A 30-year-old man is investigated for enlarged, painless cervical lymph nodes. A biopsy is taken and a diagnosis of Hodgkin's lymphoma is made.
Which one of the following types of Hodgkin's lymphoma carries the best prognosis?
Correct Answer A: Hodgkin's lymphoma - best prognosis = lymphocyte predominant.
Hodgkin's lymphoma: histological classification and prognosis:
Hodgkin's lymphoma is a malignant proliferation of lymphocytes characterized by the presence of the Reed- Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades.
Histological classification:
'B' symptoms also imply a poor prognosis:
Other factors associated with a poor prognosis identified in a 1998 NEJM paper included:
Which one of the following cytotoxic agents acts by inhibiting dihydrofolate reductase and thymidylate synthesis?
Correct Answer A:
Cytotoxic agents:
The table below summarises the mechanism of action and major adverse effects of commonly used cytotoxic agents:
A 4-year-old boy is admitted after developing a haemarthrosis in his right knee whilst playing in the garden.
The following blood results are obtained:
What is the most likely diagnosis?
Correct Answer E: A grossly elevated APTT may be caused by heparin therapy, haemophilia or antiphospholipid syndrome. A normal factor VIIIc activity points to a diagnosis of haemophilia B (lack of factor IX). Antiphospholipid syndrome is a prothrombotic condition.
Haemophilia: Haemophilia is a X-linked recessive disorder of coagulation. Up to 30% of patients have no family history of the condition. Haemophilia A is due to a deficiency of factor VIII whilst in haemophilia B (Christmas disease) there is a lack of factor IX.
Features:
Blood tests:
A 45-year-old woman is diagnosed with non-Hodgkin's lymphoma. She is a recovering alcoholic and has been left with significant alcohol-related peripheral neuropathy.
Which one of the following chemotherapy agents should be avoided if possible, given her past history?
Correct Answer B: Vincristine - peripheral neuropathy.
Cytotoxic agents The table below summarises the mechanism of action and major adverse effects of commonly used cytotoxic agents:
A 56-year-old man with metastatic prostate cancer comes for review. He is known to have spinal metastases but until now has not had any significant problems with pain control. Unfortunately he is now getting regular back pain despite taking paracetamol 1g qds. Neurological examination is unremarkable.
What is the most appropriate next step?
Correct Answer D: Metastatic bone pain may respond to NSAIDs, bisphosphonates or radiotherapy.
Bone pain often responds well to NSAIDs. Both radiotherapy and bisphosphonates have a role in managing bony pain but these are not first-line treatments.
Palliative care prescribing: pain: NICE guidelines:
In 2012 NICE published guidelines on the use of opioids in palliative care. Selected points are listed below. Please see the link for more details.
Starting treatment:
SIGN guidelines:
Other points: When increasing the dose of opioids the next dose should be increased by 30-50%. Opioid side-effects
The BNF states that oral morphine sulphate 80-90mg over 24 hours is approximately equivalent to one '25 mcg/hour' fentanyl patch, therefore product literature should be consulted. NICE give the following advice on conversion:
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