Haematology

Question 1

Monitoring and Surveillance of Lymphoma patients in remission?

Answer 1

Monitoring for relapse & complications. Key issues to discuss are - Cancer, Cardiac, Neuropsychiatric, fertility (if young)

1. Monitoring for Relapse

• 3-6 monthly first few years (depends on subtypes). History & Examination (important as relapses are usually symptomatic and rarely identified on imaging alone) and FBC, LDH and electrolytes.

2. Malignancy surveillance (risk continues at least 30y or more)

• Breast***: surveillance from 40y or 8y from irradiation. Annual Mammogram + consider annual MRI (if irradiated 10-35yo).
• Lung Ca: annual CXR, smoking cessation
• Skin Ca: annual complete skin exam, sun-screen advice
• Annual FBC (Leukaemia, MDS), Routine age-appropriate cancer surveillance: exception. Consider early colonoscopy.

3. Cardiovascular +Respiratory health

• Risk comes from Adriamycin, -Rubicins & RTx (usually 10y after)
• Minimise CV risk factors: exercise, w.loss, Mediterranean diet, smoking cessation), manage HTN and Dyslipidaemia
• Refer to Cardiology for baseline evaluation
• Resting + stress TTE: frequency based on baseline finding + CV risk factors.
• If patient had RTx to lung fields, do annual spirometry/PFT.

4. Fertility

• Offer counselling and referal for sperm/ovum banking
• Refer to reproductive endocrinologist
• Consider HRT in premature ovarian failure + DEXA screen

5. Thyroid

• Monitor for Hypothyroidism for those who had RTx to the neck or WBI - annual thyroid examination + TSH

6. Psychiatric/cognitive/Neuro evaluation

• Monitor for depression, PTSD and neurocognitive impairment, especially those at increased risk (Cranial irradiation, intrathecal therapy)
• Prompt referral to AH if developing cognitive impairment.
• Vinblastine/Vincristine: painful PN with loss of deep tendon reflexes.

Question 2

Patients who underwent Allogenic BMT - Issues?

Answer 2

Monitoring for GvHD & disease recurrence

• Goal is to maintain balance between GvHD vs. GvL effect
• Monitor:
  
  • Disease
    
    • Lymphoma: B-symptoms, LN, splenomegaly, FBC and LDH
    • AML / ALL (B-ALL): constitutional symptoms, splenomegaly, LN, FBC (anemia, thrombocytopenia, infection), blood film (leukaemic blasts), BMAT (hypercellular with blasts, extensive fibrosis, often dry tap), flow cytometry.
    • Myeloma: SFLC, BJP, B2M, Albumin, CRAB.
  • GvHD
    
    • Given multi-systemic nature, I’d be guided by symptoms
    • Screen for GI symptoms, jaundice, hepatomegaly
    • skin (scleroderma like), eyes (various), EUCs
    • LFTs, pulmonary function test
    • If patient develops high-grade GvHD (multi-organ or severe single organ involvement) I’d treat with systemic steroids at 1mg/kg/d, if no response in 2 weeks, consider adding second agent (e.g. tacrolimus) - involve haematology. Steroids will need to be transitioned to steroid sparing therapies.
    • Would have to carefully monitor for evidence of disease recurrence & intection

Infection vs. Immunosuppression

• Given that myeloablative conditioning would remove memory cells, need a complete re-vaccination: Child-hood vaccines plus Flu, Pneumovax and Hep A/B
• Pre-emptive primary prophylaxis tx
  
  • Penicillin V + Acyclovir + Bactrim 12 months
  • Azoles 1st 3 months
• Neutropaenic fever in the 1st month - bacterial/fungal
• 1-3 months: viral and OIs due to immuneSx meds
• After that standard infections, unless still on immSx
• Consider secondary prophylaxis

Monitoring from Late complications

• Consider treatment patient had prior to transplant
• multiple organ system (e.g. cardiac, lung - fibrosis if anthracyclin…etc)
• Fertility issues
• Malignancy screening
  
  • Age-specific routine
  • Guided by risk factors
• Osteoporosis & Bone health
• CV risks