ENT CPC TONSIL PROBLEMS

Hx first noticed, change, inflammatory features, dysphagia, dysarthria, B symptoms (>10% weight loss, fever >38, night sweats), other lymphadenopathy, smoking, cough, HPV, immunosuppression, medications, TB exposure, occupation, FHx Ex full oral cavity inspection; check H+N and systemically for lymphadenopathy, nasendoscopy, ear exam Ix: FBC, UEC, LFT, LDH Pre-bx workup coags, CXR, ECG etc ESR, CRP HIV, EBV, CMV CT (/MRI) H+N Bx Bx types include FNA, Core, excisional, inscisional o Histological ideal, FNA acceptable Neoplastic SCC, lymphoma, metastasis, melanoma, adenocarcinoma Non-neoplastic Actinomyces, fungi, TB/mycobacterium

Ddx:

Burkitts IgH transposition with c-myc oncogene Histopathology of LN/lymphoid tissue malignancy is indicated by architectural effacement, cytological homogeneity and cytological dysplasia CD3 Pan-T cell marker CD20 Pan-B cell marker (also shows rituximab should work) Kappa and lamba chain stains should be some heterogeneity

Dont send in formalin flow cytometry cant be done send fresh

LYMPHOMA MANAGEMENT
Management stages dx, staging, treatment, prognosis Staging NHL: Clinical (Hx B Sx, Ex) Radiological (CT and PET) o PET fusion of metabolic and anatomic (CT) information BM Bx LP (only testicular/tonsillar lymphoma) Staging informs management and prognosis. IPI score worked out based on: Anatomical stage (III/IV) see right Age (>60) LDH (burden) Number of extranodal sites ECOG performance status (2+)

Lymphoma is a very very chemo-curable cancer 5y relapse = cure, but most pts without relapse in 2-3y should be okay Mx: R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone Generic S/Es (most chemoRx) o Nausea for 72h o Mucositis (esp. mouth ulcers) o Alopecia o Lethargy o BM suppression (2nd week after chemoRx) Specific to R-CHOP o Pred insomnia o Vincristine peripheral neuropathy o Anthracyclines MDS, cardiotoxicity In testicular and tonsillar tumours, low-dose MTX is given intra-thecally Most cancers need >1 treatment modality (team approach), with MDT coordination. A combined approach like R-CHOP results in reduced individual drug doses, thus reduced toxicity risk (total dose reduced, shorter duration of chemoRx), and there is also reduced relapse risk outside the radioRx field.

RADIOTHERAPY IN DLBCL
More CHOP cycles and radioRx with higher stage; radiorx not necessary with early stage, small disease Process of radiotherapy: Clinical assessment Discussion at MDT Consent Simulation, including a CT in a thermoplastic (immobilising) mask Planning determination of best beat arrangement with modifiers to treat the target volume whilst sparing dose to critical surrounding structures

Mid-range doses for lymphoma (30-40Gy cf SCC etc 70Gy)

RadioRx S/Es: Acute (during/shortly after radioRx) o Skin reaction (erythema) o Mucositis o Temporary hair loss o Xerostomia (saliva thick and gluggy) o Fatigue Late (occur 3mo after Rx) o Complete/partial xerostomia o Gum/dental issues o Second cancers (younger age group) 5-10y latency, generally in the same region o Mandibular necrosis (rare)