Lymphoma and Myeloma Flashcards
What is significant weight loss?
10% of baseline
What questions on history would you ask if you suspected malignancy?
FHx of malignancy Past radiation/chemotherapy Use of immunosuppressive agents for transplantation Exposure to pesticides Infections - HIV - HBV - HCV
What symptoms may make you suspicious of a low platelet count?
Bruising
Bleeding when brushing teeth
Epistaxis
How large is the spleen usually on CT?
7-11 cm
What considerations are taken into account when deciding if a lymph node needs to be biopsied?
Significant enlargement
Persistent for >4-6 weeks
Progressive increase in size
Which type of biopsy is most useful for lymph nodes?
Excisional, rather than FNA
What is Richter’s transformation?
CLL transforms into large B cell lymphoma
What investigations are performed to stage a lymphoma?
Clinical history for B symptoms
PET scan
Bone marrow aspirate and trephine (BMAT)
What part of the body are PET scans not good at assessing in the context of malignancies?
Brain, because it uses a lot of glucose
What investigations are performed to enable treatment planning in lymphoma?
Bloods - FBE - UEC - LDH Assessment of cardiac function - gated blood pool scan (GBPS)/echocardiogram Assessment of viral status > give prophylaxis where appropriate - HBV - HIV - CMV - EBV
Why is cardiac function assessed before treatment is started for cancer?
Use of cardiotoxic chemoagents
What is the most common form of non-Hodgkin lymphoma?
Diffuse large B cell lymphoma (DLBCL)
What is the age distribution of DLBCL?
Incidence increases with age
How does DLBCL arise?
De novo
Transformation from lower grade disease
What is the treatment for DLBCL?
R-CHOP
- Rituximab = anti-CD20 mAb
- Cyclophosphamide = alkylating agent > damages DNA
- (Hydroxy) doxorubicin = intercalating agent > damages DNA
- (Oncovin) vincristine = binds to tubulin > prevents cell duplication
- Prednisolone = corticosteroid
What does prophylaxis against tumour lysis involve?
Hydration > good glomerular filtration
Monitor electrolytes
Drugs to lower uric acid - allopurinol
What happens in tumour lysis?
High K
High phosphate
High urea
When is a high dose of methotrexate given as CNS prophylaxis in DLBCL?
Gonadal/BM involvement
High LDH
Has high risk of CNS disease
Is DLBCL curable?
In many patients, yes
What is a low grade non-Hodgkin’s lymphoma?
Follicular lymphoma
What is the treatment for follicular lymphoma?
Watch and wait
Chemotherapy +/- radiotherapy
What grade is Burkitt lymphoma?
High grade
What imaging may be required before biopsying a lymph node?
CT to assess extent and location
PET can be useful to determine which node to biopsy
US can be useful to biopsy superficial lymphadenopathy
Why is an FNA never done when biopsying for suspected lymphoma?
Architecture critical for diagnosis of lymphoma
What are the characteristic cells seen in Hodgkin lymphoma?
Reed-Sternberg cells
What CD markers are positive in Hodgkin lymphoma?
CD15
CD30
What staging regime is used to stage Hodgkin lymphoma?
Ann Arbor staging, like in DLBCL
What percentage of lymphomas are Hodgkin lymphoma?
15%
What age group typically gets Hodgkin lymphoma?
Bimodal distribution
- Adolescents-young adults
- Elderly
Is Hodgkin lymphoma curable?
Over 70% curable
How is treatment stratified in Hodgkin lymphoma?
According to
- Stage
- Site
How do PDL inhibitors work?
PDL1 and PDL2 on tumour
PD1 and PD2 on T cells
Give mAbs that inhibit PDL > T cells remain active > kill tumour
What is one of the side effects of PDL inhibitors?
Autoimmune disease
When treating Hodgkin lymphoma, what should be considered as part of long-term management?
Minimisation of long-term toxicity
In whom is monoclonal gammopathy of uncertain significance (MGUS) common?
Elderly
What are the diagnostic criteria for MGUS?
Serum monoclonal protein low
Monoclonal bone marrow plasma cells <10%
No evidence of end organ damage due to clonal plasma cell disorder
No bone lesions on skeletal x-ray (if performed)
No clinical/lab features of amyloidosis/light chain deposition disease
What are CRAB symptoms?
C = Ca elevation in blood R = renal insufficiency A = anaemia B = lytic bone lesions/osteoporosis
What are the investigations of paraprotein?
Bone marrow examination Skeletal survey > look for lytic lesions - Skull - Spine - Long bones Spinal MRI if back pain/suspected cord compression
What is smouldering myeloma?
Monoclonal protein in serum at 3+ g/100 mL OR monoclonal plasma cells 10+% in bone marrow/tissue biopsy
No evidence of end-organ damage due to clonal plasma cell disorder
What is symptomatic myeloma?
Monoclonal plasma cells in bone marrow 10+% and/or biopsy-proven plasmacytosis
Monoclonal protein in serum and/or urine
Myeloma-related organ dysfunction
- At least 1 CRAB symptom
How is myeloma treated?
Chemotherapy
Transfusions if anaemic
Bisphosphonates/denosumab +/- radiotherapy for bone disease
What is the mechanism of action of denosumab?
RANK-L inhibitor
What does treatment of bone disease in myeloma improve?
Symptoms, not overall survival
What medical emergencies can occur due to myeloma?
Hypercalcaemia Spinal cord compression Renal failure Hyperviscosity Infections
What does initial chemotherapy for myeloma depend on?
Age
Stage
Comorbidities
Is myeloma curable?
Considered incurable, except with allogeneic transplantation
- Not standard of care
When should you suspect myeloma in a patient?
Fracture/bone pain without precipitating event
- X-ray shows lytic lesions/severe osteoporosis/crush fractures
Unexplained anaemia with rouleaux on blood film and high ESR
High total protein despite normal/low albumin
Unexplained hypercalcaemia
Unexplained renal failure
