Clinical haematology for PLAB 1

A 24 year old man has had a painless swelling in his left side of the neck for ten weeks. He has drenching night sweats requiring a change of bedclothes and has lost 9 kg. On examination there is a 4 cm rubbery non-tender cervical node. His Monospot test is negative. What is the SINGLE most likely diagnosis?

1. Toxoplasmosis Painless cervical lymphadenopathy with a mild flu-like illness, often with cat or undercooked meat exposure. Ten weeks of painless rubbery nodes with drenching sweats does not fit.
2. Infectious mononucleosis (including Epstein-Barr virus) Fever, sore throat and posterior cervical nodes in a young adult, with atypical lymphocytes and a positive Monospot, settling over weeks. Ten weeks of painless rubbery nodes with drenching sweats is beyond that course.
3. Tuberculous lymphadenitis Matted nodes that may discharge, with constitutional symptoms and a relevant exposure history. Ten weeks of painless rubbery nodes with drenching sweats makes it worth considering.
4. Lymphoma correct Correct. Painless rubbery lymphadenopathy persisting ten weeks with drenching night sweats and 9 kg of weight loss. Those are B symptoms, and the combination in a young adult with a negative Monospot makes Hodgkin lymphoma the leading diagnosis.
5. Leukaemia Marrow failure with anaemia, bleeding and infection, and blasts on the film. Ten weeks of painless rubbery nodes with drenching sweats shows nodal disease instead.

The point: B symptoms are fever above 38°C, drenching night sweats and weight loss over 10% in six months. They define the 'B' in staging and worsen prognosis. Reed-Sternberg cells mean Hodgkin lymphoma. Alcohol-induced nodal pain is rare but almost specific for Hodgkin. Diagnosis needs an EXCISION biopsy of a whole node; a fine needle aspirate destroys the architecture the pathologist needs.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 24 year old man has had a painless swelling in his left side of the neck for ten weeks. He has drenching night sweats requiring a change of bedclothes and has lost 9 kg. On examination there is a 4 cm rubbery non-tender cervical node. His Monospot test is negative. What is the SINGLE most appropriate initial investigation?

1. CT neck, chest, abdomen and pelvis Stages the disease once the diagnosis is made. Ten weeks of painless rubbery nodes with drenching sweats makes it the follow-on.
2. Fine needle aspiration Adequate for confirming metastatic carcinoma but NOT for lymphoma, because it destroys the architecture required to classify it. Ten weeks of painless rubbery nodes with drenching sweats makes it the wrong biopsy.
3. Excision biopsy of a lymph node correct Correct. The whole node must come out. Lymphoma is classified by the architecture of the node as much as by the cells in it, and subtype determines the chemotherapy regimen. Which is why a fine needle aspirate is not an acceptable substitute here even though it would be for a suspected carcinoma.
4. Full blood count and blood film Screens for marrow involvement and for leukaemia as an alternative diagnosis. Ten weeks of painless rubbery nodes with drenching sweats makes it supportive.
5. Lactate dehydrogenase A prognostic marker reflecting tumour bulk and turnover, not a diagnostic test. Ten weeks of painless rubbery nodes with drenching sweats limits its role.

The point: B symptoms are fever above 38°C, drenching night sweats and weight loss over 10% in six months. They define the 'B' in staging and worsen prognosis. Reed-Sternberg cells mean Hodgkin lymphoma. Alcohol-induced nodal pain is rare but almost specific for Hodgkin. Diagnosis needs an EXCISION biopsy of a whole node; a fine needle aspirate destroys the architecture the pathologist needs.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance

A 24 year old man has had a painless swelling in his left side of the neck for ten weeks. He has drenching night sweats requiring a change of bedclothes and has lost 9 kg. On examination there is a 4 cm rubbery non-tender cervical node. His Monospot test is negative. What is the SINGLE most appropriate immediate management?

1. Suspected cancer pathway referral within two weeks correct Correct. Unexplained lymphadenopathy persisting beyond six weeks meets the referral criteria, and B symptoms make it more urgent still. Ten weeks is well past the point where watchful waiting is defensible.
2. Urgent haematology referral For suspected marrow involvement, cytopenias, or rapid progression. Ten weeks of painless rubbery nodes with drenching sweats warrants it.
3. Aspiration of the node for culture For a suspected infective or tuberculous cause, not for suspected lymphoma. Ten weeks of painless rubbery nodes with drenching sweats points away from it.
4. Radiotherapy Used for limited-stage disease, often combined with chemotherapy. Ten weeks of painless rubbery nodes with drenching sweats makes it part of the plan.
5. Antibiotics and review in two weeks For genuinely reactive nodes with an infective cause. Ten weeks of painless rubbery nodes with drenching sweats makes it inadequate.

The point: B symptoms are fever above 38°C, drenching night sweats and weight loss over 10% in six months. They define the 'B' in staging and worsen prognosis. Reed-Sternberg cells mean Hodgkin lymphoma. Alcohol-induced nodal pain is rare but almost specific for Hodgkin. Diagnosis needs an EXCISION biopsy of a whole node; a fine needle aspirate destroys the architecture the pathologist needs.

Source: NICE NG12 — Suspected cancer: recognition and referral NICE · tier 1, national regulator or guidance