Topic 19 - Leukaemias and Lymphomas Flashcards
What is the origin of all blood cells?
Haematopoetic stem cells in the bone marrow.
Can split into lymphoid stem cells or myeloid stem cells.
Myeloid stem cells can become platelets, RBC (erithrocytes) or granulocytes such as basinophils, neutrophils or eusonophils.
Lymphoid stem cells can become t-cells, b-cells or NK cells.
Why is it important to know how cancer presents?
Can contribute to a diagnosis if you know oral presentation of cancer
What are the four categories of leukaemia?
Acute - AML, ALL.
Chronic - CML, CLL.
This is dependent on whether its of lymphoid or myeloid origin.
Which type of leukaemia is more aggressive?
Acute - aggressive and seen in younger adults -20s/30s.
Chronic - in elderly, isn’t aggressive and doesn’t warrant treatment as there are signs in bloods, but not a lot of clinical disease
What are the clinical presentations of leukaemia?
- Acute marrow failure - pt presents with symptoms of anaemia such as dizziness, pallor, fatigue, and aphthous ulceration.
- Patient can be at increased risk of fungal infections like oral candidosis or angular cheilitis
- Increased risk of bleeding. If not bc of warfarin or something and patient bleeds easily, refer for investigations.
- Pt may have ulceration and bleeding, and also hyperplastic lesions in the gums called gingival infiltrations
What are blood tests taken for in leukaemia and which ones are taken?
These blood tests are taken for diagnosis, monitoring and assessing of response to any treatment taken:
- FBC - to help identify if there’s anaemia
- Peripheral blood film - see the morphology of the cells to help diagnosis
- Bone marrow sampling - ultrafine needled passed through cortex into marrow cavity. Samples taken can be used for cytogenic analysis etc.
- PCR, gene sequencing studies and immunofluorescence can be used to pinpoint diagnosis.
What are the treatment options for acute and chronic leukaemias and why are they the methods undertaken?
- Chronic leukaemias often do not present with significant clinical disease and so do not necessitate chemotherapy.
- Acute leukaemia are very aggressive and so require aggressive treatment. Chemotherapy is done to ablate the marrow and get rid of malignant haematological cells. This is done using a combination of toxic and potent drugs.
There are two phases to chemotherapy: induce remission (induction phase) and then once remission has happened, to ensure remission continues (consolidation phase). Many different regimens are used and after diagnosis patient will be put on clinical trials.
After this, young fit patients can have a bone marrow transplant, but those who have comorbid disease or late and severe presentations can’t.
What oral healthcare consideration is there for those in induction phase of chemotherapy?
Patients may suffer from mucositis, which is GI tract shedding and can affect them from mouth to anus. They may feel very uncomfortable and can’t eat or drink.
For this reason, they’re treated as inpatients in haematology wards, and monitored for side effects of the drug.
What are the oral manifestations of leukaemia?
- Gingival features - hyperplasia, bleeding, ulcers, petechiae
- Pallor of oral mucosa
- Increased risk of fungal infections like candidosis
- Recurrent viral herpes labialis
- Ulceration that persists after the mucositis of the induction phase of chemotherapy
- Xerostomia due to medication taken
- Cervical lymphadenopathy
- Trismus due to TMJ infiltration
What are the two main types of lymphoma? Describe their features.
Hodgkin’s lymphoma.
- Bimodal incidence (occurs at approx 20 yrs age and then later in life).
- EBV association
- 1/3rd present with B symptoms - drenching night sweats, fever and weight loss.
- Reed-Sternberg cells can be seen. Giant B-lymphocyte derivatives.
Non-Hodgkin’s lymphoma.
- Fifth most common cause of cancer in young adults.
- Cervical lymphadenopathy is seen - refer to maxfax/oral surgery or follow up to see if it resolves.
What are the oral features of lymphoma?
- Painless persistent ulceration or enlargement, typically in palate.
- Neck swelling
- Facial asymmetry
- Tooth mobility
- Difficulty seating a prev well fitting denture
- As extranodal spread occurs, it can result in pain or paraesthesia
- Perineural infiltration can also occur with ulceration of mucosa
- Trismus if TMJ is infiltrated.
How can you manage lymphomas?
If early stages and relatively inactive, can just monitor and do no active treatment.
In later stages, can have a combo of radiation and therapy. Can also have monoclonal antibodies used e.g. rituximab.
A combination of drugs can be used to target specifically the type of lymphoma the patient has.
If this is unsuccessful, they can have autologous bone marrow transplant (PBSCT). Their bone marrow is ablated and malignant haematopoietic stem cells killed. The peripheral bloods are taken and their stem cells are harvested. Harvested stem cells are returned to the body.
Only used in cases where patient is fit and well with no comorbid disease as it’s a very exacting treatment.
What is an allogenic transplant?
Patient has bone marrow harvested from donor or relative transplanted into their body.
What can occur in patients who have had allogenic transplants?
GVHD.
Are there variants of GVHD?
Acute and chronic conditions.
