Lecture 15 Haematological Malignancies in Practice

Question 1

54-year-old Scaffolder
•	Over last 2 weeks - SOB and dizzy on climbing scaffold
•	Feeling hot and cold
•	Coughing up green phlegm
•	Very pale
•	Temp 38.5
•	Dull percussion note R base with decreased air entry
•	Petechiae around ankles

• Hb 45, MCV 92, WCC 0.9, Neutrophils 0.3, Plts 12

What is the diagnosis

Answer 1

Acute Myeloid Leukaemia

Question 2

20-year-old Student
• Presents with 1 month history of gradually increasing neck swelling
• What questions do you want to ask?

Answer 2

Weight loss
Itch
Night sweats
Fever
Tiredness

Question 3

Further Clinical Details
•	Weight loss of half a stone
•	Generalised itch
•	Night sweats
•	O/E 2x3 cm cervical lymphadenopathy
•	Also axillary lymphadenopathy
•	FBC – normocytic normochromic anaemia, eosinophilia

What is the differentials?

Answer 3

—	Hodgkin’s Lymphoma
—	Non-Hodgkin’s lymphoma
—	Acute lymphoblastic leukaemia
—	Metastatic non haematological malignancy
Infections:
Ø	viral – EBV, CMV, HIV
Ø	Bacterial – draining, local lymph nodes
Ø	TB, toxoplasma

Question 4

Name causes of thrombocytosis

Answer 4

Infections
Post-surgery
Malignancy
Iron deficiency
Inflammation- IBD, RA
Primary myeoproliferative disorder

Question 5

75 year old man with elevated platelets, intermittent claudication and painful toe.
• ESR 24mm/hr, CRP <4
• Ferritin 3
• Positive for JAK2 V617F mutation

What is the diagnosis

Answer 5

— Iron deficient Polycythaemia Vera

— Myeloproliferative disorder

Question 6

What is the treatment for Polycythaemia Vera

Answer 6

Aspirin, Venesection, Hydroxycarbamide

Question 7

55-Year-Old Man
•	Low back pain – progressively worse
•	Tired last few months
•	Previously fit and well
•	No weight loss

On x-ray there is a paraspinal mass and IgG paraprotein is elevated what is the diagnosis

Answer 7

Myeloma

Question 8

What is the treatment for myeloma

Answer 8

— Local – surgical decompression or radiotherapy
— Systemic – induction chemotherapy (various regimens)
— Bone protection (IV bisphosphonate Zolendronic acid)
— Consolidation (autologous stem cell transplant
— Maintenance (in clinical trial only in UK at present)

Question 9

83-Year-Old-Woman
— Admitted for bladder repair; denies other symptoms
— On examination-marked splenomegaly
— What might be the cause?

Answer 9

— Low grade lymphoma
— Chronic leukaemias (CML, CLL)
— Myeloproliferative disorders
— Portal hypertension / liver disease
— Infiltration from sarcoidosis, other malignancies
— Infections eg chronic malaria, visceral Leishmaniasis

Question 10

What are the clinical features of Myelofibrosis

Answer 10

• Splenomegaly (can be massive)
• Symptoms from cytopenias or spleen
• Weight loss, extreme tiredness
• Leukoerythroblastic blood film, teardrop red cells
• Marrow fibrosis – Reticulin stain

Question 11

What is the treatment of myelofibrosis

Answer 11

• Transfusion, hydroxycarbamide, thalidomide, JAK2 inhibitors (Ruxolitinib), allogeneic stem cell transplantation

Question 12

Name causes of lymphocytosis

Answer 12

Viral infection
TB, syphllis 
ALL
CLL
Lymphoma