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 swollen glands in the neck with a mild flu-like illness, often linked to contact with cats or undercooked meat. That does not match ten weeks of painless rubbery glands with drenching night sweats.
2. Infectious mononucleosis Fever, sore throat and swollen glands at the back of the neck in a young adult, with unusual-looking white cells (atypical lymphocytes) and a positive Monospot test, settling within weeks. It does not fit ten weeks of painless rubbery glands with drenching night sweats.
3. Tuberculous lymphadenitis Lumped-together glands that may leak fluid, with whole-body symptoms and a relevant exposure history. Here, ten weeks of painless rubbery glands with drenching night sweats points elsewhere.
4. Lymphoma correct Correct. Painless, rubbery, swollen glands lasting ten weeks with drenching night sweats and 9 kg of weight loss. Those are B symptoms, and this combination in a young adult with a negative Monospot test makes Hodgkin lymphoma the leading diagnosis.
5. Leukaemia Bone marrow failing to make enough normal blood cells, causing anaemia, bleeding and infection, with immature cells (blasts) seen on the blood film. But ten weeks of painless rubbery glands with drenching night sweats does not point to it.

The point: Lymphoma is a cancer of the lymph glands. B symptoms are a fever above 38°C, drenching night sweats and losing more than 10% of body weight in six months. These give the 'B' in staging (labelling how advanced the disease is) and mean a worse outlook. Reed-Sternberg cells, a specific type of abnormal cell seen under the microscope, mean Hodgkin lymphoma. Gland pain brought on by drinking alcohol is rare but is an almost sure sign of Hodgkin lymphoma when it happens. Diagnosis needs an EXCISION biopsy, removing a whole lymph gland; a fine needle sample (fine needle aspirate) destroys the structure the pathologist needs to see to make the diagnosis.

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 Shows how far the disease has spread (stages it) once the diagnosis has been made. That does not match ten weeks of painless rubbery glands with drenching night sweats.
2. Fine needle aspiration Good enough for confirming cancer that has spread from elsewhere but NOT for lymphoma, because it destroys the structure needed to classify it properly. Here, ten weeks of painless rubbery glands with drenching night sweats points elsewhere.
3. Excision biopsy of a lymph node correct Correct. The whole gland must be removed. Lymphoma is classified by the structure of the gland as much as by the cells inside it, and the exact type decides the chemotherapy used. This is why a fine needle sample is not good enough here, even though it would be for a suspected cancer that has spread from elsewhere.
4. Full blood count and blood film Checks whether the bone marrow is affected and rules out leukaemia as another possible diagnosis. It does not fit ten weeks of painless rubbery glands with drenching night sweats.
5. Lactate dehydrogenase A blood test that reflects how much tumour there is and how fast it is growing, used to judge outlook rather than to make the diagnosis. But ten weeks of painless rubbery glands with drenching night sweats does not point to it.

The point: Lymphoma is a cancer of the lymph glands. B symptoms are a fever above 38°C, drenching night sweats and losing more than 10% of body weight in six months. These give the 'B' in staging (labelling how advanced the disease is) and mean a worse outlook. Reed-Sternberg cells, a specific type of abnormal cell seen under the microscope, mean Hodgkin lymphoma. Gland pain brought on by drinking alcohol is rare but is an almost sure sign of Hodgkin lymphoma when it happens. Diagnosis needs an EXCISION biopsy, removing a whole lymph gland; a fine needle sample (fine needle aspirate) destroys the structure the pathologist needs to see to make the diagnosis.

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. Urgent haematology referral For suspected bone marrow involvement, low blood counts (cytopenias), or the disease progressing fast. But ten weeks of painless rubbery glands with drenching night sweats does not point to it.
2. Watch and wait The right choice for slow-growing (low-grade) follicular lymphoma with no symptoms, where treating early does not help people live longer. It does not fit ten weeks of painless rubbery glands with drenching night sweats.
3. Aspiration of the node for culture For a suspected infection, including tuberculosis, not for suspected lymphoma. That does not match ten weeks of painless rubbery glands with drenching night sweats.
4. Suspected cancer pathway referral within two weeks correct Correct. Swollen glands with no clear cause lasting more than six weeks meet the referral rule on their own, and B symptoms make it even more urgent. Ten weeks is well past the point where simply watching and waiting is reasonable.
5. Antibiotics and review in two weeks For glands that really are just reacting to an infection. Here, ten weeks of painless rubbery glands with drenching night sweats points elsewhere.

The point: Lymphoma is a cancer of the lymph glands. B symptoms are a fever above 38°C, drenching night sweats and losing more than 10% of body weight in six months. These give the 'B' in staging (labelling how advanced the disease is) and mean a worse outlook. Reed-Sternberg cells, a specific type of abnormal cell seen under the microscope, mean Hodgkin lymphoma. Gland pain brought on by drinking alcohol is rare but is an almost sure sign of Hodgkin lymphoma when it happens. Diagnosis needs an EXCISION biopsy, removing a whole lymph gland; a fine needle sample (fine needle aspirate) destroys the structure the pathologist needs to see to make the diagnosis.

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