Oncology Slide Review LaJuan Chambers, MD. 16 yo young man with fatigue, pallor and low-grade fever...

Oncology Slide Review

LaJuan Chambers, MD

•16 yo young man with fatigue, pallor and low-grade fever for 2 weeks

•On exam, spleen palpated 8cm below left costal margin

•HPD reveals WBC 200,000, Hgb 5g/dl, platelet 700,000

•Bone marrow to the left…

•What’s his diagnosis?

Chronic Myelocytic Leukemia

• Accounts for <5% of leukemias in children

• Three phases:– Chronic (<5%)– Accelerated (5-30%)– Blast (>30%)

• Therapy:– Chemotherapy

(Imantinib)– Stem cell transplant

•4 yo boy with known Wiskott-Aldrich syndrome

•Presents with right-sided neck mass of 2 week’s duration

•Two maternal uncles have had similar condition

•FNA findings to the left…

•What is his diagnosis?

Malignant Lymphoma

• Usually Non-Hodgkins lymphoma – Large cell immunoblastic (typically)

• Occasionally presents in extranodal locations and CNS

• Difficult to treat (most die within a year of diagnosis)

• Many have c-myc gene rearrangements

Case #3

• 2 yo child with fever, fatigue, epistaxis and pallor

• Exam reveals moderate splenomegaly and petechiae

• WBC 2,000; Hgb 6g/dl and platelet count 17K

• PT 17, PTT 45, INR 3.5

M3 AML

• 5-10% of childhood AML

• Blasts have granules and Auer rods

• Increased risk of bleeding diathesis

• Overall good prognosis (chemo and all-trans retinonic acid alone)

• t(15;17) PML-RARA gene rearrangement found in nearly all cases

FISH for t(15;17)

• 3 yo boy with Downs syndrome presents with extensive bruising, epistaxis and pallor

• WBC 0.5K, Hgb 7.7g/dl and platelets 4K

• Bone marrow aspirate revealed these cells

• What’s the diagnosis?

M7 AML

• Megakaryocytic leukemia

• 5-10% of AML

• Associated with:– Downs syndrome– Klinefelter’s

• Difficult to treat (chemo, stem cell transplant)

• 20 month old child presents to PCP for well child checkup

• Grandparents noticed that his eyes looked “different” on Christmas photos

• What is this “finding” called?

Retinoblastoma

• Often present at birth• 1 in 18,000 live births

in the US• Bilateral disease

present in 20-30%• May be inherited or

sporadic• 13q14 mutation may

be found

•2 yo child presents with abdominal mass and painless hematuria

•No other symptoms

•What’s in the differential? What’s the diagnosis?

Wilm’s Tumor

• Presentation:Abdominal mass

Hematuria

Hypertension

• May be associated with:– WAGR– Beckwith-Wiedemann– Denys-Drash

• May be associated with:– WT1 (11p13) gene– WT2 (11p15) gene

• Amenable to:– Surgery– Chemotherapy– Radiation to mets

• 3 yo child with hypertension, watery diarrhea and the CT scan findings to the left…

• Biopsy of mass reveals the findings shown…

• What’s in your differential?

Neuroblastoma

• Characteristics:– Neural crest origin– 1 case per 7,000 births– Median age @

diagnosis – 22 months– Catecholamine excess – Elevated urine

VMA/HVA

• Poor prognostic factors:– Age >1yr– Elevated ferritin/LDH– Extensive disease– Amplified n-MYC– Persistent bone

marrow involvement– Poor histological

differentiation

• 2yo with rapidly enlarging abdomen

• Normal HPD, but metabolic panel reveals potassium 7mmol/L, creatinine 3mg/dl, uric acid 15mg/dl, calcium 6mg/dl and phosphorus 6mg/dl

Burkitt’s Lymphoma

• Usually presents as abdominal mass:– Change in bowel

habits– Intussusception– Nausea/vomiting

• Doubling time <24 hours

• May be complicated by tumor lysis syndrome

• May have bone marrow involvement

• Treatment consists of:– Chemo (systemic and

intrathecal)

• Overall good response to therapy and good prognosis

•2 yo girl with lymphadenopathy, fever, fatigue, bruising and pallor

•WBC 46K (with 90% “atypical lymphocytes”), Hgb 5g/dl and platelets 5K

•What’s her diagnosis?

Acute Lymphoblastic Leukemia

• Most common type of leukemia in childhood (80%)

• Peak incidence age 4y

• Pts. stratified according to risk: – Low– Standard– High– Very-high

Prognostic Factors - ALL

• Good Prognosis– Age >1yr or <9.99yr– WBC <50K– No CNS leukemia– Hyperdiploidy (DI>1)– Trisomies 4,10 & 17– t(12;21) TEL/AML1

• Poor Prognosis– Age <1yr or >9.99yr– WBC >50K– CNS leukemia– Hypodiploidy (DI<1)– t(9;22) – t(4;11) MLL

rearrangement