkitt lymphomas
- Indolent (slow, growing, may not require treatement for long periods of time - watchful waiting, responds to chemo but never cured)
- Follicular lumphomas
- High grade (fast growing, symptomatic but curable)
22
Q
What are the risk factors for developing lymphoma?
A
- FH
- Immunocompromise
- HIV
- Iatrogenic e.g. methotrexate
- EBV infection (more likely to have B symptoms)
23
Q
Which cells derive from myeloid precursors and which from lymphoid?
A
24
Q
What is the classification of leukemias?
A
- Firstly categorised as
- Acute (ends in “-blastic”) or
- Chronic (begins with “chronic”)
- Then catergorised as
- Myeloid
- Lymphocytic
25
What is the most common malignancy of childhood?
acute lymphoblastic leukaemia (ALL)
26
What is the first abnormality noted in leukemia?
What investigations are essential?
Raised white cell count
1. Blood film
2. Bone Marrow aspirate
27
What symptoms might an acute leukemia present with?
Symptoms are usually indicative of bone marrow failure, and include the following:
1. Anaemia – generally feeling tired, SOB on exercise, weakness
2. Bleeding and bruising – as a result of thrombocytopaenia
3. Infection – as a result of leukopaenia
4. Bone pain – as a result of bone marrow infiltration
28
Why does the bone marrow fail in actue leukemia?
* Crowding of the bone marrow by such immature cells renders the marrow unable to produce healthy blood cells.
* The patient may therefore become anaemic and/or thrombocytopenic.
29
What are the differentials for easy bruising, and purpura
* In elderly, not always associated with underlying pathology, result of aging
* In young:
* TTP - thrombotic thrombocytopenic purpura
* HUS - haemolytic uraemic syndrome
* Infections: such as meningococcal sepsis
* Haematological malignancies: such as leukaemias
30
What is TTP?
Thrombotic thrombocytopenic purpura
* a type of Thrombotic microangiopathy (TMA)
* blood disorder that results in blood clots forming in small blood vessels throughout the body
* As platelets are used up in the formation of thrombi → low platelet count, low red blood cells due to their breakdown
* Red blood cells passing the microscopic clots are subjected to shear stress, which damages their membranes, leading to rupture of red blood cells within blood vessels, which in turn leads to anaemia and schistocyte formation.
* The presence of these blood clots in the small blood vessels reduces blood flow to organs resulting in cellular injury and end organ damage.
* Many people experience an influenza-like or diarrheal illness before developing TTP
* Neurological symptoms are very common and vary greatly in severity e.g. headache, confusion, fatigue, stroke-like
* Treatment: plasmapheresis
31
What are the classic 5 symptoms of TTP?
Classic 5 symptoms (rarely all 5):
1. Fever
2. Changes in mental status
3. Thrombocytopenia
4. Reduced kidney function
5. Haemolytic anaemia (microangiopathic hemolytic anemia).
32
What is HUS?
Haemolytic-uremic syndrome
* A type of Thrombotic microangiopathy (TMA)
* HUS occurs after ingestion of a strain of bacteria expressing Shiga toxin such as enterohemorrhagic Escherichia coli (EHEC)
* PC: Low platelets, low red blood cells, and kidney failure following a few days of bloody diarrhea
33
What is multiple myeloma?
* **Malignancy** arising from **plasma cells** (antibody producing cells)
* Proliferating **nests** of plasma cells may form **deposits** in bones, where they typically cause **osteolytic lesions** on x-ray
* In the bone marrow proliferation of plasma cells result in
* reduced erythropoesis (**anaemia)** and
* reduced production of platelets (**thrombocytopaenia)**
* Myeloma cells produce various paraproteins that may be detected in plasma (by plasma electrophoresis) or even in the urine (**Bence Jones proteins**)
* Additional features of myelomas:
* **Hypercalcaemia**
* **Bone pain**
* ↑ Plasma cells on bone marrow aspirate
* **Persistent back pain in an older subject** - particularly when associated with anaemia and hypercalcaemia, should raise the suspicion of multiple myeloma.
34
What investigations are important in myeloma?
1. Skeletal survey –may show characteristic lytic lesions – most commonly in the skull
2. Serum protein electrophoresis – determines the type of each protein present
3. Urine protein electrophoresis – identifies presence of Bence-Jones proteins
4. 24-hour urine immunofixation –this is useful for checking the subtype of light chains, e.g. IgA lambda, Bence-Jones proteins
5. Bone marrow aspirate –shows plasma cell infiltration of the bone marrow; used to calculate the percentage of plasma cells in the infiltrate; cytogenetic analysis of the aspirate may contribute prognostic information may also demonstrate amyloidosis
35
Why is examination of the abdomen for hepato-splenomegaly an integral part of the examination when dealing with a patient presenting with lymphadenopathy?
Lymphomas and other forms of haematological malignancies can commonly involve other components/organs that are part of the reticulo-endothelial system such as the spleen, liver and bone marrow.
