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“A 51 year old male with ascites and generalized lymphadenopathy”
Theo Ntenegi
Continuing Medical Education Announcement
Harvard Medical School
RSS 3081: Monthly BOTSOGO Tumor Board; 2018-2019 Academic Year
Today’s Objectives:
•Describe the need for timely cancer case presentation and referral to treatment
•Formulate a multi-disciplinary plan for the care of common and complex oncologic cases
•Adopt successful, sustainable strategies to mitigate barriers to quality cancer care common in resource constrained environments
Target Audience:
Oncologists, internists, surgeons, radiation oncologists, infectious disease specialists, nurses, physicists, therapists, technicians, research staff, administrators, policy makers.
Financial Relationships
The following planners, speakers, and content reviewers, on behalf of themselves and their spouse or partner, have reported financial relationships with an entity producing, marketing, re-selling, or distributing health care goods or services (relevant to the content of the activity) consumed by, or used on, patients:
All other individuals including course directors, planners, reviewers, faculty, staff, etc., who are in a position to control the content of this educational activity have reported no financial relationships related to the content of this activity
Name Role Type of Financial Relationship
Statements
Accreditation Statement
The Harvard Medical School is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians
Credit Designation Statement
The Harvard Medical School designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity
This activity meets the criteria of the Massachusetts Board of Registration in Medicine for 1.0 credits of Risk Management Study
Disclosure Statement
In accord with the disclosure policy of the Medical School as well as standards set forth by the Accreditation Council for Continuing Medical Education, course planners, speakers, and content reviewers have been asked to disclose any relevant relationship they, or their spouse or partner, have to companies producing, marketing, re-selling or distributing health care goods or services consumed by, or used on, patients.
Claim your CME credits!
•To claim your CME credit for attendance at this session of the BOTSOGO Tumor Board, please fill out our survey after the Tumor Board.
•You can do this at your convenience on your personal or work computer by navigating to www.botsogo.org
• Click “What We Do”
• Click “Tumor Board”
• Click the link under the section “Continuing Education Credits,” and complete and submit the survey
•Or follow the link that was emailed to our MGH BOTSOGO email list: www.tinyurl.com/tumorboard
Case Report
Patient: SN
Sex: Male
Age: 51
Address: Southern Botswana
Occupation: Free-lance builder
Case History (continued)
DOA: early 2018
Admitted to Male Medical Ward via outpatient clinic as a referral from hospital outpatient department.
Presenting Complaints
1. Abdominal Swelling
Since late 2017, worsening since early 2018.
Associated with diffuse pain.
No bowel movement changes.
No Hx of Melena
Presenting Complaints (continued)
2. Pedal Oedema
Onset early 2018
Bilateral with no alleviating factors.
Presenting Complaints (continued)
3. Lymphadenopathy
Noticed in neck area, since late 2017
More noticed in Groin area and underarms in early 2018.
Gradually increasing in size and number.
Painless
None ruptured.
Past Medical History
Weight loss noted since 2017.
On and off fevers noted prior to presentation.
No night sweats.
No chronic cough.
Past Medical History
RVD Negative (HIV negative)
No Known Co-Morbidities
No chronic medications
No Hx. of TB treatment
No Hx of STD treatment
No Hx. of Hospital admission
Past Medical HistorySeen in health facilities several times before current presentation:
• early 2018: Local Clinic – Tonsillitis and neck swelling > Given ABX.
• 2018: Local Clinic - Tonsillitis
• 2018: Local Clinic – Tonsillitis and neck swelling
• 2018: Local Clinic – UTI, Inguinal Lymphadenopathy
• Mid-2018: Local Clinic – Abdominal pain and distension > referred to hospital
• Mid-2018: Hospital –Abd. Ultrasound -Hepatomegaly +Ascites > Referred to PMH.
Personal, Social and Family History
Significant Drinking history >30 years. 6 – 10 units daily.
Significant Smoking history +/- 10 pack years.
No history of work in the mines
Family history negative for malignancy.
Physical Examination
Chronically ill looking, poorly nourished with abdominal distention and multiple masses on the neck region.
Finger clubbing + (grade 3)
No jaundice
Resp: Reduced Air Entry+ Stony dull (left lower)
CVS: Normal findings
Abd: ++Ascites, Firm Hepatomegally (span 16)
No signs of encephalopathy
Physical Examination
Generalised-Bilateral lymphadenopathy, Non-matted, Size – (0.3 – 3+cm)
Involving:
- Cervical - Axilar
- Submandibular - Antecubital
- Pre + Post Auricular - Inguinal
- Occipital - Popliteal
- Supraclavicular
Admission diagnosis
1. Chronic live disease with portal HTN
2. Disseminated TB Vs. Lymphoma
Progress In the Ward
Day 4:
CXR- Left Pleural Effusion, no lesions noted.
Paracentesis and Pleural Tap.
Day 9:
Abd. Ultrasound – Ascites, Homogeneous Hepatomegally with no focal lesions. +Pleural Effusion. Mild homogeneous Spleenomegally. +Paraaortic Lymphadenopathy. No Pericardial Effusion.
Day 11:
Ascetic Fluid : SAAG> 11g/dL, Cell Count -60; 80% Lymphocytes. No Malignant cells. Nillbacterial growth.
Pleural Fluid: Exudative.
Pathology
LN Biopsy done (cervical) – Reported on day 31
– LN with fibrotic thickened capsule and total architectural effacement. Tumour with mixed reactive component including plasma, lymphocytes, plasma cells, neutrophils and histocytes.
– Features favouring Hodgkin Lymphoma – Nodular Sclerosing Type.
– Histologically and immunohistochemically consistent with Hodgkin Lymphoma.
Pathology
Pathology
Pathology
Pathology
Pathology
Pathology
Day 24:
OGD- Early lower eosophageal varices.
Day 32:
Oncology review.
Requested CT Head, chest, abdo, pelvic.
To be initiated on chemo and refered to chemo clinic.
Day 35:
Developed Confusion – encephalopathy (GCS 14/15)
Became Septic (febrile, confused, tachypnoec)
Transferred to High dependency cubicle and septic workup initiated.
Started on Meropenem.
Oncology r/v requested.
Day 38:
Oncology Review
Septic, GCS 11/15, Left Pleural Effusion.
Not for any Oncological treatment.
Oncology request review once medically fit –suggested palliative care.
Day 45: Death Notification
Chest X-ray: on admission
Chest x-ray: during admission
A 51 year Male, RVD Negative (HIV negative) Presenting with Generalised Lymphadenopathy, ascites and hepatomegally.
Final Diagnosis: Advanced Nodular SclerosingHodgkin Lymphoma. Stage III2 (Modified Ann Arbor – Cotswold)
Investigations Reference Ranges
20/08/2018 23/08/2018 30/08/2018 03/09/2018 10/09/2018
WCC 4-10 9.44 8.55 8.3 8.2HB 12-15 10.6 11.1 12.8 12.3MCV 83-99 93.8 92.9 94.6 94.5PLTS 150-400 264 270 325 224Neut 2-7.0 5.0 5.1 5.1 5.6Lymph 1.0-3.0 1.5 1.1 1.1 1.0Eosino 0.02-0.5 0.2 0.0 0.18Na+ 135-145 130 126 132 125K+ 3.5-5.1 4.16 3.96 4.4 6.6Urea 2.0-7.0 2.5 3.2 4.1 4.08Creat 53-97 36 34 35 32Ca 2.2-2.6 2.01Mg 0.6-1.10 0.69Phos 0.8-1.55 1.12Tot Prot 60-80 61.2 78.4 55.2 59 58.2Tot Bil 1.0-25.7 11.6 7.68 13.6Conj Bil 0-3.0Albuim 35-55 23.9 22.7 25.7 21.8ALP 35-110 183 153 170 205GGT 11-50 172 169 193 240 229ALT 11-40 9.1 7.8 6.0 5.3 10AST 10-34 32.8 26.8 27 34 34LDH 210-425 205 211INR 1.21 1.4APTT 25-45 29.6 32.8 33
Hasenclever Score
Hasenclever Score
Score 0 1 Patient’s Score
Serum albumin Normal <40 g/L 1
Haemoglobin >10.5 g/dL <10.5 g/dL 0
Age <45 >45 1
Sex Female Male 1
Stage <IV IV 0
Leucocytosis <15x109/L >15x109/L 0
Lymphopenia >0.6x109/L <0.6x109/L 0
Cumulative Score 3
Discussion
Approach to a patient with suspected Hodgkin Lymphoma.
Criteria for Chemotherapy fitness.
Staging Hodgkin Lymphoma.
Preparation and Investigations prior to Oncology referral.
Questions
What can be done to promote early diagnosis of treatable malignancy in Botswana.
Are there any investigations that can be done in peripheral health facilities to support early Diagnosis of Malignancy.
What strategies can we put in place to train new doctors on how to send samples for investigation to the National Health Lab.
Available investigations in PMH.