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Haematological Malignancies in General Practice

Haematological Malignancies in General Practice. Judith Hanslip Consultant Haematologist Lister Hospital, Stevenage. Jon Lambert Consultant Haematologist UCLH & Mt Vernon Cancer Centre. Case 1. 21 year old woman with 3 week history of dry cough and cervical lymphadenopathy

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Haematological Malignancies in General Practice

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  1. Haematological Malignanciesin General Practice Judith Hanslip Consultant Haematologist Lister Hospital, Stevenage Jon Lambert Consultant Haematologist UCLH & Mt Vernon Cancer Centre

  2. Case 1 • 21 year old woman with 3 week history of dry cough and cervical lymphadenopathy • Saw GP 3 times over 4 weeks, 2 course of antibiotics • Attended A&E 5 weeks after initial presentation to GP: noted to have signs of SVC obstruction • Urgent CT neck & chest:

  3. Case 1 …necrotic anterior mediastinal mass measuring at least 7x5cm, extending from the thoracic inlet to the right atrium. This is causing severe SVC compression, with a minimum diameter of 1 mm although a patent channel of contrast is seen along its length…

  4. Case 1 • Biopsy – diffuse large B-cell lymphoma • Treated R-CHOP x 6 • Now in CR

  5. Case 2 • 75 year old man, b/g of prostate cancer (quiescent) • 2-week history of backache, followed by unsteadiness on legs, then tingling in fingers • Seen by GP, referred immediately to oncology OP • MRI spine:

  6. Case 2

  7. Case 2 • Referred immediately to NHNN • Laminectomy C2-T2 and biopsy – plasmacytoma • Bone marrow – multiple myeloma • IgG paraprotein 36g/L, normal renal function & calcium • Started treatment with dexamethasone & velcade

  8. Outline of talk • Epidemiology • Lymphoma • Myeloma • Referral of patients with suspected haematological malignancies

  9. Epidemiology

  10. UK Cancer Registrations 2007 HMRN data http://www.hmrn.org/Statistics/Incidence.aspx

  11. Incidence increases with age

  12. Lymphoma

  13. Many different subtypes of lymphoma… HMRN data 2012

  14. mostly curable mostly incurable …with very different clinical behaviour Aggressive Indolent Diffuse large B-cell Follicular Hodgkin Mantle cell T-cell Burkitt

  15. Lymphoma – when to suspect • Can affect any organ, and symptoms vary accordingly • Typically present with an enlarging cervical, axillary or inguinal lump • B symptoms are rare and indicate high disease burden • Main question should be: is there an obvious reactive cause for LN?

  16. An isolated node, or the tip of the iceberg? Patient presenting with inguinal lymphadenopathy…

  17. Lymphoma – are any tests helpful? • In most cases of lymphoma, the FBC, biochem and LDH are normal • Only whole-body imaging +/- biopsy are likely to be diagnostic (FNA is no use) • The best guide is from the history and examination

  18. Referral to hospital – when and how quickly? • Rapidly enlarging nodes with systemic or neurological symptoms need urgent referral - discuss same day • Otherwise follow 2-week wait procedure

  19. Myeloma

  20. Myeloma – epidemiology • Annual UK Incidence: 40 per x 106 (2500 new cases per year) • Median age at diagnosis 60-65 yrs • Higher incidence in Afro-Caribbean people

  21. Myeloma – epidemiology • 2% under 40 yrs • 35% under 65 yrs

  22. Myeloma – improvements in outcome over 30 years Kumar S K et al. Blood 2008;111:2516-2520

  23. 82% 51% 81% 78% 79% n = 11,000 L Ellis-Brookes et al, Brit J Cancer, Sept 2012 Myeloma – route to secondary care… …and its effect on outcome 1-year overall survival

  24. Backache particularly if persistent, unexplained or associated with loss of height and osteoporosis (esp in males and pre-menopausal females) Low blood countsesp normochromic or macrocytic anaemia, but also neutropenia or thrombocytopenia Unexplained renal impairment When to suspect myeloma? • Recurrent infectiondue to ↓immunoglobulins or neutropenia • Hypercalcaemia • Persistent ↑ESR(or plasma viscosity) esp if no obvious infective or autoimmune cause • Spinal cord/nerve root compression

  25. ESR or plasma viscosity FBC U & E, Calcium Protein electrophoresis Immunoglobulin profile Urine for BJP X-rays of painful sites + Skeletal Survey, BM, BJP quantitation Investigations in Suspected Myeloma

  26. Myeloma = M-protein + one of… Bone marrow plasma cells >10% Lytic lesions on skeletal survey Anaemia Hypercalcaemia Impaired renal function Otherwise it’s monoclonal gammopathy of unknown significance (MGUS) M-protein doesn’t necessarily indicate myeloma

  27. Kyle et al, NEJM, March 2006 MGUS Uncommon below age of 50 Risk of progression to myeloma 1% per year

  28. Guidelines for referring patients with suspected haematological malignancies

  29. 2003

  30. 2010 Patient Experience Survey • 51% of myeloma patients had visited their GP at least 3 times before referralhighest probability of delay out of 24 cancers captured in survey • The overall probability of people with suspected cancer visiting their GPs > 3 times was increased in: • Younger pats • Women • Ethnic minorites

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