Contents
1. Lymphoma - a curable cancer, a perspective in the 21st century
   
2.

Evaluation of a lump

Bone-marrow aspiration
and biopsy
   
3.

Blood stem cell transplantation for
lymphoma

Hodgkin's disease -
have we achieved the optimum treatment strategy for early-stage disease
   
4. Radiological imaging of lymphoma
   
5.

Classification and tools
in the diagnosis of lymphomas
   
6.

Cytogenetics and its role
in lymphona
   
  NCC Tumour Board
Files
   
  Quiz
   
  NCC Round Up
   
 

Staff Directory
   
  Pharmacy Tips
   
  Lymphoma - An Overview
   
  Contact
   
   
 

www.singhealth.com.sg
Reg.No.:2000026982

We welcome your contributions
to Cancer Update. Send your
queries and comments to
Postgraduate Cancer Education
/Information Support Services,
National Cancer Centre, 11
Hospital Drive, Singapore 169610. Or phone us at
(65) 6236 9425, fax us at (65)
6536 5503, or email:
daalff@nccs.com.sg

Ask The Expert
Should you have questions on
cancer treatments, log onto
http://nccs.com.sg/askthe
experts/ask-the-experts.htm
for more information.

Please note that contents are not to be quoted or repeated without the permission of the National Cancer Centre. All advice given
in Cancer Update is not intended to replace patient-doctor consultation.
   
   

 
 
From the tumour board files
 
 

Figure 1

A 43-year-old Chinese gentleman presented with a left ulcerated neck lump associated with fever for three months. He had lost more than 15 kg over the same period.

Please refer to Table 1 to jog your memory of the differential diagnosis.

Table 1: Differential diagnosis of cervical adenopathy

1) Infectious causes:
   a. Tuberculous lymphadenitis
   b. Pyogenic bacterial infection from oropharyngeal region with abscess formation
   c. HIV – progressive generalised lymphadenopathy
   d. Toxoplasmosis
   e. Infectious mononucleosis

2) Neoplastic causes:
   a. Metastatic carcinoma from nasopharyngeal/oropharyngeal cancer
   b. Lymphoma
   c. Leukaemia
   d. Distant metastases from carcinoma of any site

3) Other very rare causes:
   a. Sarcoidosis
   b. Autoimmune causes such as rheumatoid arthritis and systemic lupus.

DISCUSSION

Although common practice is to give a trial of empirical antibiotics for bacterial infections before referring the patient for further evaluation, it is prudent to refer the patient to a surgeon for a lymph node biopsy without further ado. Antibiotics can still be given while the biopsy result is pending. A lymph node biopsy is preferred over fine-needle aspiration cytology (FNAC), because the diagnosis of lymphoma commonly requires full cytoarchitectural evaluation, with histochemical staining for subtyping or even clinching the diagnosis. Such assessment is crucial since treatment may differ for subtypes of lymphoma.

He was then found to have an anterior mediastinal mass (Figure 2) on computed tomography of the thorax. Refer to Table 2 for the differential diagnoses.

After left cervical lymph-node biopsy he was diagnosed as having mediastinal diffuse large B-cell lymphoma. Chemotherapy with curative intent was started and consisted of rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisolone (R-CHOP).

He developed a neutropenic fever after the fourth cycle. His full blood count was total white 0.5 /µl, neutrophil 12% (absolute neutrophil count of 60 /µl), Hb 12.6 g/l, platelet 136, 000 /µl. He was haemodynamically stable.

Please refer to Figure 3 for management algorithm for patients with neutropenic fever. He was admitted and was given intravenous cefepime to cover gram- negative infection and intravenous cloxacillin to cover gram-positive bacteria because he had a central line. Subcutaneous granulocyte colony-stimulating factor was also given. After 3 days, when his absolute neutrophil count had recovered to more than 1500 /µl and there was no record of bacteraemia, he was discharged well.

Table 2: Oncologic causes of mediastinal mass

1) Thymic neoplasms
2) Lymphomas
3) Germ-cell tumours
4) Carcinoma
5) Cysts
6) Mesenchymal tumours
7) Endocrine tumours (thyroid/parathyroid)

Figure 2

Figure 3: Algorithm for management of neutropenic fever