20 Hematologic Malignancy Flashcards
What are the broad classes of hematologic malignancies?
What are the broad classes of hematologic malignancies?
Hematologic malignancies encompass leukemias, lymphomas, and multiple myeloma. The leukemias are either acute or chronic and classified based on myeloid or lymphoid lineage. The lymphomas are further categorized as B-cell (Hodgkin’s and non-Hodgkin’s) or T-cell neoplasms.
What are the head and neck manifestations of hematologic malignancies?
What are the head and neck manifestations of hematologic malignancies?
This can be broadly divided into nodal and extranodal manifestations.
- Nodal: Cervical lymphadenopathy is one of the commonest presentations of lymphomas and is also seen in chronic lymphocytic leukemia (CLL). Involvement of the Waldeyer’s ring is also frequently encountered.
- Extranodal: Involvement of the lymphoid tissues in the salivary glands, thyroid, and paranasal sinuses may present as masses in these regions. Endemic Burkitt’s lymphoma has a distinct propensity to present as masses of the facial bones. Extramedullary plasmacytomas can originate in the sinonasal tissues. Mediastinal lymphadenopathy could cause compression of the superior vena cava and resultant facial plethora. Other presentations are summarized in Table 20-1.
In a patient with cervical lymphadenopathy, what features should alert the clinician to the possibility of lymphoma?
- In a patient with cervical lymphadenopathy, what features should alert the clinician to the possibility of lymphoma?*
(1) Unexplained fevers with temperature above 38o C during the previous month, (2) unintentional weight loss of at least 10% of body weight during the previous six months, and (3) drenching night sweats during the previous month are the classically designated “B” symptoms and portend a poor prognosis. Although nonspecific, approximately 25% of patients with Hodgkin’s lymphoma and up to 40% of patients with non-Hodgkin’s lymphoma present with “B” symptoms. Additional suggestive features include fatigue, and for Hodgkin’s, pruritus and pain after alcohol consumption.
What are the physical exam characteristics of lymphadenopathy in lymphomas?
What are the physical exam characteristics of lymphadenopathy in lymphomas?
On palpation, lymphomatous nodes have a typical “rubbery” firm consistency, as compared to the stony hard lymphadenopathy in metastatic solid tumors. Lymphoma involved nodes are nontender, and could be matted and fixed to underlying structures.
What is lethal midline granuloma?
What is lethal midline granuloma?
This term is used to describe an aggressive form of extranodal natural-killer/T-cell lymphoma mediated by Epstein-Barr virus infection. It is common in East Asia and Latin America. Patients present with destructive masses involving the nasal cavity, sinuses, or palate, sometimes with extension into the upper airway and Waldeyer’s ring. Biopsy of these lesions usually reveals extensive necrosis with lymphomatous infiltration and vascular invasion. Localized disease is responsive to concurrent chemo-radiotherapy, but advanced stage disease is rapidly fatal despite treatment.
Should patients with cervical lymphadenopathy be given a trial of empiric antibiotics?
Should patients with cervical lymphadenopathy be given a trial of empiric antibiotics?
Empiric antibiotics are generally not useful due to the multitude of possible etiologies and could result in delay of diagnosis. There is insufficient data to support this practice. Biopsy of suspicious lymph nodes should be performed without delay.
What are the indications for cervical lymph node biopsy in suspected lymphomas?
What are the indications for cervical lymph node biopsy in suspected lymphomas?
Typically, lymph nodes that are larger than 2 cm in diameter or 2.25 cm2 (with bi-perpendicular diameter of 1.5 × 1.5 cm) are associated with a higher diagnostic yield. Persistent lymphadenopathy for more than 4 to 6 weeks and progressive increase in size are other indications.
What is the importance of performing an excisional lymph node biopsy in suspected lymphomas?
What is the importance of performing an excisional lymph node biopsy in suspected lymphomas?
Excisional biopsy is preferred because it ensures adequate quantity of tissue to perform various histologic, immunologic, and molecular biological tests. It also permits careful examination of the entire lymph node architecture including normal and abnormal zones and capsular integrity. This is crucial for precise classification of the subtype of lymphoma.
What is the role of core biopsy and fine needle aspiration of suspicious lymph nodes?
What is the role of core biopsy and fine needle aspiration of suspicious lymph nodes?
In situations where excisional lymph node biopsy is fraught with risks due to unfavorable location, or there is a suspicion of squamous cell carcinoma, fine needle aspiration can be utilized as a first step in establishing a diagnosis; however, if lymphoma cells are present, an excisional biopsy may still be indicated.
What blood tests are indicated in patients with suspected hematologic malignancies?
What blood tests are indicated in patients with suspected hematologic malignancies?
A complete blood count with differential counts, peripheral blood smear evaluation, erythrocyte sedimentation rate, coagulation profile (PT/INR and PTT), comprehensive metabolic panel, and serum lactate dehydrogenase (LDH) levels are useful basic tests in patients with suspected hematologic malignancies. Evaluation of HIV status, viral hepatitis panel, and uric acid levels might also be warranted.
Name some of the early ENT indicators of complications from treatment of hematologic malignancies.
Name some of the early ENT indicators of complications from treatment of hematologic malignancies.
Sore throat is one of the earliest manifestations of agranulocytosis. Mucosal pallor results from severe anemia due to myelosuppression. Epistaxis and palatal petechiae might indicate thrombocytopenia due to chemotherapy.
What toxicities pertaining to the head and neck result from the treatment of hematologic malignancies?
What toxicities pertaining to the head and neck result from the treatment of hematologic malignancies?
Ototoxicity, radiation induced xerostomia, hypothyroidism, fibrosis of neck muscles, carotid injury, and second malignancies are some complications to be aware of. Chronic graft versus host disease after hematopoietic stem cell transplant can cause severe xerostomia as well.
Can treatment of hematologic malignancies cause ototoxicity?
Can treatment of hematologic malignancies cause ototoxicity?
Yes. Cisplatin, vinblastine, nitrogen mustard, arsenic trioxide, and bleomycin have been implicated in the development of hearing loss. It is usually dose dependent and symptoms vary from mild tinnitus to high-frequency sensorineural hearing loss and permanent vestibulo-cochlear damage.
Which agents used in the treatment of hematologic malignancies cause impaired sense of smell?
Which agents used in the treatment of hematologic malignancies cause impaired sense of smell?
Anosmia and hyposmia have been described in patients treated with cytosine arabinoside and methotrexate, which cause mucosal cell death and impaired mucosal cell regrowth respectively. Bleomycin and cisplatin can also cause significant dysguesia and even aguesia.
What is mucositis and how is it graded?
What is mucositis and how is it graded?
Mucositis is a term used to describe inflammation and loss of mucosal integrity of the gastrointestinal tract. Mucositis is a common complication in patients undergoing hematologic stem cell transplant, especially with conditioning regimens that use high-dose melphalan and radiation. The mouth and oropharynx are frequently involved, and clinical manifestations range from mild pain that does not limit oral intake to severe ulcerations that could result in profound weight loss and even death (Table 20-2).
What is the pathogenesis of mucositis?
What is the pathogenesis of mucositis?
Chemotherapy and radiation result in DNA damage mediated by reactive oxygen species. This results in the release of proinflammatory cytokines that cause tissue damage and ulceration. Secondary colonization by bacteria, fungi or viruses results in severe manifestations that can be life-threatening (Table 20-3).
