Download 15**Know the diseases that present with generalized

15**Know the diseases that present with generalized lymphadenopathy versus localized
disease:
- Generalized: HIV (non-tender), TB, Mono, SLE,
- Localized: URI, Bacterial/Viral, CA, Catch-Scratch Disease (Bartonella henselae). With CatchScratch, treat with Azithromycin for 5 days.
** Lymph node adenopathy less than 1 cm is rarely malignant.
- Malignant nodes are characterized by being fixated/attached to the surrounding tissues and
being not freely mobile.
- Hard nodes are associated with solid tumors (pancreatic, breast).
- Rubbery nodes are associated with hematological malignancies.
- Soft and tender nodes: typical of normal inflammatory/infections processes.
Most common cause for lymphadenopathy in the USA is unexplained/idiopathic.
For acute lymphadenitis, viral etiologies present bilaterally and bacterial etiologies unilaterally.
Infectious Mono: classic triad of fever, tonsillar pharyngitis, and cervical lymphadenopathy.
Infectious Mono typically presents with generalized adenophathy not just limited to the cervical
nodes.
- Bloodwork will show lymphocytosis with atypical lymphocytes, and elevated AST/ALT from
the Ebstein-Barr Virus causing hepatitis.
- S/Sx: Splenomegaly and positive Monospot.
Kikuchi’s disease: it is a benign condition seen often in women that presents with
lymphadenopthy and fever with unknown etiology.
- It has a very similar clinical presentation to cancer such as having cervical lymphadenopathy,
fatigue, and hard nodes.
- It is self-limited and resolves.
- Biopsy should show “histiocytic cellular polyclonal infiltrate with preservation of nodal
architecture”
16.** He repeated this twice:
-Features of a Malignant Lymphadenopathy
▪ Size/Consistency: typically larger than 1 cm and with multiple nodes present;
▪ Hard fixed nodes are suggestive of solid tissue cancers [ie: metastatic carcinomas]
▪ Firm rubbery nodes are seen with hematologic cancers
▪ Take weeks to months to develop.
Breast Cancer is by far the most common cancer that causes lymphedema. It’s usually caused by
iatrogenic reasons (surgery and radiation damage lymphatic vessels).
-Sentinel node dissections have a much lower risk of causing lympedema.
Breast Cancer is also by far the most common carcinoma that presents with lympadenopathy in the
Axilla. It is treated as breast CA until proven otherwise.
-Lymphomas are the most common overall malignancies that present in the axilla.
Supraclavicular Adenopathy: Associated with higher risk of malignancy
The left supraclavicular lymph node, known as “Virchow’s Node”, more commonly presents with cancer
than the right supraclavicular node b/c it drains most of the body particularly the abdomen.
▪ Troisier’s sign/node: finding an enlarged hard/firm left supraclavicular node
▪ Abdominal Cancers: Gastric, gallbladder, pancreas, kidney, GU
In the adult, Cervical lymphadenopathy is Cancer until proven otherwise.
¬ -Head and Neck cancers from the aerodigestive tract account for the majority of masses in the cervical
region.
Masses in the anterior mediastinum are more likely to be malignant than those found in other
mediastinal compartments. The 4 T’s:
▪ - Thyroid
▪ - Thymoma: Is the most common anterior mediastinal neoplasm in adults. Associated with a number of
paraneoplastic disorders: Myasthenia Gravis and Pure Red Cell Aplasia
▪ - Teratomas
▪ - Terrible Lymphomas: Hodgkins or Non-Hodgkins arising in the anterior mediastinum
17. Hodgkin Lymphoma: ****Bimodal peak: young 20-30’s, and elderly 65-85’s****
- Cervical region is most common site for lymphadenopathy. Mediastinum is 2nd most common
site.
- You need an excisional biopsy to diagnose HL,
Two Types:
a. Classical HL
- Has the diagnostic “Reed-Sternberg Cells”
- CD15, and CD30 positive.
- Brentuximab vedotin: anti-CD30 antibody used to treat Post ASCT Classical HL
- CD3- and CD45- negative
- EBV positive
- Has Fibrosis
- Inflammatory background: T-Lymphoctes are greater than B-Lymphocytes
b. Nodular lymphocyte predominate
- “Popcorn Cells” are the diagnostic tumor cells
- better prognosis
-Is CD15 and CD 30 negative
-Is EBV negative
- Distinct sub-type due to: appearance, surface markers, and treatment.
- You use Rituximab in Nodular Lymphocyte Predominate HL b/c it is CD20+
- Does not have Fibrosis
- Inflammatorybackground: B-Lymphoctes are greater than T-Lymphocytes
- ***Nodular Lymphocyte Predominant has a higher than usual incidence of Richter’s
Transformation to a higher grade lymphoma (12% at 10yrs of tranformation into Richter
Transformation)
*** Relapse Statistics for HL-Treatment
Early stage favorable: 10-20%
Advanced stage: 30-40%
Primary refractory to therapy: 10-15%
This means 10-15% of patients don’t respond to Tx
18. B-Cell NHL is much more common than T-Cell NHL
In aggressive tumors LDH will be high***, also will have B sxms (fever, night sweats, weight
loss) + fatigue
Burkitts is most common in Peds and DLBL is most common in adults
Most likely extranodal involvement is GI
Follicular/Marginal zone lymphoma (not as aggressive) – won’t show much uptake in PET, so
need to do CT…PET is helpful for Hodgkin and aggressive NHL***
Rituximab – if CD20+…Antigen dependent cellular toxicity, Complement dependent cytotoxicity,
apoptosis***
DLBCL – Early stage (I-II) is R-CHOP x3 and involved field radiation; Advanced stage (III-IV) is RCHOP 6-8 wks***
ABC is more likely to relapse than GCB
Richter Transformation*** - when CLL transforms to DLBCL
19. Multiple Myeloma (MM)
B cell malignancy – MONOCLONAL immunoglobulin (if polyclonal -> not malignant)…know that
plasma cells maintains humoral immunity, so MM results in being immunocompromised;
Myeloma cells release cytokines, angiogenesis factors, and M proteins.
MM presentation – Bone destruction -> hypercalcemia, macrocytic anemia, renal issues
Dz – Peripheral blood: Rouleaux, but won’t be seen it in asymptomatic dz or MGUS;
Immunofixation is more expensive than Electrophoresis and is better at picking up the smaller
M spikes (e.g. MGUS); Bone Marrow Aspirate: Plasma cell w/eccentric nucleus (meaning it is
not in the center).
In active MM you will see >10% of aberrant plasma cells in marrow and end organ damage (in
smoldering, NO end organ damage)
MGUS (all they have is a smaller M spike) – may transition to MM (1%).
Solitary Plasmacytoma (of bone/extramedullary) – tx w/LOCALIZED radiation…this is more of a
risk factor than MGUS for transition to MM.
Since MM is lytic bone dz do simple Xray of bones (aka Skeletal survey = ABSOLUTE GOLD
STANDARD) not bone scan. Most common site of lytic dz is Calvarium – you’ll see punched out
holes
In high risk pts (p53 mutation) don’t do chemo. Hyperdiploidy is a good prognosis risk factor.
Tx standard = induction therapy + stem cell transplant + maintenance … Revlimid (lenalinomide)
– immunodulator, induces apoptosis, anti-apoptotic or Velcade (bortezomib) – proteasome
inhibition; standard of care for induction is RVD (revlimid, velcade, decadron); In cases of
relapse, NO analogous stem transplant (only autologous)
Plasma cell leukemia = complication of MM (only 0.6%)
Amyloidosis = complication of MM (10%)…aberrant Ig deposition; Presentation - periorbital
edema, macroglossitis, renal issues
Lecture 20
o The anemia associated with beta thalassemia minor is
Mild, microcytic, hypochromic, asymptomatic
o Hb made up of 4 beta chains- HbH- in alpha thalassemia
o Hb made up of 4 gamma chains- Hemoglobin Barts- Hydrops fetalis- alpha thalassemia
o Anemia with different thalassemias- microcytosis, hypochromatic
o Know Hydrops fetalis- which thalassemia(alpha) and the pathophysiology (absence of alpha
globin synthesis- no hemoglobin before birth- lethal- Barts Hb)
o Treatments of the different types- a and b and carrier states
o Screening and confirmation tests of thalassemia = electrophoresis
• Lecture 26
o What is the first sign of shock? Tachycardia (and cool skin, inc respiration, and axiety but NOT
hypotension)
o What is an unreliable sign of early shock? Hypotension
o What is the blood volume in an adult with an ideal body weight of 70kg? 70cc/kg = about 5 L
o What is the blood volume in a child with a weight of 20kg? (take 80 – 90 cc/kg, they weigh
20Kg = 1600 – 1800 cc)
o What is the initial IV fluid of choice? NS or LR
o What is the initial bolus amount for a child? 20cc/kg bolus
o Hypotension appears in class 3
o Initial IV fluid and bolus amounts NS or LR, initial bolus amount for kids are 20cc/kg
o What does the heart do to inc cardiac output in the setting of shock = inc heart rate
o After given appropriate amount of NS or LR, your next IV fluid of choice = blood