O&P/Tutorials/Lump in a lymph node field

Soon's notes p 55/348 AE3

• Zones of cervical lymph nodes are important - they determine the pattern of lymphadenectomy when there is disease. Radical dissections may include removal of the SCM

• COX-1 gastroprotective due to mucus secretion and prostaglandin E allows platelet adherence
  • NSAIDs also produce renal dysfunction
    • oxidative free radical
    • prostaglandin vasodilates efferent arteriole --> decreased renal blood flow
• MRI are particularly useful in brain + pelvis because bony confines cause artefacts, so we use MRI instead of CT for staging rectal cancer or neurological problems
  • Difficult to read, expensive, claustrophobia
• PET/CT together may replace CT and bone scan together
• ABVD (Adriamycin, Bleomycin, Vinblastine,Dacarbazine)
  • Side effects: febrile neutropenia, skin changes, irritable diarrhea
  • Bleomycin blasts the lungs
  • Vinblastine --> peripheral neuropathy: sensitivity to light touch, paraesthesia
• The agents you give to get rid of the cancer may cause other bone cancers -- follow these patients up

• Surgical biopsy + radiological biopsy
  • Surgeons involved when splenectomy or lymph node excision
  • Radiological aspirate is not diagnostic alone because they can get cytology, but not histology (need organisation of the cells in the lymph node [including its fibrous capsule] to classify the lymphoma). They do H+E staining, flow cytometry etc to type the note.
• Hodgkins vs NHL
  • Hodgkins: Reed-Sternberg cells (owl-eyes, lots of cytoplasm), occurs in younger people, has better prognosis, lymphadenopathy tends to be more localised
    • 10-20% of all lymphomas are HL. NHL = group of everyone with no Reed Sternberg cells
• Chemotherapy generates an intellectual 'fog' - not good for studies or working at a high level. This is because neural tissue is affected. This is a big problem for career, particularly since these people are young
• Secondary thyroid CA in HL
  • Radiotherapy during the treatment of HL can increase the risk of thyroid cancer in these patients
    • Types: papillary, follicular, medullary, anaplastic
      • Papillary thyroid CA: metastasise rapidly to LNs. Well treated with thyroidectomy and chemotherapy. Survival >100% because they overtake the controls in their function
      • Anaplastic: poor prognosis, only 2-3 weeks
• Remission isn't a guarantee it won't come back, it can always come back
• HL is a minority of lymphomas and they do better
• It's very rare for people after chemotherapy to be better physiologically after chemotherapy - so Lance's story was dodgey
• Aetiology of lymphoma (see here: http://www.cancer.org/cancer/non-hodgkinlymphoma/detailedguide/non-hodgkin-lymphoma-risk-factors)
  • Genetics
  • Radiation
  • HIV/immunocompromised
  • infliximab; immunosuppression
  • EBV, HHV8
  • H. pylori - associated with mucosa associated lymphomas
  • Leukaemias
• Consensual decision making - need patient compliance
  • If you don't complete treatment, you're exposed to all the risk without getting benefit
  • Providing information, possibly in a number of formats
  • Family meeting, bring all stakeholders - help patient make a decision
  • Pushing someone to difficult treatment with 80% remission
    • If someone makes a decision that gives them a bad prognosis, you need to lure them
    • Explain the adverse effects of not treating e.g. painful death
    • Check their understanding to see why they make a poor decision
    • Make sure patient is lucid
    • If they're lucid and sanely making a poor decision, you have to accept their decision
• If parents in charge of a kid make a poor decision, get guardianship and give them the treatment. Then follow up the parents in case
• Exam point: show empathy if you don't know
  • If you don't know, at least show you're a good person

• In regards to heuristics, if the Px refuses Tx once, the procedure is to reinform the Px of the situation & the recommended course of action → check the Px’s understanding → offer the Tx again
  • If the Px refuses again, the practitioner must oblige by the Px’s wishes
  • People aren't robots, and don't know how to use percentages. Instead people just follow intuition. It's important to personalise some of the statistics.
  • Heuristics = rules of thumb ignoring evidence. But in practice you can't follow EBM all the time. Therefore you sometimes need to use heuristics - but make sure not using heuristics even in the face of evidence to the contrary.
    • Need to be flexible enough to change your decision making when their is evidence

• Freeze eggs/sperm before chemotherapy! Fertility can be lost

• Thyroid mass rises with swallowing, unlike neck lymphadenopathy
• Note the commonest cause of enlarged lymph node in the neck is infection e.g. dental cavity
• Thyroglossal cyst = attached to foramen cecum at the back of the tongue, it moves when you protrude your tongue. Therefore different to enlarged lymph node.
• Breast cancer tends to metastasise to bowel mucosa
• Chemotherapy: fatigue, diarrhea, mood disturbance
  • costs of treatment
  • 2 year loss of income due to chemotherapy fog
• refuse treatment
  • influence from other sources
  • need relatives on side for the pt to be compliant
  • counsel the patient if their relatives are providing disinformation
• adjust expectations for patient - laser therapy for prostate CA - you need to work within what the PBS can do
  • there is a bias towards the
  • CRAAP test for information the patients have been using: a lot of it is commercial