Hematological / Oncological
- Lymphoma is a malignancy of the lymphatic system.
- Categorized into Hodgkin Lymphoma and non-Hodgkin lymphoma.
- Include a wide variety of hematologic malignancies with varying clinical presentations.
- Some patients will present with symptoms secondary to extra-nodal involvement, which can include many common ED complaints such as GI complaints, headache, back pain etc.
Initial Presentation – Signs and Symptoms
Hodgkin Lymphoma – generally slow progression:
- Non-tender, firm lymph node (cervical/mediastinal more common).
- Constitutional symptoms: fever, night sweats, or unintended weight loss.
- Other symptoms: Pruritus, fatigue, alcohol-associated pain, splenomegaly, hepatomegaly.
- Incidental findings: Mediastinal Mass on CXR, Hypercalcemia, Anemia, Eosinophilia.
Non-Hodgkin Lymphoma – progression to extra nodal involvement can be rapid, wide variety of initial presentations:
- Most commonly: lymphadenopathy and constitutional symptoms similar to Hodgkin lymphoma.
- GI involvement: Abdominal mass/organomegaly, vomiting, early satiety, obstruction.
- CNS: headache, focal deficits, seizures, meningitis, back pain, cord compression.
- Tumor Lysis Syndrome: hyperkalemia, hyperphosphatemia, and hypocalcemia and associated symptoms.
- Other: Airway obstruction, pericardial tamponade, SVC syndrome.
- CBC with differential
- CRP, ESR
- Extended electrolytes: Na, K, P, Mg, Ca
- LFTs & Kidney function
- LDH, uric acid
- HIV, Hep B & C
- CXR/Chest CT
- Further imaging depending on clinical presentation (eg. CT head, CT abdo-pelvis)
Ultimately patients will need lymph-node biopsy (excisional ideally), but this is not routinely done in the Emergency.
Patients will need to be referred to oncology for consideration for chemotherapy +/- radiation. Protocols vary based on classification of lymphoma.
Chemotherapy protocols and PPOs available from BC Cancer (link below).
When to use steroids:
- Patients with known lymphoma may present to ED with oncologic emergencies that may benefit from corticosteroids, 2 examples of this below.
- Generally pre-biopsy steroids are avoided if other treatments promptly available.
- Steroids can cause apoptosis in. lymphoma which has been reported in some cases to delay accurate histologic diagnosis.
- Spinal cord compression:
- when signs and symptoms of cord compression (back pain, neurologic deficits) are present the entire spine should be evaluated with MRI ideally (CT if MRI not available).
- Urgent neurosurgery/radiation oncology/medical oncology consultation.
- If corticosteroids pursued, Dexamethasone (eg. 10-16mg IV, subsequently 16mg PO daily until definitive management).
- Hypercalcemia in most Hodgkin and up to a third of Non-Hodgkin lymphoma is due to increased calcitriol.
- Hypercalcemia in these cases may respond well to corticosteroid treatment (eg. 20-40mg PO prednisone daily).
- Symptomatic or severe hypercalcemia is also treated with IV hydration and calcitonin (4-8 IU/kg SC or IM q6-12 hrs) for acute management.
- IV bisphosphonates (Zoledronic acid 4mg IV) and Denosumab (120mg SC) will reduce calcium over next few days. Generally, do not repeat dose within one week.
Complications secondary to treatment:
- Tumor lysis syndrome:
- tumor lysis can release large amounts of potassium, phosphate, and uric acid.
- Can be life threatening and can lead to AKI, arrhythmias, or seizures.
- Cardiac monitoring and ICU admission likely needed.
- Treatment involves IV fluids to maintain good urine output, treatment of hyperkalemia, phosphate binders can be considered to treat hyperphosphatemia, Rasburicase for hyperuricemia (0.2 mg/kg/day), and lastly calcium replacement once phosphate is corrected or if symptomatic (tetany/arrhythmias).
- Dialysis is indicated if these measures do not fix above electrolyte abnormalities, or there is fluid overload/renal deterioration.
- Febrile neutropenia:
- Treatment of febrile neutropenia involves recognition of fever or SIRS response in context of neutropenia and early initiation of empiric antibiotics.
- Empiric treatment guidelines can be found at BC Cancer (link below).
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
When lymphoma is highly suspected, avoid pre-biopsy steroids unless alternative treatment is not urgently available.
Low Grade Recommendation: NICE guidelines recommend avoiding pre-biopsy steroids even in metastatic spinal cord compression but this recommendation is based on low quality observational studies.
2019 surveillance of metastatic spinal cord compression in adults: risk assessment, diagnosis and management (NICE guideline CG75) [Internet]. National Institute for Health and Care Excellence. 2019 Feb 7.
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Jan 19, 2022
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