Malignancies Cases Flashcards
A 65 year old man takes aspirin because of a previous history of TIA.
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How does asprin work?
REDUCES PLATLET AGGREGATION - inhibits cyclooxygenase from working, inhibits arachadonic acid from turning into thrmoboxane A2.
which drugs prevent pletlet funciton?
clopidogrel, adciximab, ticagrelor.
how does dabigatran work?
small molecule whichh bind to and inactivates thrombin
54m scaffolder, tiredness over 2-3 weeks.
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what other sy would oyu ask about?
SOB, dizziness, palpitations – anaemic symptoms
Bleeding, diet - ?cause of anaemia
Mood, appetite, sleep pattern, motivation - ?depression
Weight gain, constipation, skin and hair changes - ?hypothyroidism
Fevers, sweats, weight loss - ?infection, ?malignancy
Systemic enquiry
Over last 2 weeks - SOB and dizzy on climbing scaffold. Feeling hot and cold. Coughing up green phlegm.
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on examination Very pale, Temp 38.5, Dull percussion note R base with decreased air entry,Petichiae around ankles, POTENTIALLY PNEUMONIA – CURB65,
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what ix would you do?
fbc, film, coag screen, heametrics (b12, folate, ferritin), uande’s, lft’s, crp, suptum culture, cxr
fbc results: Hb 45, MCV 92, WCC 0.9, Neutrophils 0.3, Plts 12, what is the ddx?
A – Acute leukaemia, B – Aplastic anaemia, C - B12 deficiency, D – Metastatic ovarian cancer
referred to haematology: Gum hypertrophy/infiltration, Circulating blasts on blood film
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what is the diagnosis and why?
Acute myeloid leukaemia (AML) - Short history, Uncontrolled proliferation of immature myeloid cells therefore acute
20m, Presents with 1 month history of gradually increasing neck swelling What questions do you want to ask?
WEIGHT LOSS, PAIN, MYELOMA HX, NIGHT SWEATS, LOSS OF APETITE, LENGTH OF TIME, CHANGE IN SIZE,
Weight loss of half a stone, Generalised itch, Night sweats, O/E 2x3 cm cervical lymphadenopathy, Also axillary lymphadenopathy, FBC – normocytic normochromic anaemia, eosinophilia
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whata re the DDX?
Hodgkin’s Lymphoma
Non-Hodgkin’s lymphoma
Acute lymphoblastic leukaemia, Metastatic non haematological malignancy, Infections(viral – EBV, CMV, HIV, Bacterial – draining, local lymph nodes, TB, toxoplasma)
what further ix would you do?
Lymph node biopsy, Virology (particularly HIV)
what is the common px of lympoma?
Lymphadenopathy, Splenomegaly +/- hepatomegaly, B symptoms , fever >38oC, weight loss >10% body weight in 6 mths, night sweats, Symptomatic anaemia or other cytopenias
on biopsy Reed-sternberg cells are seen (characteristic of OA and Hodgkins disease) Hodgkins disease…
Staged by PET-CT scan, Stage IIB, Combination chemotherapy - ABVD
75m, intermittent claudication for 2yrs, admitted with painful toe
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what are the causes of high platelets?
Infections, Post surgery / trauma, Malignancy, Iron deficiency, Inflammation – IBD, Rheumatoid arthritis, Primary myeloproliferative disorder
what Ix would you do for thrombocytosis?
FBC, Blood film, Inflammatory markers (ESR, CRP), Ferritin, JAK2, CALR & MPL mutation screening, Consider BCR-ABL, Other investigations if clinical suspicion of malignancy, Bone marrow examination not first line
Ix results are: ESR 24mm/hr, CRP <4, Ferritin 3, Positive for JAK2 V617F mutation
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what is the diagnosis and Tx?
Iron deficient Polycythaemia Vera - Myeloproliferative disorder. Treatment - Aspirin, Venesection, Hydroxycarbamide.
55m, low back pain getting progressively worse, tired last few months, previously fit and well, no weight loss.
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what are the key questions asked for back pain?
duration, is it getting worse, serevity, interference with sleep, radiation, leg weakness or numbness, bladder or bowel disturbance?
what Ix would you do?
FBC, ESR, UandE, Ca, Phos, immunoglobulins and protein electrophoresis. Bence jones proteins, xray of the spine.
on Ix there are igg kappa paraproteins, bony lytic lesions and a paraspinal mass
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what biopsies should you do? And what would be seen?
paraspinal mass shows plasmacytoma, Bone marrow aspirate shows myeloma
what is myeloma?
cancer from plasma cells
Tx of myeloma?
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)
83f, admitted for a bladder repair, denies other symptoms, On examination-marked splenomegaly
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what may be the cause of marked splenomegaly?
Low grade lymphoma, Chronic leukaemias (CML, CLL), Myeloproliferative disorders, Portal hypertension / liver disease, Infiltration from sarcoidosis, other malignancies, Infections eg chronic malaria, visceral Leishmaniasis
blood film shows Leukoerythroblastic blood film with teardrop poikilocytes, blasts and giant platelets
Extensive reticulin fibrosis in bone marrow
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what do tear drop cells mean?
dacrocytes) are frequently associated with infiltration of the bone marrow by fibrosis, granulomatous inflammation, or hematopoietic or metastatic neoplasms.
what are the characteristic features of myelofibrosis?
De novo and transformed can cause Splenomegaly (can be massive)
Symptoms from cytopenias or spleen
Weight loss, extreme tiredness
Leukoerythroblastic blood film, teardrop red cells
Marrow fibrosis – Reticulin stain
Most positive for one of JAK2/CALR/MPL mutations
Tx = Transfusion, hydroxycarbamide, thalidomide, JAK2 inhibitors (Ruxolitinib), allogeneic stem cell transplantation
72f, Blood count prior to elective cholecystectomy, Otherwise asymptomatic
Hb 120g/l, WCC 38.1, Lymph 34.7, Neut 3.1, Platelet 230
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what are the possible causes of lymphocytosis?
Viral infection (e.g. EBV, CMV, HIV), Other infections – TB, brucellosis, syphilis, Vasculitis, Acute lymphoblastic leukaemia, Chronic lymphocytic leukaemia, Lymphoma
blood film shows small, mature, homogenous lymphocytes, Smear Cells, Red cells and platelets are normal
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what is cytometry?
cells labelled by monoclonal antibodies conjugated to fluorochromes directed against cell surface markers
what might be the underlying cause?
EBV, CMV, HIV serology, Brucella, syphilis serology, Monospot test.
