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Senior Academic Half Day: Malignant Haematology Beth Harrison Department of Haematology University Hospitals Coventry and Warwickshire NHS Trust.

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Presentation on theme: "Senior Academic Half Day: Malignant Haematology Beth Harrison Department of Haematology University Hospitals Coventry and Warwickshire NHS Trust."— Presentation transcript:

1 Senior Academic Half Day: Malignant Haematology Beth Harrison Department of Haematology University Hospitals Coventry and Warwickshire NHS Trust

2 Normal haematopoiesis Investigations in malignant haematology Approach to a patient with pancytopenia Diagnosis and management

3 Case 1 35 year old male 6 weeks recurrent throat infections 2 weeks easy bruising Hb 8.6 WCC 1.2 Platelets 12 Pancytopenia – he will need a bone marrow examination

4 Bone Marrow Examination

5 Normal Bone Marrow Aspirate

6 Normal bone marrow trephine

7 Case 1 35 year old male 6 weeks recurrent throat infections 2 weeks easy bruising Hb 8.6 WCC 1.2 Platelets 12

8 Hb 8.6 WCC Platelets 12 = Acute Leukaemia

9 What is acute leukaemia? What is a “blast”?

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11 What is a stem cell?

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15 Case 1 + Diagnosis = Acute myeloid leukaemia Bone marrow failure Blasts in bone marrow (+blood) Molecular diagnostics

16 Case 1 The Patient receives some chemotherapy Presents to A&E Pyrexial Shivery, vomiting, diarrhoea

17 Neutropenic Sepsis

18 Treat as neutropenic without waiting for FBC result Blood cultures Broad spectrum antibiotics within 30 minutes of presentation IV fluid resuscitation Get help

19 Fungal Pneumonia – Probably Aspergillus

20 Management of acute leukaemia Chemotherapy BUT: –Filtered air –No plants or flowers –No unnecessary visitors –Washed food – no salad or grapes or black pepper –Antifungal prophylaxis –Mouthcare

21 Indications for bone marrow Diagnostic –Abnormal FBC –Investigation of paraproteinaemia –Bone lesions in pelvis accessible by this route –Pyrexia of unknown origin ? TB in HIV+ ? foreign travel / splenomegaly –Isolated splenomegaly with diagnosis unclear from PB Staging –Hodgkin Lymphoma / Non Hodgkin Lymphoma Treatment response –Leukaemia, Myeloma, Lymphoma etc

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23 Case 2 56 year old man back pain, vomiting and constipation Na 145 Calcium 3.25 K 5.7 Total protein 126 Urea 46 Albumin 34 Creat 565 Hb 8.7

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25 Investigations: Protein electrophoresis – of what? Bone marrow examination – for what? Skeletal survey – is what?

26 Investigations: Serum / urine electrophoresis Bone marrow examination Skeletal survey

27 What is the diagnosis? Multiple myeloma First management issues? Correct calcium Give fluids

28 Renal Failure in Myeloma Light chain deposition in kidney Hypercalcaemia Hyperuricaemia Dehydration Non-steroidal anti-inflammatories Plasma cell infiltration of kidney

29 Urine free light chains: An old story Previous polyclonal antisera against light chains could not distinguish light chains bound into whole immunoglobulin molecules from free light chains

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31 Case 3 35 year old woman with 2 years of lethargy and intermittent LUQ pain now complaining of dizziness Visible white cells

32 Case 3 On examination: Massive splenomegaly Fundal haemorrhages Diagnosis Chronic myeloid leukaemia with hyperviscosity resulting from WCC Immediate management Get the white cell count down!!

33 Myeloproliferative Disorders Clonal, pre-leukaemic Uncontrolled proliferation of one or more bone marrow lineages: –Red cells – primary polycythaemia –Platelets – essential thrombocythaemia –White cells (myeloid) – chronic myeloid leukaemia –Fibroblasts - myelofibrosis

34 Myeloproliferative Disorders Primary Polycythaemia and Essential Thrombocythaemia: –Increased vascular events –Treatment is aimed at reducing these Hb>19? Plts>700? Ask!

35 Causes of hyperviscosity Paraprotein (IgM > IgA > IgG) High WCC (CML / AML > CLL) High red cell mass (polycythaemia) Raised platelet count –(>1,000, myeloproliferative rather than reactive)

36 Causes of splenomegaly Haematological –Chronic myeloid leukaemia, Myelofibrosis –Chronic lymphatic leukaemia –Acute lymphoblastic leukaemia –Lymphoma (various) Infective –EBV –Chronic malaria –Visceral Leishmaniasis LiverOther –HCV / HBV with portal hypertension –Any cause cirrhosis with portal hypertension

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38 Case 4

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40 Indications for lymph node biopsy Generalised lymphadenopathy, FBC unhelpful. –(Also palpable cervical LN with mediastinal LN on CXR) Isolated lymphadenopathy – no obvious pathology in the anatomical region drained –(ENT: nasendoscopy NAD, FNA unhelpful) Regional lymphadenopathy with obvious primary pathology inaccessible to biopsy

41 Findings on lymph node biopsy? Reactive Necrotic Granulomatous – TB, Sarcoid? HIV? Metastatic Carcinoma Metastatic Melanoma Lymphoma

42 Non-Hodgkin’s Lymphoma: T cell Hodgkin Lymphoma Non-Hodgkin’s Lymphoma: B cell

43 Case 4 Nodular Sclerosing Hodgkin Lymphoma

44 Risks of treatment? Case 4 Risks of treatment: –Breast cancer –Thyroid cancer –Secondary leukaemia / myelodysplasia –Infertility –Other endocrine failure - early menopause –Bones –Cardiac damage (chemo + radiotherapy) Treatment: Chemotherapy Radiotherapy

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46 Intraabdominal lymphoma

47 PET-CT in staging lymphoma

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49 Indolent Non-Hodgkin Lymphoma: localised to one site

50 Aggressive Non-Hodgkin Lymphoma

51 Thank you


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