Diagnosis and Staging of Cancer in Developing Countries

1. Diagnosis and Staging of Cancer in Developing Countries Dr. SameerBakhshi Associate Professor Department of Medical Oncology Dr. B. R. A. Institute Rotary Cancer Hospital AIIMS, New Delhi

3. AIIMS is the largest hospital in India. • There are 3.2 million patients seen in outpatient every year.

4. IRCH has a load of 11000 new cancer cases/year and around 1000 of those are pediatric cancer cases. • It is one of the largest center for pediatric cancers in India.

5. What do we need for diagnosis of acute leukemias? • Clinical skills • Good morphology • Immunocytochemistry • Flow-cytometry • Cytogenetics and Molecular diagnostics

6. Case 1 • A 7-year old boy presented with 2 weeks H/O cough and progressive difficulty in breathing. • PE: • Small cervical LN • No Hepatosplenomegaly • Reduced air entry on right side • Muffled heart sounds.

7. Case 1 (Contd) • CXR: Right Pleural & Pericardial Effusion. • HMG: Hb- 7.5g/dl, MCV=85FL TLC- 22,000/mm3 Platelets: 140,000/mm3 Diff- P20, L75, M5 • Pleural fluid: Exudative; Cells: Lymphocytes +

8. Case 1 (Contd) • Treated with ATT with steroids and Blood transfusion. • No improvement with ATT for 4 weeks and required 3 additional transfusions. • Transferred to Ped Cardiology at AIIMS where patient was put on a pigtail catheter for pericardial fluid drainage. ATT and steroids were continued.

9. Case 1 (Contd) • Pericardial fluid cytology sent which revealed abnormal lymphoid cells. • PS and BMA confirmed diagnosis of T-ALL. • Patient improved within 10 days of induction therapy and is presently in maintenance phase.

10. Key Messages • Look at each and every parameter of CBC. • Do NOT ignore normocytic normochromic anemia. • Transfusions is not the answer for anemia without knowing the etiology for anemia. • A good PS can clinch the diagnosis in such cases.

11. Case-2 5 yrs. male child bilateral protrusion of eyeballs for 6 weeks painless, no loss of vision systemic symptoms - low grade fever no significant past history

12. Clinical picture

13. Case-2 (contd.) Investigations Hb – 9.5 g/dl TLC – 15,000/ul Platelet counts – 1,30,000 /ul Imaging – CECT orbit

14. CECT orbit

15. Case-2 (contd.) Biopsy of the orbital mass - Granulocytic sarcoma Subsequently, Peripheral smear Bone marrow examination

16. Myeloblasts

17. Case-2 (contd.) Final diagnosis AML M2 with bilateral orbital granulocytic sarcoma (chloroma)

18. J Pediatr Hematol Oncol 2008

19. Key Messages Bilateral proptosis is often due to AML or neuroblastoma. A simple PS and BMA may clinch the diagnosis before performing an orbital biopsy.

20. Key Messages Bilateral proptosis is often due to AML or neuroblastoma. A simple PS and BMA may clinch the diagnosis before performing an orbital biopsy.

22. Flow cytometry • Once MPO is positive, it is AML. • Morphologically MPO negative blasts can be identified correctly in 90% cases. • Differentiates T and B ALL but there may not be a difference in treatment strategy necessarily. • Useful for identifying MPO negative AML.

23. Case 3 • A 7-year old girl presented with abdominal distension, respiratory difficulty and progressive pallor of 4 weeks duration. • Physical examination revealed Pallor Reduced air entry on right side of chest with dullness on percussion Abdomen was grossly distended with an ill- defined mass extending from right iliac fossa to epigastrium.

25. Case 3 • Hb 8 g/Dl, TLC 14,000/mm3; Platelets: 90,000/mm3: PS-No blasts. • Chest X-ray: Massive right pleural effusion • CT Abdomen:

27. Case 3 • Abdominal mass biopsy was C/W Burkitt’s lymphoma. • Pleural fluid: Positive for malignant cells. • BMA: 50% lymphoblasts L3 morphology with positive staining for surface immunoglobulins.

28. Diagnosis • Stage 4 Burkitt’s lymphoma OR • Acute B-cell leukemia

29. CXR and USG is sufficient. • We do not need CT scan for this staging. • We also do not need surface immunoglobulins OR flow cytometry to treat. • What we need is the subtype of lymphoma.

30. Case 4 • A 12-year-old boy presents with fever, weakness, throat pain and a 3 cm size left cervical lymph node of 4 days duration. • Hb 12 g/dL, TLC: 18,000/mm3,Platelets: 160,000/mm3, PS: Normal except for 65% lymphocytes.

31. Case 4 • FNAC: Immature looking cells suggestive of NHL. • Came to IRCH on day 7 of illness with by which time symptoms had subsided but neck had a 2 cm size lymph node. No other positive physical finding.

32. Case 4 • HMG/PS/BMA: Normal • CT Chest/abdomen: Normal • LDH: Normal • FNAC slide review: Immature looking cells suspicious of lymphoma, advise LN biopsy. • Patient however had no LN to biopsy • Patient reassured but kept under follow up for 4-6 weeks, and then cleared.

33. Final diagnosis • Probably a viral infection, resolved spontaneously. • Key message: Do not perform unnecessary tests as they may create more confusion.

34. Case 5 • A 7 month old infant presented with URI symptoms, fever and barking cough of 5 days duration. • RR 40/min, Chest: Bilateral rhonchi. • HMG: Normal • Chest X-ray

37. Case 5 • FNAC of mediastinal mass showed activated lymphocytes with hyperchromatic nuclei ?malignancy of thymus/?lymphoma. • BMA: Normal • Referred for lymphoma. • Patient clinically fine yet no change in chest X-ray.

38. Case 5 • Diagnosis: Viral croup with physiologically enlarged thymus. • Key message: -Remember that thymus may be enlarged in infancy and regresses at end of first year. -NHL is an extremely uncommon diagnosis in infancy.

39. Conclusions • Look at the patient carefully. • Look at CBC carefully including the cell indices. • Fancy investigations certainly improve care but even without them perhaps >80% can be managed adequately.