P ointers to lymphoma and acute lymphoid leukaemia diagnosis - PowerPoint Presentation

Slide1

Pointers to lymphoma and acute lymphoid leukaemia diagnosis

Prof Ivy A E

Ekem

16

th

September 2016

Slide2

Blood

Slide3

Slide4

en.wikipedia.org / M.

Komorniczak

. Accessed 08.09.16

Slide5

Development of blood cells

en.wikipedia.org

Slide6

Site of blood formation

www.healthline.com>Ref Library

Slide7

Peripheral blood and marrow

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Slide9

Outline

What lymphoma and acute lymphoid leukaemia are

Who they affect

How they present and why

How the diagnosis made

C

ardinal points in making diagnosis ----history, examination, selected investigations and their proper interpretation

Slide10

What is lymphoma? What is acute lymphoid

leukaemia (ALL)?

Lymphoma – cancer of a white cell in the lymph nodes. Two broad groups:

Hodgkin lymphoma

Non-Hodgkin lymphoma e.g. DLBCL,

Burkitt

Acute lymphoid /

lymphoblastic leukaemia -

cancer of a

white cell in the marrow. Three subgroups:

L1

L2

L3 (

Burkitt

type)

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Lymphoma

Affects lymph nodes;

the

spleen; thymus

gland.

Lymph nodes:

neck, armpits, groin, chest, abdomen and

pelvis.A

lymphoma develops when

an abnormal clone develops

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Acute lymphoid leukaemia

Affects the bone marrow

Immature lymphoid cells called

lymphoblasts

appear

Proliferate rapidly to populate the bone marrow and blood

Depopulate the marrow of normal cells – red cells, normal white cells, platelets

‘Bone marrow failure’

Lymph nodes, spleen may also be affected

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Same disease?

World Health Organization (WHO) classification of lymphoid

tumours

– listed together

Same cell, different stages of the cell at genetic change and type of change

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Who they affect

All ages and sexes, but in lymphoma,

Hodgkin

lymphoma

bimodal peak, third and eighth decades

NHL

increases with age

In leukaemia

ALL

is more

common in childhood, especially

between 2

and 5

years of age.

Risk increases again

in people

aged 45 and above.

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How they present and why

ALL

Bone marrow failure

Fever, night sweats

Enlarged lymph nodes

Lymphoma

Enlarged lymph nodes

Fever, night sweats

Unexplained weight loss

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Why?

L

ymphoma

is the most common etiology of neoplastic fever of

unknown

origin.

The pathophysiology:

tumour necrosis factor and interleukins 1, 2, 4

Night sweats: body temperature regulation and circadian rhythm. Periodic

increases in interleukins (IL-1α, IL-2, IL-4, IL-6) and tumor

necrosis factor.

N

o research

found to support this

though.

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How the diagnosis made

History, physical examination for both

Blood film and marrow for ALL

Lymph node / tissue biopsy for lymphoma

Other tests for further classification and staging

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Cardinal points in making diagnosis: history

,

examination,

selected

investigations

and their proper

interpretation

History: Onset; suddenness in ALL. Swelling, systemic symptoms

examination: lymph node areas

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Lymph node areas

www.healthresource4u.com

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Case ‘stories’

Father insistence on marrow examination

B

one marrow trephine revealed diagnosis posthumous

B

one lesions in the young followed as for the elderly

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Case 1: Father insists

A 14 year old previously well BECE candidate is admitted with unexplained fever and difficulty in walking of 2 weeks duration unto the medical ward.

Examination reveals a febrile young boy, well nourished and with

paraparesis

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Investigations among others reveal a normal blood count

Marrow is requested (by father), not obliged (re…route of request).

Father insists a friend’s son presented similarly and was found to have leukaemia

Patient seen though, but on account of normal counts

……marrow not

done

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Case 1 continued…..

Investigations continue for TB, viral illnesses etc.

LDH done

Presented at clinical meeting for leads to diagnosis

Bone marrow suggested and done on account of same history and high LDH

Diagnosis – Acute lymphoid leukaemia. Father was right.

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Case 2: Posthumous diagnosis

51 year old man

Splenectomized

for

pancytopaenia

4 years earlier

Presented with febrile illness and severe joint pain

Managed for sepsis and rheumatoid arthritis…….improved

Pancytopaenia recurred when steroids were tapered

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Some FBC results

Hb

– 8.1 g/dl; WBC - 3.66 x 10

9

/l with 85%L; Platelets – 63 x 10

9

/l

Hb

- 7.9 g/dl; WBC - 5.96 x 10

9

/l with 79.8L; Platelets – 111 x 10

9

/l

Hb

- 8.0 g/dl;

WBC

– 0. 88 x 10

9

/l with 93.6%L; Platelets – 34 x 10

9

/l

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Case 2 ctd….

Hb

dropping

Trephine biopsy done

Read after patients demise

Diagnosis - ALL

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Case 3: Bone lesions in the young

A young man, early 30s presented with features of a rapidly evolving debilitating illness

Amongst investigations, x-rays showed lytic lesions

Investigations continued as for myeloma….

More investigations revealed an LDH of over 2000U/L

?? Myeloma…. Patient demise

Post mortem: Lymphoma

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A note on Lactate dehydrogenase (

LDH)

A

n enzyme

found in nearly all living cells (animals, plants, and prokaryotes).

Catalyzes

the

inter-conversion

of lactate to pyruvic

acid and so doing converts NAD

+

to NADH and back.

Raised levels in numerous medical conditions from

haemolysis

, through heart failure to malignancies however……

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LDH ctd…

I

nvolved

in tumor initiation and metabolism

.

Cancer

cells rely on increased

glycolysis rather than aerobic respiration, thus

increased lactate production

This

allows

tumour

cells to convert the majority of their glucose stores into lactate

thus shifting

use of glucose metabolites from simple energy production to the promotion of accelerated cell growth and replication.

Slide30

The unusual presenter

Listen. Follow every lead in the history. Retake history as often as necessary

Chase every result requested for. It must have been needed for it to have been requested. Consult the laboratory physician

Interpret results with patient in mind. Remember that every patient is unique in their signs and symptoms.

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Take home messages for all of us

K

eep learning

Don’t take patient for granted

Lymphomas and acute lymphoid

leukaemias

can be difficult to diagnose but

good history taking,

efficient investigations and interpretation

W

ill give the diagnosis away in the great number of cases.