a lump in the neck lent term year 2. the case a 58 year old man went to his gp after he noticed a...

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)