Tag: hodgkin’s

Haematology, Suspicion of Cancer Referral

Scott McLaughlin
Haematological Cancers

Haematological cancers can present with a variety of symptoms. A combination of symptoms and signs, often non-specific, may suggest haematological cancer and warrant further examination, investigation and possible referral.

Leukaemia (acute and chronic)

Approximately 630 people are diagnosed with leukaemia in Scotland each year.1 Although all ages can be affected, around 70% of cases occur in people aged over 60 years. Symptoms and/or signs of bone marrow failure such as fatigue, pallor, bruising, bleeding and infections can occur. Fatigue and vulnerability to infection can result from most types of haematological cancer but are particularly severe in acute leukaemia. Some leukaemias may present with lymphadenopathy and/or hepatosplenomegaly. The most common form of leukaemia in adults is chronic lymphocytic leukaemia (CLL), which is often an indolent disease and an incidental finding.

Non Hodgkin’s lymphoma

Approximately 1,000 new cases of Non Hodgkin’s lymphoma are diagnosed in Scotland each year. Although all ages an be affected, around 70% of cases occur in patients aged over 60 years. Common symptoms or signs at presentation include fatigue, weight loss, night sweats, lymphadenopathy and hepatosplenomegaly.

Hodgkin’s lymphoma

Approximately 170 new cases of Hodgkin’s lymphoma are diagnosed in Scotland each year,1 with 50% of cases occurring in people under the age of 40 years. Clinical features at presentation are similar to those for Non-Hodgkin’s lymphoma but 95% of patients present with lymph gland involvement.

Myeloma

Approximately 400 new myeloma cases are diagnosed in Scotland each year. About 80% of cases occur in patients aged over 60 years.1 Clinical features at presentation include bone pain, symptoms of anaemia, renal impairment, and symptoms of hypercalcaemia (such as polyuria and polydipsia).

The presence of an isolated paraprotein or monoclonal gammopathy of unknown significance (MGUS) is not a cancer, and is a common incidental finding in the elderly (10% over 85 years). However, 12% of patients will develop myeloma or related disease within 10 years. All patients with MGUS should therefore be monitored to detect progression in paraprotein level. Some patients with a paraprotein are at more risk of developing myeloma than others, and this can often be predicted from results. Discussion with a haematologist is therefore encouraged if in any doubt.

For patients presenting with these non-specific symptoms, the GP should always consider checking the human immunodeficiency virus (HIV) status along with other routine investigations.

Routine tests and investigations should be repeated at least once if a patient’s condition remains unexplained.

If myeloma is suspected, urine as well as serum electrophoresis should be performed.

 

Arrangements for biopsy of persistent abnormal lymph glands vary locally.

All patients presenting with symptoms or signs suggesting haematological cancer should be referred to a team specialising in the management of haematological cancer, depending on local arrangements.

Urgent suspicion of cancer referral
  • Blood count film reported as suggestive of acute leukaemia or chronic myeloid leukaemia.*
  • Lymphadenopathy (>2cm) persisting for 6 weeks or increasing in size or generalised (HIV status should always be checked if generalised).
  • Hepatosplenomegaly in the absence of known liver disease.
  • Bone pain associated with a paraprotein and/or anaemia.
  • Bone x-rays reported as being suggestive of myeloma.
  • The following clinical features may also merit urgent referral:
    • fatigue
    • night sweat
    • weight loss
    • itching
    • bruising
    • recurrent infections
    • bone pain
    • polyuria and polydipsia (hypercalcemia)

* will normally be identified in the laboratory and communicated to the GP for management to be agreed.

Primary care management

  • CLL in an older person should be discussed with a local haematologist but many cases do not require detailed haematological review.
  • Asymptomatic monoclonal gammopathy may be followed up in primary care depending on local arrangements – consider discussion with a haematologist if any concern.

Reference:
Scottish Referral Guidelines for Suspected Cancer. Scottish Government, August 2014
Nice – Suspected cancer: recognition and referral 2015
Lead Clinician: Dr Lyndsay Mitchell, Consultant Haematologist, Monklands DGH
Review Date March 2017