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Senior Academic Half Day: Malignant Haematology. Beth Harrison Department of Haematology University Hospitals Coventry and Warwickshire NHS Trust. Normal haematopoiesis Investigations in malignant haematology Approach to a patient with pancytopenia Diagnosis and management. Case 1.

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senior academic half day malignant haematology

Senior Academic Half Day:Malignant Haematology

Beth Harrison

Department of Haematology

University Hospitals Coventry and Warwickshire NHS Trust

slide2
Normal haematopoiesis
  • Investigations in malignant haematology
  • Approach to a patient with pancytopenia
  • Diagnosis and management
case 1
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

case 11
Case 1
  • 35 year old male
  • 6 weeks recurrent throat infections
  • 2 weeks easy bruising
  • Hb 8.6
  • WCC 1.2
  • Platelets 12
slide8
Hb 8.6
  • WCC 1.2 +
  • Platelets 12

=

Acute Leukaemia

slide9
What is acute leukaemia?

What is a “blast”?

case 12
Case 1

+

+

Diagnosis = Acute myeloid leukaemia

Bone marrow failure

Blasts in bone marrow (+blood)

Molecular diagnostics

case 13
Case 1
  • The Patient receives some chemotherapy
  • Presents to A&E
  • Pyrexial
  • Shivery, vomiting, diarrhoea
neutropenic sepsis1
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
management of acute leukaemia
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
indications for bone marrow
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
slide23
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
slide25
Investigations:
  • Protein electrophoresis – of what?
  • Bone marrow examination – for what?
  • Skeletal survey – is what?
slide26
Investigations:
  • Serum / urine electrophoresis
  • Bone marrow examination
  • Skeletal survey
what is the diagnosis
What is the diagnosis?
  • Multiple myeloma
  • First management issues?
  • Correct calcium
  • Give fluids
renal failure in myeloma
Renal Failure in Myeloma
  • Light chain deposition in kidney
  • Hypercalcaemia
  • Hyperuricaemia
  • Dehydration
  • Non-steroidal anti-inflammatories
  • Plasma cell infiltration of kidney
urine free light chains an old story
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

case 3
Case 3
  • 35 year old woman with 2 years of lethargy and intermittent LUQ pain
  • now complaining of dizziness

Visible white cells

case 31
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!!
myeloproliferative disorders
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
myeloproliferative disorders1
Myeloproliferative Disorders
  • Primary Polycythaemia and Essential Thrombocythaemia:
    • Increased vascular events
    • Treatment is aimed at reducing these

Hb>19?

Plts>700?

Ask!

causes of hyperviscosity
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)
causes of splenomegaly
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
indications for lymph node biopsy
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
findings on lymph node biopsy
Findings on lymph node biopsy?
  • Reactive
  • Necrotic
  • Granulomatous – TB, Sarcoid?
  • HIV?
  • Metastatic Carcinoma
  • Metastatic Melanoma
  • Lymphoma
slide42
Non-Hodgkin’s Lymphoma: T cell

Hodgkin Lymphoma

Non-Hodgkin’s Lymphoma: B cell

case 41
Case 4
  • Nodular Sclerosing Hodgkin Lymphoma
case 42
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?

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