1. A lump in the neck
Lent term year 2

2. The case
A 58 year old man went to his GP after he noticed a lump growing in the right side of his neck
He had been feeling tired recently and had noticed some night sweats over the past three weeks
He had also noticed some itching of his skin all over his body

3. What can cause lumps in the neck?

4. Lumps in the neck Congenital or acquired
Think of organs within the neck
Skin: lipoma, epidermoid cyst
Congenital rests: thyroglossal cyst; branchial cysts
Thyroid: cysts, goitre, tumour: adenoma or carcinoma
Pharyngeal pouch
Salivary gland swelling; vascular swelling
Lymph nodes

6. Causes of lymphadenopathy
Viral: “Glandular fever”EBV; CMV; HIV
Bacterial: draining area of sepsis
Tuberculosis; brucellosis
Collagen disease
Sarcoidosis
Metastatic cancer e.g stomach; head & neck
Lymphoma

7. Lymphoma: a histological diagnosis
Hodgkin’s disease (20%). Reed-Sternberg cells
Non-Hodgkin’s disease (80%): over 20 types
B- cell lymphomas
T- cell lymphomas
Others: AIDS-related and CNS lymphoma

8. Classification of NHL:
Anaplastic large cell
Burkitt
Cutaneous T-cell
Diffuse large B-cell
Follicular
Lymphoblastic
MALT
Mantle cell
Mediastinal large B-cell
Nodal marginal zone B-cell
Peripheral T-cell
Small lymphocytic
Thyroid
Waldenstrom's macroglobulinaemia

9. Investigations: diagnosis and staging
Histological biopsy
Chest X-ray
CT/MRI/PET scanning
Liver function tests
Full blood count
? Bone marrow sampling

10. Histology: Diffuse B Cell Lymphoma (High Grade)

12. PET scanning: Positron Emission Tomography

13. Staging of NHL: Stage 1: involving one lymph node group
Stage 2: more than one group on one side of diaphragm
Stage 3: involvement of lymph nodes both sides of diaphragm
Stage 4: extralymphatic spread: liver, spleen, lungs, stomach, bone marrow

14. What sort of treatment will our patient be offered, and what is the prognosis?

15. Treatment for stage 4 high-grade NHL
Depends on –histological type, age, general health, other organ involvement
An MDT approach
Will require patient’s consent after discussing type of treatment, advantages, disadvantages, risks, side effects and other options

16. International Prognostic Index: 2 or more factors <50% relapse-free at 5 years
Age >60 years of age
Serum lactate dehydrogenase-LDH elevated
Performance status (0 or 1 versus 2-4),
Stage III or IV
Extranodal site involvement

17. Performance status Grade Description
Fully active, able to carry on all pre-disease performance without restriction 1
Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work 2
Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours 3
Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours 4
Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair 5
Dead

18. Overall survival Risk Group Number of Factors % 5 year OS % 10 year OS
Low
0-1
90.6
70.7
Intermediate 2
77.6
50.9
High
3 or higher
52.5
35.5

19. Our patient was offered chemotherapy with Ritoximab (R-CHOP)
R- Ritoximab IV
C- cyclophosphamide IV
H- Doxorubicin (red) IV
O- Vincristine IV
P- Prednisolone orally 60-80mg 5 days
6-8 cycles over 21 days

20. Ritoximab Monoclonal Ab Locks onto protein CD20 on B lymphocytes
Given as IV infusion over a few hours
May insert PICC line

21. What side effects would you warn him about?

22. Side effects (variable)
During infusion: ‘flu-like symptoms, flushing, allergic reactions
Reduced resistance to infection
(neutropenia)
Bruising/bleeding (thrombocytopenia)
Anaemia
Fatigue
Nausea and vomiting

23. And more… Hair loss Stomatitis Altered taste (dysguesia)
Dyspepsia and hunger (steroids)
Cystitis (cyclophosphamide)
Numbness/tingling of fingers (vincristine)
Oedema (prednisolone)
photosensitivity

24. And more… Mood swings (prednisolone) Nail changes
Cardiac arrhythmias (doxorubicin cardiomyopathy)
Tissue necrosis as venous infusion site
Raised blood sugar (prednisolone)
Cushing’s syndrome (prednisolone)