MR 24 - 28 May

Teaching rounds with Dr Panella covered a case of head and neck cancer with an unusual neuroendocrine tumor located in the tonsillar fossa.  Some key points of evaluating a patient with a neck mass were discussed.  If the mass is tender and infection is a possibility, a two week trial of antibiotics is a reasonable first step.  If the mass persists beyond that point, invasive testing with FNA is appropriate as well as consideration of CT imaging.  This AAFP article has a nice review of the topic.

Another case discussed this week was a patient that was admitted with progressive pain and malaise and was found to have a markedly elevated WBC at her oupatient visit (>80K).  Her peripheral smear supported a diagnosis of CLL but this alone did not completely explain her multifocal pain.  A bone scan was requested that revealed multifocal osteoblastic disease.  Bone marrow aspirate revealed metastatic adenocarcinoma, indicating the simultaneous presentation of 2 malignancies.

Pearls:
CLL is the most common type of leukemia in adults.  Many patients are diagnosed incidentally when a CBC is checked for other reasons.  Other cases are identified during evaluation of patients for unexplained lymphadenopathy.  Very few cases are symptomatic, and when symptoms occur it usually consists of fevers, chills, and night sweats (B symptoms) and not pain.  This disease is usually managed with watchful waiting, but new advances in prognostic markers may push some patients towards earlier treatment if they have high risk features.  See this NEJM review for more details.  Alemtuzumab is a monoclonal antibody therapy (anti CD52) approved for therapy of CLL.

CLL patients seem to be at risk of developing other malignancies, particularly other leukemias, lymphomas, melanomas and sarcomas.  The fact that CLL is often asymptomatic makes it more likely that the CLL will not be discovered until workup for the other malignancy, making them appear to be "simultaneous", though the CLL may have been present for quite some time.

Good pictures from American Society of Hematology Atlas of CLL shown here.