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A lump in the neck
Lent term year 2
The case• A 58 year old man went to his GP after he
noticed a lump growing in the right side of his neck
• He had been feeling tired recently and had noticed some night sweats over the past three weeks
• He had also noticed some itching of his skin all over his body
What can cause lumps in the neck?
Lumps in the neck• Congenital or acquired
• Think of organs within the neck
• Skin: lipoma, epidermoid cyst
• Congenital rests: thyroglossal cyst; branchial cysts
• Thyroid: cysts, goitre, tumour: adenoma or carcinoma
• Pharyngeal pouch
• Salivary gland swelling; vascular swelling
• Lymph nodes
Causes of lymphadenopathy• Viral: “Glandular fever”EBV; CMV; HIV
• Bacterial: draining area of sepsis
• Tuberculosis; brucellosis
• Collagen disease
• Sarcoidosis
• Metastatic cancer e.g stomach; head & neck
• Lymphoma
Lymphoma: a histological diagnosis
• Hodgkin’s disease (20%). Reed-Sternberg cells
• Non-Hodgkin’s disease (80%): over 20 types
B- cell lymphomas
T- cell lymphomas
Others: AIDS-related and CNS lymphoma
Classification of NHL:• Anaplastic large cell • Burkitt • Cutaneous T-cell • Diffuse large B-cell • Follicular • Lymphoblastic • MALT • Mantle cell • Mediastinal large B-cell • Nodal marginal zone B-cell • Peripheral T-cell • Small lymphocytic • Thyroid • Waldenstrom's macroglobulinaemia
Investigations: diagnosis and staging
• Histological biopsy
• Chest X-ray
• CT/MRI/PET scanning
• Liver function tests
• Full blood count
• ? Bone marrow sampling
Histology: Diffuse B Cell Lymphoma (High Grade)
PET scanning: Positron Emission Tomography
Staging of NHL:
• Stage 1: involving one lymph node group
• Stage 2: more than one group on one side of diaphragm
• Stage 3: involvement of lymph nodes both sides of diaphragm
• Stage 4: extralymphatic spread: liver, spleen, lungs, stomach, bone marrow
What sort of treatment will our patient be offered, and what is
the prognosis?
Treatment for stage 4 high-grade NHL
• Depends on –histological type, age, general health, other organ involvement
• An MDT approach
• Will require patient’s consent after discussing type of treatment, advantages, disadvantages, risks, side effects and other options
International Prognostic Index: 2 or more factors <50% relapse-free at 5 years
• Age >60 years of age • Serum lactate dehydrogenase-LDH
elevated• Performance status (0 or 1 versus 2-4), • Stage III or IV • Extranodal site involvement
Performance statusGrade
Description
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead
Overall survival
Risk Group Number of Factors % 5 year OS % 10 year OS
Low 0-1 90.6 70.7
Intermediate 2 77.6 50.9
High 3 or higher 52.5 35.5
Our patient was offered chemotherapy with Ritoximab
(R-CHOP)• R- Ritoximab IV
• C- cyclophosphamide IV
• H- Doxorubicin (red) IV
• O- Vincristine IV
• P- Prednisolone orally 60-80mg 5 days
6-8 cycles over 21 days
Ritoximab• Monoclonal Ab
• Locks onto protein CD20 on B lymphocytes
• Given as IV infusion over a few hours
• May insert PICC line
What side effects would you warn him about?
Side effects (variable)• During infusion: ‘flu-like symptoms,
flushing, allergic reactions
• Reduced resistance to infection
(neutropenia)
• Bruising/bleeding (thrombocytopenia)
• Anaemia
• Fatigue
• Nausea and vomiting
And more…• Hair loss
• Stomatitis
• Altered taste (dysguesia)
• Dyspepsia and hunger (steroids)
• Cystitis (cyclophosphamide)
• Numbness/tingling of fingers (vincristine)
• Oedema (prednisolone)
• photosensitivity
And more…• Mood swings (prednisolone)
• Nail changes
• Cardiac arrhythmias (doxorubicin cardiomyopathy)
• Tissue necrosis as venous infusion site
• Raised blood sugar (prednisolone)
• Cushing’s syndrome (prednisolone)