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 Hb 8.6 WCC 1.2 Platelets 12 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 Hb 8.6 WCC 1.2 Platelets 12 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”?

11. What is a stem cell?

15. Blasts in bone marrow (+blood) Molecular diagnostics
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. Neutropenic Sepsis 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

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

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

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
Liver Other
HCV / HBV with portal hypertension
Any cause cirrhosis with portal hypertension

38. Case 4

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

46. Intraabdominal lymphoma

47. PET-CT in staging lymphoma

48. PET-CT in staging lymphoma

49. Indolent Non-Hodgkin Lymphoma: localised to one site

50. Aggressive Non-Hodgkin Lymphoma

51. Thank you