Module 6 Ics

Front 1

List the conditions that may lead to lymph node enlargement.

Back 1

1. infection or reaction to infections

2. tumors

3. miscellaneous

Front 2

Examples of infections or reactions to infections that may lead to lymph node enlargement

Back 2

1. Enlargement of nodes draining areas of local infection or portals of entry of infection
-- skin or oral infections

2. Generalized LN enlargement due to systemic infections
-- mono
-- AIDS

3. Infection of LN by organisms
-- Staph
-- Pasteurella pestis

4. Granuloma formation as reaction to infection
-- TB
-- Histoplasma capsulatum

Front 3

Examples of TUMORS that may lead to lymph node enlargement

Back 3

Primary tumors of lymphocytic lineage
1. Hodgkin's lymphoma
2. Non-Hodgkin's lymphoma
3. ALL
4. CLL

Tumors that metastasize
1. adenocarcinomas and epithelial tumors
-- breast, lung, head, neck
2. Myeloid leukemias
-- acute and chronic

Front 4

Examples of MISCELLANEOUS causes that may lead to lymph node enlargement

Back 4

1. Autoimmune D/O's
-- SLE
-- RA
-- other "collagen disorders"

2. Immune response to non-infectious agent
-- serum sickness after ingestion foreign protein

3. Sarcoidosis

4. Berylliosis

Front 5

What is important in the Hx and PE when evaluating pt w/ lymphadenopathy?

Back 5

1. Age and occupation

2. Location and size of LN

3. Duration of lymphadenopathy

4. Presence of associated symptoms

5. Physical characteristics of LN
-- hard vs. rubbery
-- static vs. freely moveable

Front 6

What basic lab evaluations of a patient w/ lymphadenopathy?

Back 6

1. CBC

2. Mono test

3. BM aspiration if abnormal cells in the peripheral blood, anemia, or persistance of symptoms

ADDITIONAL STUDIES:
-- CXR
-- CT of chest, abdomen, pelvis
-- excisional LN biopsy

Front 7

Why is it important to understand Hodgkin's lymphoma (HD)?

Back 7

1. historical importance: first dissiminated malignancy ever cured w/ systemic chemo

2. Majority of pts w/ HD diagnosed today can be cured

3. Since mostr pts diagnosed w/ HD will be cured, primary care physicians will ultimately have to follow these patients and manage many of the long-term complications of the therapy of HD

Front 8

Clinical characteristics of HD?

Back 8

PRESENTS WITH
-- centripetal and axial involvement, including cervical, supraclavicular, mediastinal lymphadenopathy
-- typically spreads to contiguous nodal areas
-- adenopathy can be waxing and waning

More than 80% of patients have lymphadenopathy above the DIAPHRAGM
-- disseminated is rare
-- Waldeyer's ring involvement is rare
-- occipital, epitrochlear, mesenteric sites are rare

Approx 40% experience systemic or "B" symptoms
-- fever, night sweats, pruritis, or 10% body loss
-- occur more frequently in elderly and have negative impact on prognosis

Front 9

How is HD staging based?

Back 9

ANATOMICALLY BASED since it spreads to contiguous nodal areas in the majority of the cases

Front 10

Staging should include...?

Back 10

1. Hx and physical
2. CBC
3. LFTs
4. LDH, albumin, calcium
5. CXR
6. CT of chest, abdomen, pelvis
7. BM aspiration and biopsy
8. Lymphangiogram in selected cases
9. Staging laparotomy in selected cases

Front 11

Ann Arbor Staging Classification?

Back 11

STAGE I:
-- involvement of single LN region or a lymphoid structure (spleen, thymus, waldeyer's ring, etc)

STAGE II:
-- involvement 2 or more LN regions on SAME side of diaphragm

STAGE III:
-- LN regions or structures on both sides of the diaphragm

STAGE IV:
-- involvement of extranodal site(s) beyond the designated "E"
-- typically means extranodal disseminated disease such as BM and liver involvement

FOR ALL STAGES:
A --> no systemic symptoms
B --> presence of systemic symptoms
-- fever >38C, night sweats, weight loss of more than 10% body weight over 6 months

STAGES I to III:
E: involvement of a single, extranodal site contiguous to known nodal site

Front 12

HD Treatment?

Back 12

1. without --> 5-yr survival of less than 5%

2. Stage is most important determinant of treatment and outcome

3. Sensitive to radiation and chemo; all pts should be treated w/ curative intent

4. Stages I and II: radiation
Stages III and IV: combination chemo

5. Disease is so sensitive to chemo that some pts initially treated w/ radiation that relapse can be salvaged w/ combo chemo

6. Pts that do not attain complete remission or suffer relapse can be cured w/ high dose chemo and autologous BM transplant

Front 13

Long-term complications of HD treatment?

Back 13

SECONDARY MALIGNANCIES:
-- myelodysplastic syndromes
-- acute myelogenous leukemia
-- non-Hodgkin's lymphoma
-- acute lymphocyic leukemia
-- sarcoma, lung, thyroid
-- other solid tumors

ENDOCRINE COMPLICATIONS
-- infertility
-- hypothyroidism

PULMONARY COMPLICATIONS
-- pulmonary fibrosis
-- bleomycin lung toxicity

CARDIAC COMPLICATIONS
-- cardiomyopathy
-- accelerated atherosclerotic heart disease
-- pericarditis and pericardial fibrosis

Front 14

What are non-Hodgkin's lymphomas (NHL)?

Back 14

heterogenous group of lymphoid malignancies
-- different morphologic features
-- varying clinical course
-- varying response to therapy

Neoplasms arise from monoclonal prolif of a malignant cell of lymphoid origin
-- T OR B cell

Rationally subclassified according to histologic findings and clinical behavior

Front 15

Etiology and Epidemiology of NHL?

Back 15

-- About 45K new cases/yr
-- incidence rising rapidly

Cause remains unclear
-- virus and infectious agents
-- chrom translocations
-- chemo and radiation therapy
-- immunodeficiencies

Front 16

Staging of NHL?

Back 16

Ann Arbor can be applied to NHL but:
-- does not reflect the noncontiguous nature of NHL
-- fails to account for tumor bulk or number of extranodal sites

NHL trtmt requires different therapy based on areas of involvement -- extent of disease important for prognosis and treatment planning

HISTOLOGIC SUBCLASS is primary determinant of survival and cure potential

Front 17

Treatment of low grade NHL?

Back 17

-- less aggressive behavior, prolonged survival

Most pts have advanced disease at diagnosis
-- only 10% have stage I or II disease

Few pts that present w/ localized disease: treat w/ radiation

Dissiminated disease: NOT curable w/ chemo
-- treat w/ palliative intent

Front 18

Treatment of aggressive NHL?

Back 18

Most: combo chemo
-- rapidly progressive disease that requires treatment

Commonly use "CHOP"
-- cyclophosphamide
-- Adriamycin
-- Oncovin
-- Prednisone

Treatment program cures 1/3 pts w/ diffuse large cell lymhoma (one of most common intermediate-grade)

40-50% that relapse after first-line chemo can be cured w/ BM transplant