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A young man with a mass on the neck
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Journal Article
A young man with a mass on the neck
2018
Overview
Pruritus and alcohol induced pain in involved lymph nodes are characteristic, albeit rare Frequent involvement of anterior mediastinum and contiguous spread to nodal regions on positron emission tomography-computed tomography Reed-Sternberg cells on biopsy Nodal non- Hodgkin's lymphoma B symptoms Multiple peripheral nodes and extranodal involvement common Non-contiguous spread to nodal regions on positron emission tomography-computed tomography Leukaemia Bruising or splenomegaly Abnormally high or low white cell counts Peripheral blood smear might show blasts Metastases Skin cancers typically spread to regional nodal basins Risk factors: smoking, drinking alcohol, occupational exposure Histological and immunohistochemical features on biopsy Infection Variable presentation: fever, chills, malaise, oropharyngeal exudate, dyspnoea Risk factors: high risk sexual behaviour, food, insect or animal contact, travel history Culture and disease specific serology to differentiate pathogens Autoimmune disorders Variable presentation: arthralgia and joint stiffness, muscle weakness, rash Auto-antibodies in serum such as antinuclear antibody Sarcoidosis Skin change, cough, dyspnoea, hilar lymphadenopathy Non-caseating granulomas on biopsy Radiograph shows bilateral hilar lymphadenopathy and interstitial infiltrates Increased serum angiotensin converting enzyme Medications Lymphadenopathy, otherwise well Improves after suspending the medication Superior vena cava obstruction Facial swelling and plethora, upper limb swelling, dilated chest wall veins Mediastinal and lung mass and lymphadenopathy on radiography/computed tomography.Lymphocyte depleted and mixed cellularity Hodgkin's lymphoma have poorer prognoses; however, treatment depends on stage and risk factors rather than histological subtypes. 7 Arrange blood tests to screen for hepatitis B, hepatitis C, and human immunodeficiency virus. 8 These infections are associated with increased risk of Hodgkin's lymphoma, and should also be treated if detected. 4 Positron emission-computed tomography imaging is the baseline investigation for staging and subsequent assessment of treatment response. 4 8 It can also detect bone marrow involvement with high sensitivity (bone marrow biopsy is only indicated if positron emission-computed tomography is not available).Advanced stage is stage IIB with extranodal disease and/or large mediastinal mass as risk factors, and stage III or IV. 4 8 Malignant cells in classical Hodgkin's lymphoma typically stain positive for CD15 and CD30 and negative for CD20 and CD45 (which is a leucocyte common antigen), while nodular lymphocyte predominant Hodgkin's lymphoma cells express CD20, CD45, and epithelial membrane antigen, and are negative for CD15 and CD30. 4 How would you manage this condition?In the first-line setting, the treatment protocol usually entails two to eight cycles of combination chemotherapy followed by radiotherapy in selected patients, depending on the risk group. 4 8 9 Patients in remission from Hodgkin's lymphoma are at risk of long term sequelae, including cardiovascular and pulmonary toxicities, and most notably secondary cancer induced by irradiating normal tissue. 4 8 Concerns regarding the risks of radiotherapy have led to a decline in the use of this treatment. 4 8 10 Up to 80% of patients with advanced stage disease and more than 90% with early disease achieve long term remission with standard first line treatment. 4 8 Even with relapse, a substantial number of patients achieve second remission.
