Practice Paper 5: Answers
Anthony B. Starr, Hiruni Jayasena, David Capewell, Saran Shantikumar in Get ahead! Medicine, 2016
Acute lymphoblastic leukaemia (ALL) is the most common leukaemia in children, and is caused by the clonal proliferation of lymphoid precursor (blast) cells that have been arrested at an early stage of development. The blast cells infiltrate the marrow and lymphoid tissue, causing pancytopenia and lymphadenopathy, respectively. The central nervous system (CNS) can also be affected, causing headache, vomiting, meningism, cranial nerve palsies and seizure. The marrow failure and subsequent pancytopenia produce the common features of anaemia, bleeding/bruising and infection. Bone pain is another common presenting symptom. A full blood count confirms anaemia and thrombocytopenia, but demonstrates a high white cell count (due to circulating blast cells). The investigation of choice is bone marrow aspiration, which shows a hypercellular marrow with >20% blasts. Treatment involves the use of chemotherapy, as well as supportive measures such as transfusion and antibiotics. Chemotherapy is traditionally delivered in three main stages: remission induction, consolidation and maintenance (which can be for a number of years). Since patients with ALL are at high risk of neurological disease, they are often given CNS prophylaxis in the form of intrathecal methotrexate and radiotherapy. The prognosis of ALL is good with appropriate treatment.
Bladder cancer
Pat Price, Karol Sikora in Treatment of Cancer, 2014
Ultimately, the diagnosis of bladder carcinoma is made on cystoscopy with pathological evaluation of a resected tumour specimen. The initial examination for patients with haematuria is often by flexible cystoscopy under local anaesthetic. Abnormal findings are confirmed under general anaesthetic, with bimanual examination to confirm the presence, extent and fixity of any palpable bladder mass. The presence of induration or a palpable mass on bimanual examination following apparent complete resection of tumour implies extra-vesical extension, whereas resolution of these features implies organ-confined disease. Cystoscopic evaluation involves inspection of the entire urethra, prostate and bladder neck with retrograde pyelography when the upper urinary tract has not already been satisfactorily visualized. The number, location, size and configuration of all tumours and any associated mucosal abnormalities should be noted, and documented on a bladder map. Biopsy or resection of a tumour should be accompanied by directed biopsies of adjacent and normal-appearing bladder mucosa and should only be performed once satisfactory evaluation of the entire urinary tract is undertaken. General assessment of the patient should include full blood count, biochemistry and a chest x-ray and a bone scan when there is a history of bone pain.
Management of bone pain
Nigel Sykes, Michael I Bennett, Chun-Su Yuan in Clinical Pain Management, 2008
For localized sites of bone pain, simple external beam radiotherapy is the most effective and appropriate. This should not be undertaken without definitive evidence of metastasis at the site of pain and having excluded other causes such as degenerative disease as the primary cause of the pain. It is also important in weight-bearing areas to have excluded pathological fracture for which internal fixation will be indicated. High risk lesions can be identified based on the extent of cortical erosion.12[II] Having confirmed metastatic bone pain then the radiotherapy technique will be chosen to give a homogeneous radiation dose across the involved bone, while as far as possible avoiding sensitive normal structures, a particular concern when treating ribs where there is underlying lung and the lumbo-sacral spine and pelvis where abdominal contents will encroach. The radiotherapy procedure follows a series of defined steps as follows.
Incapacitating pain from Tenofovir Induced Hypophosphatemic Osteomalacia in a Hemophilia Patient – A Case Report
Published in Canadian Journal of Pain, 2020
Emma Woo, Dinesh Kumbhare, Paul Winston
There is a growing database of literature on the assessment and management of pain in hemophilia.3,4 This literature, however, primarily addresses acute and chronic pain as it relates to arthropathy from hemarthrosis and does not specifically address the need to accurately diagnose the pathology of the underlying pain. Though the differential diagnosis for pain in hemophilia is usually limited to acute pain from arthropathies, there are other pathological entities that account for pain in people with hemophilia (see Table 1). Downstream effects of hemarthrosis and hematomas can also lead to chronic pain from synovitis, degenerative arthropathy, and pseudotumors.5,6 Hemophilia pain can also have extrinsic associations, including deconditioning, associated illnesses, neurological injuries/impairments, medication side effects, and trauma. Determining the characteristics of the pain is important in distinguishing arthropathies from other causes. Specifically, pain with arthropathies tends to be initially acute, localized, and severe and become “arthritic” with time and increased joint damage.4 Bone pain, on the other hand, will typically present as a dull aching pain unless due to a fracture, which will cause sharp, radiating pain.7
Magnetic resonance imaging as a diagnostic modality in a child with acute lymphoblastic leukemia
Published in Baylor University Medical Center Proceedings, 2019
Nishath Farhad, Krista Birkemeier, Lea H. Mallett
ALL is the most common form of childhood cancer. The peak incidence occurs between the ages of 2 and 5 and is more common among boys than girls. ALL typically presents with nonspecific symptoms and can therefore be difficult to distinguish from other pediatric pathologies. Some early signs and symptoms of ALL include hepatosplenomegaly, lymphadenopathy, musculoskeletal pain, mediastinal mass, and peripheral blood abnormalities.1 Bone pain is a presenting symptom in 20% to 40% of cases of acute leukemia2 but is also a common symptom in metastatic cancers and multiple other nonmalignant conditions. Blood work in ALL patients typically reveals anemia and/or thrombocytopenia with a normal to elevated white blood cell count, and a peripheral smear can contain lymphoblasts. The presence of atypical cells in peripheral blood, cytopenia in more than one cell line, and/or concerning symptoms such as hepatosplenomegaly, lymphadenopathy, or bone pain warrant a bone marrow examination.
Bone-targeted agent treatment patterns and the impact of bone metastases on patients with advanced breast cancer in the United States
Published in Current Medical Research and Opinion, 2019
David Henry, Roger von Moos, Jean-Jacques Body, Alex Rider, Jonathan De Courcy, Debajyoti Bhowmik, Francesca Gatta, Guy Hechmati, Yi Qian
Patient demographics and clinical characteristics included time from initial breast cancer diagnosis to bone metastasis diagnosis, time from bone metastasis diagnosis to survey completion date, menopausal status, and family history of breast or ovarian cancer. The presence of bone pain was indicated at the initial diagnosis of bone metastasis and at survey completion. The grade of bone pain, indicated as mild, moderate or severe, was measured using the Brief Pain Inventory (BPI), a validated instrument used to assess pain intensity and interference with daily activities26. The range of BPI worst pain was from 0 (no pain) to 10 (worst pain), with ratings from 1 to 4 corresponding with mild pain, 5 to 6 with moderate pain and 7 to 10 with severe pain. Use of analgesics, including weak or strong opioids, was also evaluated using the Analgesic Quantification Algorithm27.