Week 4

Question 1

Most common NHLs

Answer 1

High grade diffuse large b cell lymphoma and low grade follicular lymphoma.

The median age at presentation is older than 50 years, except for patients with high-grade lymphoblastic and small noncleaved lymphomas, which are the most common types of NHL observed in children and young adults. Low-grade lymphomas are very rare in children

Other two most common = high grade primary cutaneous lymphoma and low grade extra nodal marginal MALT lymphoma.

Question 2

Which diseases increase the risk of MALT lymphoma in particular?

Answer 2

Sjogren’s, hashimoto’s, H.pylori.

Question 3

Presentation of low grade lymphoma

Answer 3

Painless, slow growing lymphadenopathy and nodes may regress. systemic symptoms of cancer are uncommon. Bone marrow involvement and cytopenias. Splenomegaly and hepatomegaly.

High grade can be characterised by rapidly growing and bulky lymphadenopathy, testicular mass, systemic symptoms, obstructive hydronephrosis.

Skin lesions: associated with cutaneous T-cell lymphoma (mycosis fungoides), anaplastic large-cell lymphoma and angio-immunoblastic lymphoma.
Lymphoblastic lymphoma: high-grade lymphoma, which often manifests with a mediastinal mass, superior vena cava syndrome and meningeal disease with cranial nerve palsies.
Burkitt’s lymphoma: often presents with a large abdominal mass and symptoms of bowel obstruction.

Question 4

Most common treatment for NHLs?

Answer 4

Rituximab is recommended for use in combination with a regimen of cyclophosphamide, doxorubicin (hydroxydaunorubicin), vincristine (Oncovin®), and prednisolone (CHOP) . can also have MCP iand CVP in advanced follicular. Mantle can also have FCR with RCHOP.

Question 5

Complications of NHL

Answer 5

Neutropenia, anaemia, thrombocytopenia (secondary to bone marrow infiltration).
Bleeding secondary to thrombocytopenia, disseminated intravascular coagulation or direct vascular invasion by the tumour.
Large pericardial effusion or arrhythmias secondary to cardiac metastases.
Respiratory problems secondary to pleural effusion and/or parenchymal lesions.
Superior vena cava obstruction secondary to a large mediastinal tumour.
Spinal cord compression secondary to vertebral metastases.
Neurological problems secondary to primary CNS lymphoma or lymphomatous meningitis.
Gastrointestinal obstruction, perforation, and bleeding in a patient with gastrointestinal lymphoma (may also be caused by chemotherapy).
Pain secondary to tumour invasion.
Chemotherapy-related complications - eg, cytopenias, nausea and vomiting, fatigue. Tumour lysis syndrome (commonly occurs after treatment of high-grade bulky lymphomas) may lead to hyperuricaemia, hyperkalaemia, hyperphosphataemia, hypocalcaemia and acute kidney injury.

Question 6

Chronic Lymphocytic Leukaemia

Answer 6

Malignant Bcell proliferation with accumilation of the abnormal cells in the blood, marrow, spleen, lymph nodes and liver. It is 1/4 of all leukaemias. Average age of onset is 72. Some around 50.

More than 5,000 monoclonal B lymphocytes/mcL for the duration of at least three months.

The bcells are small, mature and have dense nucleus without nucleoli and chromatin aggregation.

Complications include immunocompromise, hyperviscosity syndrome with high wcc and lymphomatous transformation to Richter’s syndrome which is terminal.

Question 7

CLL signs and symptoms

Answer 7

Susceptibility to infection (pneumonia, herpes simplex and herpes zoster).
Symmetrically enlarged lymph nodes.
Abdominal discomfort from an enlarged spleen.
Bleeding or petechiae in skin or mucous membranes - from thrombocytopenia.
Tiredness and fatigue from anaemia.

Local or generalised lymphadenopathy.
Splenomegaly.
Hepatomegaly.
Petechiae.
Pallor.
Skin infiltration (rare).
Tonsillar enlargement.
Involvement of the lacrimal and salivary glands (Mikulicz's syndrome) is rare.

Question 8

first line treatment of CLL

Answer 8

Fludarabine, Cyclophosphamide and Rituximab. Allogenic stem cell transplant is the only cure.

Question 9

Tonsillitis

Answer 9

Tonsillitis is inflammation due to infection of the tonsils. Pharyngitis is inflammation of the oropharynx but not the tonsils. The tonsils tend to atrophy in early adulthood. In laryngitis there are few visible signs of infection but with soreness lower down the throat often associated with a hoarse voice.

Only give phenoxy methyl penicillin or clarithromycin if symptoms become extreme and systemic.

Question 10

Tonsillitis signs and symptoms

Answer 10

Pain in the throat is sometimes severe and may last more than 48 hours, along with pain on swallowing.
Pain may be referred to the ears.
Small children may complain of abdominal pain.
Headache.
Loss of voice or changes in the voice.

The throat is reddened, the tonsils are swollen and may be coated or have white flecks of pus on them.
Possibly a high temperature.
Swollen regional lymph glands.
Classical streptococcal tonsillitis has an acute onset, headache, abdominal pain and dysphagia.
Examination shows intense erythema of tonsils and pharynx, yellow exudate and tender, enlarged anterior cervical glands.
Tonsillitis tends to be misdiagnosed, leading to inappropriate treatment with antibiotics.

Question 11

Richter’s syndrome (RS)

Answer 11

Richter’s transformation, is a transformation of B cell chronic lymphocytic leukemia (CLL) or hairy cell leukemia into a fast-growing diffuse large B cell lymphoma, a variety of non-Hodgkin lymphoma which is refractory to treatment and carries a bad prognosis.

Question 12

Pharyngitis

Answer 12

Acute pharyngitis is characterised by the rapid onset of sore throat and pharyngeal inflammation (with or without exudate). Absence of cough, nasal congestion, and nasal discharge suggests a bacterial, rather than viral, aetiology. Acute pharyngitis can be caused by a variety of viral and bacterial pathogens, including group A Streptococcus (GAS), as well as fungal pathogens (Candida). Bacterial pharyngitis is more common in winter (or early spring), while enteroviral infection is more common in the summer and autumn. Acute pharyngitis is generally a self-limiting condition with resolution within 2 weeks.

Question 13

Ranitidine

Answer 13

Antacid used for indigestion, heartburn, gord. Speculation associated with cancer.

Question 14

Four main types of thyroid cancer

Answer 14

Papillary, follicular, medullary and anaplastic

Diagnosis is ultrasound needle aspiration

Question 15

Oral and pharyngeal squamous cell carcinoma locations

Answer 15

Buccal mucosa.
Retromolar triangle.
Alveolus.
Hard palate.
Anterior two thirds of the tongue.
Floor of the mouth.
Mucosal surface of the lip.

Question 16

Most common primaries for secondary oral cancer

Answer 16

Breast, lung, kidney, adrenal

Question 17

Oral cancer symptoms from location

Answer 17

Mobile tongue: The patient may develop speech and swallowing dysfunction.
Pain occurs when the tumour involves the lingual nerve and this pain may also be referred to the ear.

Tongue base: usually silent
Tonsils: Patients with tonsillar carcinomas may present with a neck mass, usually in the jugulodigastric region. Even if the neck mass is not evident on casual inspection, careful palpation may reveal cervical lymphadenopathy.
Sore throat, ear pain, foreign body or mass sensation, and bleeding may occur.
Trismus is an ominous sign because it probably indicates involvement of the parapharyngeal space. Such tumours may be large enough to involve or encase the carotid sheath. In addition, the tumour may extend to the skull or mediastinum.

the tumour has involved the tongue base, contralateral nodes may be involved.
Primary tonsillar tumours may grow entirely beneath the surface. The clinician may therefore see nothing suspicious or may see only a slight increase in the size of the tonsil or the firmness of the area.
Alternatively, an exophytic fungating mass with central ulceration and heaped-up edges may be present. It may be deep red to white.
Weight loss and fatigue are not uncommon.
Treatment may lead to pain, xerostomia, infections, poor wound healing, dysphagia, fistula formation, trismus, potential disfigurement and fatigue.

Question 18

Oral cancer staging

Answer 18

TX - primary tumour cannot be assessed.
T0 - no evidence of primary tumour.
Tis - pre-invasive cancer (carcinoma in situ).
T1 - tumour 2 cm or less in greatest dimension.
T2 - tumour larger than 2 cm but not larger than 4 cm.
T3 - tumour larger than 4 cm.
T4a - through cortical bone, deep/extrinsic muscle of tongue, maxillary sinus, skin.
T4b - masticator space, pterygoid plates, skull base, internal carotid artery.

Question 19

Management of oral cancer

Answer 19

Consider a suspected cancer pathway referral (for an appointment within two weeks) for oral cancer in people with either:
Unexplained ulceration in the oral cavity lasting for more than three weeks; or
A persistent and unexplained lump in the neck.
Consider an urgent referral (for an appointment within two weeks) for assessment for possible oral cancer by a dentist in people who have either:
A lump on the lip or in the oral cavity; or
A red or red and white patch in the oral cavity consistent with erythroplakia or erythroleukoplakia.

Chemotherapy and altered fractionation radiotherapy and neck dissection/irritation/resection.

Question 20

Thyroglossal cysts

Answer 20

A thyroglossal duct cyst (TGDC) represents a segment of the duct that fails to regress and consequently differentiates into epithelial-lined cysts. Can be infrahyoid or suprahyoid, intralingual, suprasternal. Most common congenital abnormality of the neck. Visible as non tender (unless infected), mobile mass. If infected may have dysphagia, dysphonia, draining sinus, fever or neck mass. May present like urti. Intralingual can close the airway. Should always be surgically removed.

Question 21

Achalasia

Answer 21

In achalasia, the muscles in the oesophagus do not contact correctly and the ring of muscle can fail to open properly, or does not open at all. Food and drink cannot pass into the stomach and becomes stuck. It is often brought back up. Makes difficulty swallowing.

While pneumatic dilatation is superior to botulinum toxin injection surgical myotomy provides the best long-term control of symptoms in patients with achalasia. Conclusion: Laparoscopic myotomy should be the initial treatment for most patients with achalasia.

Question 22

Glandular fever/infectious mononucleosis

Answer 22

Self limiting infection of the Epstein Barr virus. Spread via saliva and very close contact. Most common in adolescents. Symptoms include sore throat, swollen glands, malaise, fever, puffy eyes, splenomegaly. Self resolving.

Question 23

Peritonsillar abscess

Answer 23

Quinsy. Complication of acute tonsillitis where pus is trapped between the tonsillar capsule and the lateral pharyngeal wall. Often caused by strep. Pyogenes, staph aureus, haemophilus influenza. Can also be a complication of glandular fever.

Symptoms include: Severe throat pain which may become unilateral with swollen nodes.
Fever.
Drooling of saliva.
Foul-smelling breath.
Swallowing may be painful.
Trismus (difficulty opening the mouth).
Altered voice quality ('hot potato voice') due to pharyngeal oedema and trismus.
Earache on the affected side.
Neck stiffness symptoms.
Headache and general malaise.
Uvula is displaced away from the lesion.

Treat with amoxicillin with clindamycin or metronidazole via iv along with needle aspiration, incision and drainage and tonsillectomy.

Spreading infection can result in necrotising fasciitis, other abscesses, pneumonia and sepsis. Erosion to vessels is extremely dangerous.

Question 24

Causes of referred otalgia

Answer 24

dental disease, tonsillitis, temporomandibular joint disorders and cervical spine pathology represent the most frequent causes. Ear pain may also be the first sign of a head and neck malignancy.

Question 25

Hypo pharyngeal cancer

Answer 25

Hypopharyngeal cancer is a rare type of cancer that affects the inlet to the oesophagus (gullet).

This is a hidden area and cancers may often present in a later stage because of this.

Question 26

Dermoid cysts

Answer 26

A dermoid cyst is a collection of tissue under the skin. They are caused by skin and skin structures become trapped during fetal development. It may contain hair follicles, oil, and sweat glands. In some cases it may contain bone, teeth, or nerves. A dermoid cyst may appear at birth or soon after. Dermoid cysts are often found on the head, neck, or face, most often around the eyes. Can rupture and infect surroundings.

Question 27

Nasal vestibulitis

Answer 27

Carriers of pyogenic staphylococci which can produce an infection of the skin of the nasal vestibule with consequent soreness and fissuring of the nasal site. The site will also become encrusted.

Treatment of this condition consists of prolonged use of topical antibiotic/antiseptic ointment and systemic flucloxacillin.

Question 28

Nasopharyngeal Carcinoma

Answer 28

Nasopharyngeal carcinoma is a poorly differentiated carcinoma that may appear at any site in the upper respiratory tract, but most commonly, in the lateral wall of the nasopharynx around the ostium of the Eustachian tube - the fossa of Rosenmuller.

It is most commonly seen in south-east Asia, especially in the Chinese, in whom it appears to be a genetically- determined risk. It may be associated with the Epstein-Barr virus, with exposure to smoke or to chemical pollutants, and in California and Malaysia, to the ingestion of salted fish.

Presentation tends to be late and due to features of metastases rather than of the primary tumour. Both older people over 50 years of age, and people in the second and third decades are usually affected.

Question 29

Plummer-Vinson syndrome

Answer 29

Plummer Vinson syndrome is the formation of an oesophageal web above the aortic arch in association with concomitant iron deficiency in women.

Sometimes there may be chronic atrophic glossitis, koilonychia, angular stomatitis and achlorhydria. The main complaint is of dysphagia.

The condition is premalignant and is associated with the development of a carcinoma in the cricopharyngeal region. Initial treatment is by balloon dilatation at endoscopy and iron replacement medication. Once anaemia is corrected and a fuller diet can be taken orally, there is dramatic symptomatic improvement.

It is the only head and neck malignant condition occurring more often in women than in men. The developing carcinoma is radiosensitive.

Question 30

Retropharyngeal abscess

Answer 30

Retropharyngeal abscess is usually seen in infants or young children.

It may be caused by an upper respiratory tract infection that then causes an adenitis. The adenitis, which is in the retropharyngeal nodes, suppurates and forms an abscess.

The abscess is limited to one side of the midline. This is because of the intervening median raphe of the bucco-pharyngeal fascia which is firmly attached to the pre-vertebral fascia.

Question 31

Primary Sjogren’s syndrome

Answer 31

Primary Sjogren’s syndrome is the association of
keratoconjunctivitis sicca and/or xerostomia, with arthritis or other connective tissue disorder
Sicca refers to dryness most often involving the eyes and mouth due to inflammation and resultant pathology of the lacrimal and salivary glands.

Salivary gland biopsy shows sialadenitis. Involvement of other secretory glands is common causing dyspareunia, dry skin, dysphagia, otitis media and pulmonary infection.

Up to one-half of affected individuals also develop extra-glandular involvement implying the occurrence of signs and symptoms in organs distinct from the salivary and lacrimal glands including the joints, skin, lungs, gastrointestinal (GI) tract, nervous system, and kidney

Other possible features include dental caries, attacks of monilial stomatitis, neuropathy, hepatosplenomegaly and renal involvement.

Associations include renal tubular acidosis, adverse drug reactions and lymphoma.

Secondary Sjogren syndrome frequently occurs in conjunction with other autoimmune disorders including rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE)