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Human Diseases > W17 60 leukaemias, lymphomas and bone marrow disorders > Flashcards

W17 60 leukaemias, lymphomas and bone marrow disorders Flashcards

1
Q

What are some differential diagnoses of gingival hypertrophy?

A

Acute or chronic infections
Medications: phenytoin, ciclosporin, calcium channel blockers
Acute myeloid leukaemia

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2
Q

What is acute leukaemia?

A

A disorder of haematopoietic stem cells resulting in the rapid accumulation of clonal IMMATURE precursors in the bone marrow. An acute life threatening condition.

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3
Q

Is leukaemia associated with a high white cell count?

A

Not always, very often in acute leukaemia, all of the white cells are trapped in the bone marrow as immature precursors and people often present with a pancytopenia rather than a leucocytosis.

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4
Q

What is pancytopenia?

A

Having low levels of all 3 blood counts - WBCs, RBCs and platelets

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5
Q

What is leucocytosis?

A

A high white blood cell count

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6
Q

What are the 2 types of acute leukaemia?

A

Acute myeloid leukaemia (AML) - most common in adults
Acute lymphoblastic leukaemia (ALL) - most common in treatment

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7
Q

When do you need to treat acute leukaemias?

A

Requires treatment within hours/days of diagnosis - risk of death from bleeding/infection if delay.

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8
Q

What is the presentation of acute leukaemia?

A

Marrow failure - so anaemia, leukopenia, thrombocytopenia
Hyperviscosity due to leucocytosis - so headaches, breathlessness, visual blurring, confusion
Leukaemic infiltration (of malignant immature cells)

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9
Q

What can marrow failure in acute leukaemia cause?

A

Anaemia: fatigue, SOB, headaches, palpitations. Can result in end organ failure so MI and stroke.
Leukopenia: infections, mouth ulcers
Thrombocytopenia: purpura, bleeding, bruising

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10
Q

What does hyperviscosity due to leucocytosis in acute leukaemia cause?

A

Hyperviscosity due to leucocytosis means blood flow is slowed by the increase viscosity due to the presence of an excess number of both large and sticky WBCs.
Causes headaches, breathlessness, visual blurring, confusion

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11
Q

What does leukaemic infiltration (of malignant immature cells) in acute leukaemia cause?

A

AML can cause gingival hypertrophy
Skin lesions ‘chloromas’
Hepatosplenomegaly

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12
Q

What are key diagnostic investigations for assessment of leukaemias?

A

Clinical assessment
Full blood count
Blood film
Bone marrow assessment

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13
Q

What abnormal factor is seen in a full blood count in acute leukaemias? (PG588 DATA)

A

WBC is larger than the sum of all the parts beneath it, seen in acute leukaemias because the immature cells are not routinely reported. Blast cells not there and often make up the difference between the total of mature cells and total white cell count given.

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14
Q

What is haematopoiesis?

A

Production of blood cells. They have differential processes.

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15
Q

What are the different groups that come from multipotent stem cells to make each individual blood cell? (DIAGRAM PG588)

A

Common myeloid progenitor - megakaryoblasts-promegakaryoblast-megakaryocyte—>platelets; proerythroblasts-erythroblasts-reticulocyte—>RBCs; myloblasts—>basophils, neutrophils, eosinophils, macrophages; mast cells
Common lymphoid progenitor - lymphoblasts- T and B lymphocytes- plasma cells

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16
Q

What are the most numerous granulocyte?

A

Neutrophils are more numerous than basophils and eosinophils

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17
Q

What do monocytes end up as?

A

Macrophages that take up residence and present antigens through the tissues

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18
Q

What are the different types of leukocytosis (raised white cell count)?

A

Neutrophilia/monocytosis
Eosinophilia/basophilia
Lymphocytosis

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19
Q

What is neutrophilia/monocytosis and when does it occur?

A

Raised counts of neutrophils and monocytes
Usually raised due to a bacterial infection or inflammation
Neutrophilia can also come with raised steroid use

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20
Q

What is eosinophilia/basophilia and when does it occur?

A

Usually raised in allergy, parasitic infections
Eosinophilia also associated with a number of inflammatory and autoimmune diseases as well as drug side effects

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21
Q

What is Lymphocytosis and when does it occur?

A

Increased lymphocyte count
Usually raised due to viral infections or inflammation
Also can be seen in a number of lymphoproliferative diseases

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22
Q

What is neutropenia?

A

Low neutrophil count

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23
Q

What might happen in neutropenia and what should you do?

A

If the neutrophil count is low, life-threatening infection may develop rapidly - the presence of fever is a ‘medical emergency’ - needs immediate treatment with antibiotics.

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24
Q

What is febrile neutropenia?

A

Evidence of infection but low neutrophil count

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25
A low neutrophil count should always prompt assessment of the cause, particularly if:
It is associated with symptoms There are other cytopenias eg pancytopenia It is persistently low
26
Should you perform dental procedures whilst patients are neutropenic?
It may be dangerous to perform dental procedures while patients are neutropenic - ideally avoid (especially in a time when the causes are known or there is expected to be a recovery of the neutrophil count)
27
What are some common causes of neutropenia?
Drugs - methotrexate, azathioprine, chemotherapy (commonly drugs used to treat autoimmune disease or prevent organ transplant rejection) Viral infection, including HIV. (neutropenia = secondary to infection not a cause of infection) B12/folate deficiency
28
What are some less common but still important causes of neutropenia?
Alcohol Ethnicity Hypersplenism Bone marrow failure Leukaemia
29
What is the spleen?
A site of a lot of haematopoietic stem cells. A large spleen means a lot of blood cells will pool in the spleen, leading to a low neutrophil count, as well as low platelet count and anaemia in some patients.
30
In a blood film, what are blast cells like and what are they indicative of? (Pg590)
Blast cells have a very large nuclei, not much cytoplasm. Usually resident in the bone marrow in very small numbers. Seeing them out in peripheral blood in a FBC is grossly abnormal and highly suspicious of acute leukaemia.
31
Where is a good place to find haematopoiesis?
Bone of the pelvis
32
What will you see in an aspirate?
All of the precursors for the cells you will see in health PG591 IMG
33
What are the 2 main types of chronic leukaemia?
Chronic lymphocytic leukaemia (CLL) Chronic myeloid leukaemia (CML)
34
Describe chronic lymphocytic leukaemia?
Disease of old age Usually found as an isolated persisting Lymphocytosis on a full blood count Number not necessarily proportionate to disease Can also present with lymphadenopathy, fevers, weight loss and pancytopenia Treatment is similar to non-Hodgkin’s lymphoma
35
Describe chronic myeloid leukaemia
Often presents slightly younger Presents over months, with tiredness and a large spleen Diagnosed with a FBC and genetic tests Treated with targeted therapy (imatinib)
36
What is an allogeneic stem cell transplant?
Bone marrow transplant
37
What is treatment of AML?
4 cycles of chemotherapy, 7-10days each Allogeneic stem cell transplantation if there is a high risk of relapse
38
What follows for 2-3weeks after chemotherapy?
Pancytopenia In many malignancies, the bone marrow suppression is an unwanted side effect of chemotherapy.
39
What is the treatment of ALL?
2-3 years of intermittent chemotherapy Complex schedules with multiple phases May also require stem cell transplantation if high risk of relapse
40
Why might an allogeneic stem cell transplant be needed?
High dose chemotherapy +/- radiotherapy will completely oblate the entire bone marrow Pt will not recover without a stem cell donation - must be matched against the different HLA types
41
What are the side effects of leukaemia treatment?
Bone marrow suppression (anaemia, neutropenia, thrombocytopenia) Tumour lysis syndrome (arrhythmias/renal failure) Hair loss Nausea/vomiting Profound fatigue Chemotherapy induced tissue damage: heart, lungs, brain, GI mucosa Increased risk of secondary malignancy Death
42
What is tumour lysis syndrome?
Malignant cells will breakdown, sometimes in an uncontrolled way, spilling their contents into the blood = tumour lysis syndrome. The most problematic of those contents is uric acid, potassium and phosphate. Can cause renal impairment and arrhythmias.
43
Supportive treatments for leukaemia
Blood and platelet transfusions Antibiotics and antifungals Antiemetics Nutrition Psychological support
44
What are some oral complications of leukaemia treatment?
Mucositis (grade 4 on WHO oral toxicity scale) Opportunistic infections eg Candida, HSV, xerostomia (from radiotherapy), oral GvHD
45
What is the WHO oral toxicity scale?
Grade 1 - soreness +/- erythema Grade 2 - erythema, ulcers, patient can swallow solid food Grade 3 - ulcers with extensive erythma; patient cannot swallow food Grade 4 - mucositis to the extent that alimentation is not possible (grade 3 and 4 are severe mucositis)
46
What is prophylactic treatment for Candida?
Flucanozole
47
What is prophylactic treatment for HSV?
Acyclovir
48
What is GvHD?
Graft-versus-host disease: happens if you have the immune system of someone else who has been transplanted into yourself as a patient. Immune system is new and will recognise the patient as foreign where the graft attacks the host (opposite of organ rejection)
49
What is GvHD mediated by?
T cells
50
What does acute and chronic GvHD affect?
Acute - skin, liver, gut - more upper GI tract Chronic - skin, mouth, eyes, gut, lungs, joints (any part of body almost)
51
What is oral GvHD characterised by?
Lichenoid inflammation Sclerosis Salivary gland dysfunction Predisposition to HSV and secondary oral cancers
52
How should you as a dentist manage patient oral health during chemotherapy?
Conduct prior to chemotherapy, where practical Avoid dental treatment whilst neutropenic or severely thrombocytopenic Regular oral mouthwashes - chlorhexidine (corsodyl) or benzydamine (Difflam) Soft dental brush Prophylactic drugs - fluconazole and acyclovir Regular inspection
53
What is the lymphatic system?
Lymph nodes contain (adaptive) immune cells which proliferate and differentiate in response to immune challenges
54
What is lymphoma?
A malignant proliferation of mature lymphocytes inside lymphoid tissue
55
How do you classify lymphomas?
Hodgkin vs non-Hodgkin Type of lymphocyte - B cell or T cell Grade: high grade (fast growing, rapidly life-threatening, curable) or low grade (slow growing, usually incurable)
56
What is the typical presentation of lymphoma?
Progressive swelling of lymph nodes - often painless, can be localised or generalised, common sites are cervical, axillae, groin, mediastinum Extranodal involvement - bones, liver, lung… Can be accompanied by ‘B symptoms’
57
What are ‘B symptoms’ that present during lymphoma?
Unintentional weight loss of 10% over 6 months Fevers greater than 38° Night sweats (drenching)
58
How can intra-oral lymphomas present?
Gum swelling Dental abscesses Osteonecrosis Mucosal lesions
59
How can lymphomas as other sites in the head/neck region present?
Cervical lymphadenopathy Nasal obstruction (affecting nasopharynx) Facial pain (if affecting nerves) Conductive hearing loss Visual problems Cranial nerve palsies CNS signs
60
What are the commonest lymphomas of the head and neck region?
Affecting the tonsils, Nasopharynx, parotid and salivary glands
61
How do you diagnose lymphoma?
Biopsies Pathological work-up - other gene tests etc
62
What biopsies are good for the diagnosis of lymphoma?
Excision lymph node biopsy = good standard Core biopsies also useful Cytology (fine needle aspirate) is poor
63
How do you stage lymphoma? (PG600 DIAGRAM!)
Stage 1 - lymphoma localised to 1 nodal site Stage 2 - more than 1 nodal site, on the same side Stage 3 - diseases within nodal sites on both sides of the diaphragm Stage 4 - involvement of lymphoma on both sides of the diaphragm, also involving non-nodal tissues eg the liver or the bones
64
What imaging can be used in lymphoma?
CXR CT PET-CR
65
Which areas will always show up in a PET-CT?
Brain, heart, kidneys, bladder
66
What is treatment for lymphoma?
Observation if asymptomatic and low grade disease Chemotherapy/immunotherapy Radiotherapy - if disease is bulky or localised Stem cell transplantation - might be autologous or allogeneic
67
What is an autologous stem cell transplant?
Where own stem cells are given back to as a form of rescue from high dose chemotherapy
68
Prognosis of Hodgkin vs non-Hodgkin lymphoma?
Hodgkin lymphoma - good prognosis Non-Hodgkin lymphoma - varies with subtype. Low grade is generally incurable but slow growing and treatment is only indicated if symptomatic. High grade often curable but can be rapidly life-threatening if not treated.
69
What is multiple myeloma?
Malignancy of the plasma cells
70
What are plasma cells?
Mature, terminally differentiated B lymphocytes that normally produce immunoglobulins. Plasma cells accumulate in the bone marrow and secrete clonal immunoglobulins into the plasma, resulting in a paraprotein or ‘M protein’.
71
What are the clinical features of myeloma?
CRABI C - hypercalcaemia R - renal impairment A - anaemia B - bone pain and destruction I - infection (even before treatment)
72
What is the investigation for myeloma?
Full blood count and blood film Renal function and calcium Monoclonal protein Bone marrow showing plasma cells Imaging shows lytic lesions of bone
73
What is the treatment for myeloma?
Chemotherapy Autologous bone marrow transplant - given high dose chemotherapy followed by stem cell transplant IV bisphosphonates for bone protection, eg zoledronic acid or Pamidronate
74
What is MRONJ?
Medication-related osteonecrosis of the jaw. Destructive process affecting jaw associated with antiresorptive therapy esp bisphosphonates, denosumab. Can be triggered by dental work, more extensive dental procedures confer high risk. Can be spontaneous.
75
What is the diagnostic criteria for MRONJ?
Currently receiving, or has previously received, treatment with a relevant drug Exposure, necrotic bone in the maxillofacial region persisting for more than 8 weeks No evidence of cancer at the site No history of radiation therapy to the jaws
76
How do you prevent MRONJ?
Identify patients at risk Completed all necessary dental work before starting treatment, or within window period of lower risk eg 6 months for zolendronic acid Pause bisphophonates before and after dental work Some bisphosphonates have a lower risk (oral is less than IV, Pamidronate less than zolendronic acid) Antibiotic prophylaxis might have a role
77
What is treatment for MRONJ?
Avoidance of any further or extensive surgery If necessary, gentle debridement Use of anti-microbial mouthwashes such as chlorhexidine Antibiotic therapy when/where active infection is clinically evident

Human Diseases (75 decks)

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