SLIDE 1
“A 51 year old male with ascites and generalized lymphadenopathy” Theo Ntenegi
SLIDE 2 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
- ncologic 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.
SLIDE 3 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
SLIDE 4 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.
SLIDE 5 Claim your CME credits!
- To claim your CME credit for attendance at this
session of the BOTSOGO Tumor Board, please fill out
- ur survey after the Tumor Board.
- You can do this at your convenience on your personal
- r 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
SLIDE 6
Case Report Patient: SN Sex: Male Age: 51 Address: Southern Botswana Occupation: Free-lance builder
SLIDE 7
Case History (continued)
DOA: early 2018 Admitted to Male Medical Ward via outpatient clinic as a referral from hospital outpatient department.
SLIDE 8 Presenting Complaints
Since late 2017, worsening since early 2018. Associated with diffuse pain. No bowel movement changes. No Hx of Melena
SLIDE 9 Presenting Complaints (continued)
Onset early 2018 Bilateral with no alleviating factors.
SLIDE 10 Presenting Complaints (continued)
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.
SLIDE 11
Past Medical History Weight loss noted since 2017. On and off fevers noted prior to presentation. No night sweats. No chronic cough.
SLIDE 12
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
SLIDE 13 Past Medical History
Seen 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.
SLIDE 14
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.
SLIDE 15
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
SLIDE 16 Physical Examination
Generalised-Bilateral lymphadenopathy, Non- matted, Size – (0.3 – 3+cm) Involving:
- Cervical
- Axilar
- Submandibular
- Antecubital
- Pre + Post Auricular - Inguinal
- Occipital
- Popliteal
- Supraclavicular
SLIDE 17 Admission diagnosis
- 1. Chronic live disease with portal HTN
- 2. Disseminated TB Vs. Lymphoma
SLIDE 18
Progress In the Ward Day 4: CXR- Left Pleural Effusion, no lesions noted. Paracentesis and Pleural Tap.
SLIDE 19 Day 9:
- Abd. Ultrasound – Ascites, Homogeneous
Hepatomegally with no focal lesions. +Pleural
- Effusion. Mild homogeneous Spleenomegally.
+Paraaortic Lymphadenopathy. No Pericardial Effusion.
SLIDE 20
Day 11: Ascetic Fluid : SAAG> 11g/dL, Cell Count -60; 80% Lymphocytes. No Malignant cells. Nill bacterial growth. Pleural Fluid: Exudative.
SLIDE 21
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.
SLIDE 22
Pathology
SLIDE 23
Pathology
SLIDE 24
Pathology
SLIDE 25
Pathology
SLIDE 26
Pathology
SLIDE 27
Pathology
SLIDE 28
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.
SLIDE 29
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.
SLIDE 30
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
SLIDE 31
Chest X-ray: on admission
SLIDE 32
Chest x-ray: during admission
SLIDE 33
A 51 year Male, RVD Negative (HIV negative) Presenting with Generalised Lymphadenopathy, ascites and hepatomegally. Final Diagnosis: Advanced Nodular Sclerosing Hodgkin Lymphoma. Stage III2 (Modified Ann Arbor – Cotswold)
SLIDE 34 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 8.2 HB 12-15 10.6 11.1 12.8 12.3 MCV 83-99 93.8 92.9 94.6 94.5 PLTS 150-400 264 270 325 224 Neut 2-7.0 5.0 5.1 5.1 5.6 Lymph 1.0-3.0 1.5 1.1 1.1 1.0 Eosino 0.02-0.5 0.2 0.0 0.18 Na+ 135-145 130 126 132 125 K+ 3.5-5.1 4.16 3.96 4.4 6.6 Urea 2.0-7.0 2.5 3.2 4.1 4.08 Creat 53-97 36 34 35 32 Ca 2.2-2.6 2.01 Mg 0.6-1.10 0.69 Phos 0.8-1.55 1.12 Tot Prot 60-80 61.2 78.4 55.2 59 58.2 Tot Bil 1.0-25.7 11.6 7.68 13.6 Conj Bil 0-3.0 Albuim 35-55 23.9 22.7 25.7 21.8 ALP 35-110 183 153 170 205 GGT 11-50 172 169 193 240 229 ALT 11-40 9.1 7.8 6.0 5.3 10 AST 10-34 32.8 26.8 27 34 34 LDH 210-425 205 211 INR 1.21 1.4 APTT 25-45 29.6 32.8 33
SLIDE 35 Hasenclever Score
Hasenclever Score Score 1 Patient’s Score Serum albumin Normal <40 g/L 1 Haemoglobin >10.5 g/dL <10.5 g/dL Age <45 >45 1 Sex Female Male 1 Stage <IV IV Leucocytosis <15x109/L >15x109/L Lymphopenia >0.6x109/L <0.6x109/L Cumulative Score 3
SLIDE 36
Discussion
Approach to a patient with suspected Hodgkin Lymphoma. Criteria for Chemotherapy fitness. Staging Hodgkin Lymphoma. Preparation and Investigations prior to Oncology referral.
SLIDE 37
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.
