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Haematological cancers

 

Adults-Unexplained lymphadenopathy or splenomegalyLeukaemia –Leukemia occurs when alteration in normal cell regulatory processes cause uncontrolled proliferation of haematopoeitic stem cells in the bone marrow

Symptoms can be vague and non-specific A GP may only see one case of blood cancer every 2 years High rate of presentation as emergency ( all blood cancers )
Particularly Acute Lymphoblastic Leukaemia ( ALL ) Leukaemia can present with
○ anaemia
○ reduced normal white cells
○ thrombocytopaenia Symptoms may include
○ pallor
○ bruising
○ propensity to infection Chronic leukaemias are usually symptomless and only identified on routine FBC testing Four common subtypes seen in primary care are
○ acute lymphoblastic leukaemia ( ALL )
○ acute myelogenous or acute myeloid leukaemia ( AML )
○ chronic lymphocytic leukaemia ( CLL )
○ chronic myelogenous or chronic myeloid leukaemia ( CML )

Adults with any
 of the following-Pallor Persistent fatigue Unexplained fever Unexplained persistent or recurrent infection Generalised lymphadenopathy Unexplained bruising Unexplained bleeding Unexplained petechiae Hepatosplenomegaly-Consider a very urgent FBC 
( within 48 hrs ) to assess 
for leukaemia

Children and 
young people-Unexplained petechiae or hepatosplenomegaly.Refer for immediate specialist 
assessment ( admit )

Pallor Persistent fatigue Unexplained fever Unexplained persistent infection Generalised lymphadenopathy Persistent or unexplained bone pain Unexplained bruising Unexplained bleeding-Offer a very urgent FBC ( within 48 hrs )
 to assess for leukaemia

Myeloma-People aged 60 and over with persistent bone pain , particularly back pain , or unexplained fracture -Offer
 FBC Bone profile Plasma viscocity or ESR

to assess for myeloma-Plasma viscocity or ESR consistent with possible myeloma-Urgent electrophoresis and a Bence-Jones protein within 48 hrs.  People aged 60 and over with hypercalcaemia or leukopenia and a presentation that is consistent with myeloma.Offer very urgent
 protein electrophoresis Bence-Jones protein urine test ( within 48 hrs )

Lymphoma-Lymphomas encompass a group of lymphoproliferative malignant diseases that originate 
from T and B cells in the lymphatic system. Majorty ( ~ 85 % ) are B-cell type ) hodgkins lymphoma-marked by presence of Reed-Sternberg cells Bimodal peak
20-29 and second
around 60 Rare cancer- a GP likely to diagnose 1 Hodgkins lymphoma during their career One of the most common cancers in young people Most common symptom is lymphadenopathy which may be accompanied by other symptoms as
○ fever
○ pruritus
○ weight loss
○ night sweats Four most common histological subtypes are
Lymphocyte predominant
Nodular sclerosing
Mixed cellularity
Lymphcyte depleted One of the most curable form of malignant disease.Adults- Unexplained lymphadenopathy-Take into account any associated symptoms particularly fever, night sweats , SOB , pruritus , weight loss or alcohol induced lymph node pain-Consider suspected cancer referral – for appt within 2 weeks

Children and young people- unexplained lymphadenopathy-Take into account any associated symptoms particularly night sweats , SOB , pruritus or weight loss-Consider urgent appt within 48 hrs for specialist assessment

non-Hodgkins lymphoma-NHL encompass a heterogenous group of over 40 lymphoproliferative malignancies with diverse patterns of behaviour and responses to treatment Prognosis depends on area involved ,histological subtype , stage and Rx About 85 % are of B cell and 15 % o T or NK
 ( natural killer ) cell origin Incidence has increased markedly ( ageing population and better diagnosis ) Most common symptom of NHL lymphadenopathy sometimes accompanied by other symptoms as 
○ fever
○ pruritus
○ weight loss 
○ night sweats Risk factors include immunosuppression ( eg HIV , medications ), occupational exposure, infections Prognosis -widely used International prognostic Index for NHL


Adults-Unexplained lymphadenopathy or splenomegaly-Take into account any associated symptoms particularly fever, night sweats , SOB , pruritus , weight loss or alcohol induced lymph node pain-Consider a suspected cancer pathway referral for an appt within 2 weeks

Children and young people with unexplained lymphadenopathy or splenomegaly-Take into account any associated symptoms particularly night sweats , SOB , pruritus or weight loss-Consider urgent appt within
 48 hrs for specialist assessment

LINKS AND RESOURCES

Myeloma UK https://www.myeloma.org.uk/

Blood wise leading UK Blood cancer charity https://bloodwise.org.uk/

Lymphoma charity https://lymphoma-action.org.uk/

Leukaemia care https://www.leukaemiacare.org.uk/

Charity helping find potential blood stem cell donors https://www.dkms.org.uk/en/about-blood-cancer

A charity supporting young people with cancer http://www.shinecancersupport.org/

RCGP free learning module developed with leukaemia care https://elearning.rcgp.org.uk/course/info.php?id=184

References


  1. Oxford Handbook of Clinical Haematology -Drew Provan et al
  2. Leukemia : an overview for primary care Am Fam Physician. 2014 May 1:89(9): 731-8
  3. CKS Haematological cancers- recognition and referral October 2015
  4. Suspected cancer : recognition and referral NICE guideline NG 12 June 2015
  5. Alberta Health Services Lymphoma Clinical Practice Guideline LYHE-002 Version 11 July 2018

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