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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Although a history of sweating may be suggestive of lymphoma, there is no definitive way to
distinguish tuberculosis from lymphoma or to differentiate the types of lymphoma without a
biopsy. No further testing is required to confirm diagnosis after this. The remainder of the tests
are to determine the stage.
The main point of staging is to determine who needs extensive combination chemotherapy and
who can be safely treated with localized radiation and a lower dose of radiation. Any patient
with “B” symptoms, such as fever, weight loss, or night sweats, should receive predominantly
chemotherapy. This patient seems, so far, to have lymphoma limited to a single lymph node
group. If further testing confirms that the disease is localized, she can be treated primarily with
radiation.
Although most Hodgkin’s lymphoma is localized to 1 or 2 lymph node groups in 80–90% of
patients, and non-Hodgkin’s lymphoma disease is more widespread, the only way to be truly
certain which one the patient has is with an excisional lymph node biopsy.
Further Diagnostic Plan/Results
No adenopathy; liver and spleen WNL
No abnormalities
Negative
Discussion
Hodgkin’s disease is a common form of lymphoma whose peak occurrence is in a bimodal
pattern. It occurs at age 15–35 and age >50. Diagnosis rests on identification of Reed-
Sternberg cells in the pathologic specimen.
CT scan of abdomen and pelvis1.
PET scan (occasionally)2.
Bone marrow biopsy3.
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Four histologic patterns exist:
When staged accurately, histologic pattern is not an independent predictor of response to
treatment or prognosis.
Patients have documented defects in cell-mediated immunity. They are often anergic and are
more susceptible to herpes zoster. Hodgkin’s disease spreads in a stepwise fashion to
contiguous lymph node chains. Prognosis is related to the number of involved sites. In some
cases, lymph node sites are “skipped.” Patients often present with constitutional symptoms.
These include fever, night sweats, and weight loss of >10% of body weight. Pruritus is not
considered a B symptom, although it commonly occurs.
Staging is as follows:
Stage I 1 lymph node chain
Stage II ≥ 2 chains on one side of diaphragm
Stage III Involvement of both sides of diaphragm; may
include spleen
Stage IV Liver, bone marrow, or extranodal involvement
Staging evaluation should be directed at determining different treatment plans.
Lymphocyte predominant
Nodular sclerosing
Mixed cellularity
Lymphocyte depleted
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One late concern is the development of secondary malignancies that appear to be treatment-
related. Secondary acute myelocytic leukemia is seen in patients treated with chemotherapy and
particularly with chemotherapy/radiation therapy. These are seen predominantly in the first 10
yrs. Solid tumors are seen with increased frequency in the radiation field at >10 yrs after
treatment. Coronary artery disease and valvular abnormalities are often seen 20–30 yrs after
radiation therapy for Hodgkin’s disease.
CLINICAL PEARL
Stages I/II: treat with chemotherapy combined with involved field radiation therapy
Stages III/IV: treat with higher-intensity chemotherapy
The presence of bulky disease (i.e., >1⁄3 mediastinal diameter) requires both chemotherapy
and radiation to shrink the lesion so as to make it more likely for response.
CT of the abdomen is used to exclude stage III disease; if it is normal, PET scan is used to
rule out lymph nodes of normal size which may have distorted architecture from
involvement.
Staging laparotomy is no longer the standard of care.
Stages III/IV and those with B symptoms: treat with high-dose chemotherapy with ABVD
alone (doxorubicin, bleomycin, vinblastine, dexamethasone)
MOPP combination chemotherapy is no longer used due to association with leukemia
later in life.
—
Prognosis ranges from >90% disease-free survival for early disease, to 50–60% with
more advanced stage disease.
—
The presence of systemic symptoms is a negative prognostic indicator.—
Patients who relapse after radiation therapy alone can often be cured with chemotherapy.
Those who relapse >1 yr after chemotherapy are often still sensitive and can be retreated.
Those who relapse <1 yr after chemotherapy or are not achieving remission have an
extremely poor prognosis.
—
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Hodgkin’s lymphoma
Follow-up Management and Prevention
Follow up with combined modality therapy: specifically, 3 to 4 cycles of chemotherapy
(ABVD) and radiation to the cervical nodes. Know the long-term adverse effects:
Chemotherapy frequently causes infertility.
Final Diagnosis
Hodgkin’s disease, stage IA
Clinically: night sweats, weight loss, fatigue
Lymphadenopathy
Chest x-ray shows mediastinal lymphadenopathy (unilateral or bilateral).
Lymph node biopsy shows Reed-Sternberg cells
Radiation: thyroid disease, lung and breast cancer
Radiation markedly accelerates coronary artery disease
Vincristine: peripheral neuropathy
Bleomycin: pulmonary fibrosis
Adriamycin (doxorubicin): cardiomyopathy
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Case 5
Chief Complaint
“I have a cough, fever, and headache.”
History and Physical Examination
A 55-year-old man comes to the office with a recurrent cough productive of yellow
sputum and fever. He was recently treated with 2 weeks of antibiotics for pneumonia. He
had bloody sputum 3 days ago. He has a decrease in appetite and weight loss of 12 lb
over the past month. He smoked 2 packs of cigarettes a day for the past 30 years.
He is ill-appearing. BP 150/90 mm Hg, pulse 100/min, T 37.8 C (100.0 F). He has facial
edema and plethora. His neck is supple without adenopathy, with prominent jugular
venous distention. There is marked dilatation of peripheral veins across the anterior chest.
Chest is clear. Abdomen soft and nontender, with no hepatosplenomegaly. There is mild
edema of upper extremities. Neuro exam nonfocal.
Differential Diagnosis
Initial Management
Lung cancer/superior vena cava syndrome1.
Lymphoma/superior vena cava syndrome2.
Tuberculosis3.
Infectious pneumonia4.
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Setting: emergency department
Diagnostic/Therapeutic Plan
Test Results
Further Management
Test Results
Chest x-ray
CBC
Calcium level
LFT
Normal saline
Oximeter
Oxygen
Chest x ray: large perihilar mass extending into mediastinum; normal cardiac silhouette;
right-sided infiltrate distal to the mass
CBC normal
Calcium level: 13 mg/dL (normal 8.5–11.5 mg/dL)
LFT normal
CT scan of chest
Pamidronate
Continue normal saline
Bronchoscopy with biopsy
CT scan of chest: Large hilar mass extending into mediastinum with compression of superior
vena cava
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Assessment
This patient has a pulmonary mass extending into the mediastinum with superior vena cava
syndrome and hypercalcemia. The evidence for the superior vena cava syndrome on
examination is the facial fullness (or plethora), dilation of chest veins, and the upper extremity
edema. Diuretics are not needed for hypercalcemia management unless there is no urine output
with fluid administration. Patients with hypercalcemia have a massive volume depletion.
CCS NOTE
Significant procedures that take time, such as a bronchoscopy, will require you to
advance the clock. A note will pop up, asking if you are sure that you’ll want to
advance the time. This does not mean you have made a mistake!
Discussion
Lung cancer is the leading cause of cancer death in the United States for both men and women.
Asbestos exposure is associated with a tenfold increase in risk that is further amplified by
concurrent smoking. Roofers and workers with tar, nickel, hydrocarbons, and uranium are at
increased risk.
The main histologic subtypes include adenocarcinoma, squamous cell, small cell, and large
cell. Bronchoalveolar carcinoma is seen in <5%. Patients may present with hemoptysis from an
ulcerating lesion or recurrent pneumonia caused by an obstructing lesion and the development
of postobstructive pneumonia. Dyspnea may develop from lymphangitic spread or from the
development of a malignant pleural or pericardial effusion. Hoarseness may result from injury
Bronchoscopy: squamous cell cancer
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to the recurrent laryngeal nerve. Tumor involving the upper lobes can produce Pancoast
syndrome, which is associated with infiltration of the brachial plexus and sensory and/or motor
findings in the upper extremity. Squamous and large-cell carcinomas tend to present with
central lesions, with the latter more likely to metastasize to distant sites.
Adenocarcinoma more commonly presents with peripheral lesions, making sputum cytology
less reliable. It can arise in areas of former scars and tends to cause symptoms by
metastasizing. Bronchoalveolar carcinoma is often multifocal, due to transbronchial spread,
and is associated with significant bronchorrhea.
This patient shows signs of superior vena cava syndrome. This is the result of a tumor invading
the mediastinum and compression on the superior vena cava with resultant increased venous
pressure transmitted to the neck, head, and upper extremities. Physical findings include facial
and upper extremity edema, distended neck veins, and engorged collaterals on the chest wall.
Neurologic symptoms include mood disturbance and irritability. When this condition is severe,
cardiac output is compromised because of poor venous return, and this constitutes an oncologic
emergency that requires emergency radiation therapy.
A variety of paraneoplastic syndromes are associated with lung cancer. These include
syndrome of inappropriate antidiuretic hormone secretion (SIADH: associated with small-cell
carcinoma), Cushing syndrome (associated with production of adrenocorticotropic hormone;
ACTH), and hypercalcemia caused by parathyroid-like hormone production seen in
conjunction with squamous cell carcinoma.
Staging relates to tumor size, lymph node involvement, and evidence of metastatic disease.
This staging system frequently changes and the specifics are beyond the scope for USMLE. In
general though as the size of the tumor and the number of involved lymph nodes increase, the
stage becomes higher and the overall prognosis worsens.
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Stage I and II are generally treated with surgical resection with or without post-surgical
(adjuvant) chemotherapy. Surgery for stage IIIA is controversial, and studies are ongoing
regarding the efficacy of presurgical (neoadjuvant) chemotherapy in this setting. Stage IIIB is
treated with radiation therapy. The role of chemotherapy for stages IIIB or IV is for palliation
and can increase the quality and quantity of a patient’s life.
Follow-up Management
Final Diagnosis
Squamous cell lung cancer/superior vena cava syndrome
Radiation of tumor mass
Repeat calcium level
Continue normal saline and bisphosphonates (e.g., pamidronate)
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Case 6
Chief Complaint
“I feel a lump in my left breast.”
History and Physical Examination
A 52-year-old nulliparous woman finds a lump in the left breast while doing a self-exam.
The mass is hard but not tender. She had her first menstrual period at age 12 and has been
postmenopausal for 3 years. Her last mammogram was 1 year ago. Her mother had a
history of breast cancer diagnosed at age 70. She has 3 sisters, all of whom are in good
health.
Physical examination shows a 3-cm movable mass in the retroareolar region of the left
breast. The mass is nontender. There is no nipple discharge, retraction, or dimpling. The
skin above the lesion appears normal. Axillary examination on the left reveals a few small
lymph nodes that are freely movable. The right breast is free of masses. Her lungs are
clear, and her abdomen is soft without hepatosplenomegaly. Neurologic examination is
nonfocal.
Differential Diagnosis
Benign cystic disease
1.
Breast carcinoma
2.
Metastatic disease to the breast
3.
Fibroadenoma of the breast
4.
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