Episode 003
Professor Hare: [00:00:00] Hey folks, welcome to the be excited podcast. This is professor Hare, and today on episode three, we have with us for our hematology oncology discussion, Lydia Popichak welcome to the podcast, Lydia,
Professor Hare: Thanks for being here.
Lydia Popichak: It’s Nice to be here.
Professor Hare: let’s talk about what your service is, where you’re working and what kind of work you do there and why you like that work?
Lydia Popichak: I graduated back in 2018 and for the first three years, I worked on the malignant hematology service at Shadyside hospital, which was a new service at the time. I was one of the first couple of people on that service when we started it. And it was a new service that took care of the lymphoma myeloma chronic leukemia and myeloproliferative disease patients.
Lydia Popichak: So from working them up to treating them, to basically taking care of anything that they had going on we were a primary service That also took care of the oncologic needs. we manage everything from blood pressure to surgical need [00:01:00] to diabetes on our service, but then we also take care of their heme issues too.
Professor Hare: one thing that I think is often misunderstood, at least by students in this process is the difference between oncology as a solid tumor service versus in a hematology oncology service, which covers leukemia lymphomas. proteinemias multiple myeloma,
Professor Hare: The tumor side of things is more bulky disease where we’re seeing an actual nidus of tumor somewhere in the body for that. How would you describe the primary hematologic oncologic focus that you had?
Lydia Popichak: these usually originate either in the bone marrow or the spleen or lymph nodes. So a lot of times when you think of a leukemia that originates in the bone marrow, and then the lymphomas originate in the lymph nodes but they can arise other areas in the body, but those are the main areas that they’re involved in.
Professor Hare: this is a source of a, lot of cells that are often problematic throughout the entire body of those blast cells, creating new [00:02:00] cells that are proliferating and moving throughout the body in the bloodstream. So white cells and in t he lymphatic system. why did you initially go into hem-onc so you went straight out of school, right?
Lydia Popichak: Yeah, actually pre PA I was a patient care technician on the bone marrow transplant floor at shady side. And I’ve always loved that world. Those people you get to have a good relationship with them and their families and you spend a lot of time with them.
Lydia Popichak: I’ve always liked that. So I knew I wanted to do that
Lydia Popichak: when I started. . And unfortunately there wasn’t a bone marrow transplant job available at the time.
Professor Hare: I find it interesting this particular area of medicine that have a significant diagnosis to begin with a significant morbidity and mortality causing diagnosis to begin with.
Professor Hare: I don’t know that I could actually do that. If I’m honest,
Lydia Popichak: it’s definitely a lot especially when you work someone up and sometimes you’re with these people from their diagnosis to their death, and it’s definitely straining sometimes, but it is nice to be able to really get [00:03:00] to know them and know their families and be with them through their whole process whether it’s good or bad.
Lydia Popichak: And it is nice when we get to see people finish their chemo too. So it has its rewarding time.
Lydia Popichak: as,
Lydia Popichak: much as it has its hard times.
Professor Hare: in other words, it seems to be emotionally rewarding, but at the same time, emotionally draining at times I appreciate that the procedural side of things the bone marrow biopsies that you’re doing more significantly now tell me about the kind of procedures that you do in this position.
Lydia Popichak: So the biggest one is bone marrow biopsies.
Lydia Popichak: So we’ll use that as a diagnostic tool sometimes to figure out what’s going on with the patient. we use to monitor how treatment is going for the patient as well. especially in the transplant patients or the leukemia patients, they’ll do marrows throughout their treatment course to figure out how the treatment is working on them.
Professor Hare: tell me about the intrathecal treatments that you do.
Lydia Popichak: So we also do intrathecal chemotherapy injections. The patients will be done in radiology and someone else will do a lumbar puncture on them. And they’ll take fluid out that we usually send [00:04:00] off to look for cancer cells in their CSF fluid.
Lydia Popichak: And then they’ll send off cell count all the normal stuff. And then we also send type cytology so we can see if there’s any cancer in that fluid. And then after they take the fluid out, we put chemotherapy into their CSF. It’s a very small amount. Usually it doesn’t cause any issues , but we are the ones that inject the chemo.
Professor Hare: Let’s talk about our diagnoses, the primary diagnoses that we have to worry about in leukemias lymphomas and these kinds of hematologic oncologic situations.
Professor Hare: let’s start off with the basic diagnoses, leukemia, and lymphoma. Leukemia is white cell based, and it’s coming from the bone marrow, and the lymphomas are primarily occurring in the lymph nodes in the system. What kind of symptoms do you see that differentiate in the early presentation of leukemias and lymphomas
Lydia Popichak: they can have a similar presentations. A lot of the leukemias will come in because they’re really tired or they’ll notice new bruising They’re short of breath. And a lot of that comes down to their [00:05:00] counts are low, or they might have a new infection because their white counts low. if their platelets are low, they could have bruising.
Lydia Popichak: Or if they have a low hemoglobin, they might be short of breath. So some of them are found incidentally or on routine labs or they’re really tired all the time. And then a lot of times when , with lymphoma, they show up with a lump somewhere. So whether it’s in their neck, their armpit, their groin anywhere, they’ve noticed a lump.
Lydia Popichak: That’s probably the biggest thing we find, or they’ll have shortness of breath and you do a chest x-ray and you find a mediastinal mass, in their chest.
Professor Hare: We’ve talked before on the podcast about fatigue, being a very common issue in primary care settings and emergency room settings for that matter in any, generalist setting.
Professor Hare: So fatigue in this case, one of the differentials that we get concerned about would be an anemia that points us to a leukemia like scenario.
Professor Hare: Some of the other things a fever or recurrent fever, presumably of unknown origin in those cases, or is that an actual infection that you are, [00:06:00] finding a source of infection that might be causing the fever and then backing up to the CBC
Lydia Popichak: Sometimes it can be an actual infection, but a lot of time, these people have, a cyclic fever.
Lydia Popichak: A lot of times it’s the same time every day. And sometimes we’ll even see it When we’re concerned for relapse on these patients, if they’ve already had a diagnosis, they’ll start getting a fever every day at two AM. And it’s, a high fever and it’s the same every day. And our infectious workup has been negative.
Professor Hare: the fever of unknown origin that keeps coming back over time in other words. our list of must not miss diagnoses here. One of the first that you listed in our early discussions was cord compression. Can you tell me about what happens with cord compression and what other conditions it’s associated with?
Lydia Popichak: we actually get a lot of rule-out cord compressions pretty frequently, inpatient, especially in multiple myeloma patients or lymphoma patients. what happens with those people is sometimes they’ll get usually it’s a mass. So in the case of lymphoma, it would be. a tumor [00:07:00] Or in multiple myeloma a plasmacytoma, which is a collection of those plasma cells and they will be around the spine and they’ll actually put pressure on the spine, which can cause neuro symptoms like paralysis.
Lydia Popichak: So we want to watch those people closely because a lot of them need to be started on steroids and have a neurosurgery evaluation. ASAP.
Professor Hare: this patient might be presenting to family medicine, for instance, or primary care or to orthopedics, or maybe to neuro, and then the realization that there’s a red flag there that might be sending them on for more significant workup in the hem-onc space.
Professor Hare: then the w the work up that you would do to differentiate that from a pure musculoskeletal or neurologic condition then would be a CT scan in that case.
Lydia Popichak: So we prefer MRIs a lot of these people will come in with just back pain. So anytime we have a myeloma that comes in with back pain,
Lydia Popichak: We prefer MRIs of the whole spine and if we’re doing one part of the spine. We usually just look at the whole spine because you can get compression at any level. So [00:08:00] we prefer MRIs, but if they can’t get an MRI, we can do CTS. Okay. So back pain, weakness, any symptoms of bowel or bladder incontinence or retention.
Professor Hare: Then would you send someone with cord compression and some sort of bulk that’s causing that onto surgery and what service would be doing that surgery?
Lydia Popichak: they would stay on our service, but since we’re the primary, but we always stat consult neurosurgery. If we’re concerned for cord compression and then they’ll direct us.
Lydia Popichak: usually we’ll start steroids. So you start with a big loading dose and then you keep a dose on continuously every six hours, but sometimes they will do de-bulking surgeries more so in the lymphoma situations and myeloma they actually respond really well to radiation. So a lot of times we’ll start out with radiation for those patients.
Professor Hare: Okay. the next one on your list here, neutropenic fever and sepsis. We alluded to this earlier with low neutrophil counts. That can be a consistent concern with fevers. And then sepsis is obviously another element of that. have you [00:09:00] experienced any specific cases along that line a classic scenario in which you might talk through that
Lydia Popichak: so, especially in the patients getting chemo a lot,
Lydia Popichak: it’s almost expected that they’re going to come in with a neutropenic fever because a lot of the chemos will intentionally. because they’re trying to cure your bone marrow, wipe out the bad stuff in your bone marrow, which then kills off the good as well.
Lydia Popichak: So then you’re getting rid of your neutrophils and that puts you at a big risk for infection, because those are your body’s first line of defense. So when you have low counts, you’re susceptible to a lot of infections. So that’s a very pivotal point in these patients because they could die from a little infection.
Professor Hare: they are on precautions presumably to keep them from getting to that point. what do those precautions look like for those patients?
Lydia Popichak: Usually for all times we have people on acyclovir, which is an antiviral because these patients are at risk for shingles. we want to prevent shingles because I’ve seen some really nasty shingles around the eye,
Professor Hare: right.
Professor Hare: herpetic infection
Professor Hare: can, cause actual damage [00:10:00] as
Lydia Popichak: I’ve seen it in, in the CSF. too that was bad. we will put people on antifungal treatment. So usually fluconazole is our go-to and then antibacterial. So we usually use Levaquin or Levofloxacin..
Professor Hare: And you are doing kinds of prophylactic antibiotic treatments how long a period of time do they usually need to be on that?
Lydia Popichak: so that depends on how long they’re neutropenic. So we based that off of their neutrophil count, their absolute neutrophil count. So if it’s under 500, we usually have them on both the antifungal and antibacterial.
Professor Hare: Okay. that’s really interesting. I think the absolute neutrophil count is one of those things that gets reported in the CBC consistently.
Professor Hare: Anytime you get a CBC with diff and noting that absolute neutrophil count is one of those things, you know, sometimes I see it my family medicine setting where we get
Professor Hare: Absolute neutrophil counts that go into the very low single digits. And we start to watch that with concern for infection We have some medications in psychiatry that can actually do that as well. But we like to keep a close eye on those. Absolute neutrophil count is, [00:11:00] probably the one that really has the most basic risk associated with it.
Professor Hare: I don’t know if you would agree with that or not.
Lydia Popichak: That’s the main thing personally I know, the leukemia people look at blasts a lot. I don’t personally usually take care of acute leuk patients,
Professor Hare: but
Lydia Popichak: they look at the blasts and the different numbers in the CBC. But a lot of times, at least with the lymphomas in the myeloma is when they’re getting chemo.
Lydia Popichak: We look at the ANC, which is the neutrophilic.
Professor Hare: Moving on to number three on that list is DVT and PE. And presumably this is a result of the, kind of proliferation of red cells. In that case, are we getting thickened blood? Getting a pan increase in cells coming from the bone marrow in some of these cases, or so what’s causing that DVT risk to go up.
Lydia Popichak: cancer just in a whole is a hypercoagulable disorder. these patients can get a clot at any time. So if they come in with lower extremity swelling, we want to Doppler them or upper extremity, or if they have any shortness of breath, tachycardia symptoms of a PE, we want to scan them as well, because [00:12:00] despite some of them having low platelets, they’re still at risk for getting a clot, which I’ve seen.
Lydia Popichak: And it’s a very difficult circumstance when someone has platelets of 20, but then a new clot,. And then you’re kind of in this balance of You have to figure out which one to treat.
Professor Hare: Yeah. That certainly sounds difficult between the, situation that you would normally want to have with low platelets combined with the DVT at the same time.
Professor Hare: So we have increased coagulation, but at the same time, low potential for coagulation. do you see those extend into pulmonary embolisms frequently in your service?
Lydia Popichak: We, I see quite a bit of pulmonary embolisms unfortunately. if we have one, we’ll look for the other, especially PE to DVT, because then that’ll sometimes determine how long treatment and how to treat them, especially in the setting of low platelets.
Lydia Popichak: but, we get a handful of both.
Professor Hare: it sounds as if, just from our initial discussion as if there is a significant amount of whole body care going on with these patients. Which is, I think most folks would consider that comforting to know that, we’re not just farming things out to multiple services to make that happen, [00:13:00] you’re looking at all of that with one service and having those, those other services available for consult, as you go through the care of that patient the next one is airway compromise, and I assume that’s SVC syndrome that superior vena cava going along with that or not.
Lydia Popichak: So that, and just bulky lymphadnopothy. So I’ve seen different lymphoma patients, especially they’ll come in, they’ll have huge lymph nodes that either. Deviate their trachea, or it just cuts off their airway. And we’ve even had to intubate some of these people right off the bat because they can’t breathe or their lymph nodes are growing so quickly or just to safely give them chemo.
Lydia Popichak: We’ve had to intubate some of the patients.
Professor Hare: That’s not just an initial presentation where they come in and they’re having difficulty breathing. that’s a rapid growth of those lymph nodes that it’s occurring even in established patients is that something that you’re sending a patient home for a period of time during their treatment, is that something that you are talking to them about and the possibility of that airway compromise being something that you may need to go into the emergency room if you experienced these kinds of symptoms.
Lydia Popichak: So we always tell [00:14:00] patients if you get any shortness of breath, but generally the ones that have airway compromise, you’re going to see those from the beginning. They’re either going to come in with that or present to the ER with difficulty breathing or you’re going to notice it throughout their stay, that you’re not going to send them home.
Lydia Popichak: Like. that. one case that I remember she was a CLL patient or chronic lymphocytic leukemia, who was progressing to something that we’ll talk about later, which is Richter’s transformation, which is when you go into a aggressive B-cell lymphoma and her lymph nodes were growing so quickly that steroids weren’t touching it.
Lydia Popichak: And her neck just was so large that she just couldn’t breathe any more. She wasn’t able to swallow, she couldn’t breathe. we had to send her to the ICU and they unfortunately intubated her during the time. So we could give her chemos to hopefully shrink those lymph nodes
Lydia Popichak: cause
Lydia Popichak: a lot of times lymphoma responds pretty quickly to steroids or chemo if it’s going to respond.
Lydia Popichak: the hope is that they are not intubated long, that we can give them treatment to kind of calm things down so they can get off. of that.
Professor Hare: [00:15:00] next in the list, let’s talk about tumor lysis syndrome. Can you tell me about that?
Lydia Popichak: tumor lysis syndrome is when either spontaneously or when you’re treating one of the cancers their cancer cells burst open. And when that happens, those cells will release all their contents. So they release potassium, they release phosphorus, they can skyrocket at LDH. And that can damage the kidneys because it’s releasing all these things that are bad for your body.
Lydia Popichak: we have to keep a close eye, especially if someone’s potassium goes up, that we watch their heart. And we’ll hydrate these people with fluids. uric acid also goes up.
Professor Hare: LDH is lactate dehydrogenase. And what do we normally use LDH for?
Lydia Popichak: we will monitor people’s LDH because that looks at cell turnover.
Lydia Popichak: if it’s 100 one day, and then the next day, it’s 3000. We’re going to see that those cells are breaking apart quicker than they should be. Sometimes with chemo, it can make them break open quicker. So their LDH can go up, which is good because it’s [00:16:00] showing that it’s working against the chemo, but then that can also be bad.
Lydia Popichak: Cause then with more cell turnover, you can damage your kidneys because everything’s being released. So we’ll watch those people very closely with frequent lab draws. and. If their uric acid goes up too high, we have rescue medications to help with that too.
Professor Hare: is that a balance then between the treatment that you’re giving and the tumor lysis that actually occurs during that time?
Lydia Popichak: We usually just keep the treatment up the chemo and then we treat the tumor lysis. So if we know that they’re a high risk to start, we’ll start at a higher rate of fluids. If we can, we always start allopurinol on the patients to prevent their uric acid from going up. And then we can start phos binders if their phos goes up or give them Rasburicase, which is a protective medication against uric acid.
Lydia Popichak: And then we can protect other things. Sometimes patients have to go on dialysis if they have
Professor Hare: question. Yeah.
Lydia Popichak: tumor lysis, I’ve seen that quite a bit.
Professor Hare: again, the whole body treatment really comes into play there where you’re keeping an eye on all these labs are keeping an eye [00:17:00] on the full patient spectrum.
Professor Hare: And there’s another service that you might need to consult during that time. that can be helpful, but I’m sure frustrating to have to think about those kinds of things and those moments for those patients, that’s kind of a step backwards in their progression of their treatment.
Professor Hare: some of the discussions that we have with leukemia and lymphoma, we assume especially with those two, that there is an associated morbidity and mortality with the conditions themselves. But we had talked about, there are some other big morbidity and mortality conditions that are associated with those
Professor Hare: and we talked about some of the, symptoms, and issues that might crop up already. Let’s talk about some of the big issues that, that start during that time that might be more concerning for you.
Professor Hare: Let’s start with Burkitt’s lymphoma is on the list. tell me a little bit about the morbidity and mortality of Burkitt’s lymphoma. I assume it to be pretty big actually, because I’ve seen that in some cases. Tell me about.
Lydia Popichak: So Burkitt’s is one of the most aggressive types of lymphoma.
Lydia Popichak: So [00:18:00] we grade lymphomas into three different major groups. So indolent, which are the chronic lymphomas
Lydia Popichak: the indolent lymphomas are ones that you can sometimes just monitor those patients. They don’t always have to be treated and they’re a condition that’s usually not going to go away. So they’re going to live with that. We have the intermediate lymphomas, which you have to treat like that middle range.
Lydia Popichak: So sometimes people can survive them. But then we have the really aggressive lymphomas, which Burkitt’s is one of them. It’s very aggressive, but it can be. Survivable, because since it is so aggressive, those cells respond pretty well to chemo because they’re growing so rapidly and chemo targets rapidly dividing cells.
Lydia Popichak: So if you have more cells dividing, hopefully that chemo will work better on. it.
Professor Hare: I see BL as a acronym I assume that BL is Burkitt’s lymphoma and that’s one of our more aggressive ones.
Professor Hare: Indolent is one of those words. It’s not a common usage word in the English language, but slow growing is the, the primary usage here. And then we have the intermediate [00:19:00] and then the, more aggressive versions.
Lydia Popichak: Burkitt’s is usually in younger people and sometimes it can be associated with HIV, I’ve seen that
Professor Hare: The aggressive cancers in younger patients like Ewing’s sarcoma, for instance, are, big focuses of treatments and diagnostics in oncology, moving on to number three. Richter’s transformation. Tell me about Richard’s transformation.
Lydia Popichak: that’s when CLL transforms into a more aggressive lymphoma, like a diffuse large B cell, for example it is a lot more aggressive and like that lady I mentioned earlier, their cells can grow very quickly.
Lydia Popichak: So whenever a CLL patient would come in and they’re not responding to treatment or their white cell rapidly increases, or their lymph nodes are rapidly increasing, we want to think of Richter’s. we usually rebiopsy those patients or we’ll do a repeat bone marrow biopsy to look for Richter’s because that would be in different type of treatment and a more aggressive treatment.
Professor Hare: the next one you have on the list, mantle cell lymphoma.
Lydia Popichak: mantle cells also can be very [00:20:00] aggressive. It’s kind of in its own class, but there’s a subset that you can monitor, mantle cell can also be very aggressive. And you want to figure out if it is the kind that you need to treat, because those can grow very rapidly and I’ve seen some of them just start out with spontaneous tumor lysis before you even give chemo.
Lydia Popichak: And I’ve seen people rupture their spleen with mantle cell cause their spleen can get so large that it just ruptures on its own or it ruptures with treatment
Professor Hare: as a result of the breakdown of those cells in other words. The mantle zone within an individual lymph node is just inside the outer layer the thinner, outer marginal zone of a lymph node, but not in the germinal center, not in the primary central area of the individual lymph nodes. So that’s where this one appears to originate.
Professor Hare: moving on to the last one the double triple hit lymphoma and my understanding of leukemias and lymphomas is that it is always in the background. this genetic testing looking for what genes are present. tell me [00:21:00] about the double and triple hit and how that applies to genetic testing and lymphomas.
Lydia Popichak: in general, whenever we do, a biopsy of a sample, whether it’s bone marrow, whether it’s just peripheral blood flow or it’s a. Lymph node or a tumor, and we send it off for genetic testing because there are certain genetic markers in any of the diseases that have a worst prognostic factor.
Lydia Popichak: with lymphomas, especially like diffuse large B-cell we want to see if they’re double or triple hit. So we’re looking for certain markers, such as. MYC, BCL 2 and BCL 6
Lydia Popichak: And if a patient has MYC with one of the other two markers, it’s a more aggressive lymphoma. So we have to treat it more aggressively.
Lydia Popichak: So we determine if they have, double or triple HIT, we have to step up and give them the more aggressive chemo Whereas someone who was just normal diffuse large B cell could maybe get an outpatient chemo regimen. Whereas the person with double triple. hit is going to be admitted and they would get prophylactic, lumbar punctures with intrathecal chemo.
Professor Hare: this is genetic testing [00:22:00] of the cells coming from the tumor from the lymph node in this case. And you’re seeing more than one
Professor Hare: mutation in that particular area,
Lydia Popichak: they look for translocations. of those areas. So if there’s a translocation at MYC or
Lydia Popichak: either BCL 2 and, or BCL 6 that increases the aggressiveness of the disease. So we have to treat it more. aggressively
Professor Hare: BCL two and six are two locations on the chromosomal makeup of that particular B-cell germinal center. MYC is MYC, I believe another translocation that we might see in the B-cell Again, a lot of specific locations in the chromosomes for these changes that are going on. going back then for a second, the symptomatology then is not what’s driving those decisions to get more aggressive with treatment. it’s the genetic translocations, the things that we’re seeing, even if their symptomatology they don’t seem to be that ill having that, genetic makeup of those B cells is far more concerning.
Professor Hare: And it’s going to prompt a much
Lydia Popichak: at least in this case. Yeah. If someone has double or triple hit [00:23:00] even if they look fine, act fine, feel fine. We’re going to treat them more aggressively.
Professor Hare: moving on to amyloidosis, tell us why amyloidosis is a concern with our patients in this space.
Lydia Popichak: we can have patients with Amyloidosis pretty rare and there’s different types of amyloidosis, but we often see it in the setting of. Either ALL amyloidosis or in setting of a patient with multiple myeloma. what happens with amyloidosis is they get amyloid protein deposits in different areas of their body and especially areas like their gut, their kidneys, or their heart.
Lydia Popichak: you want to find this one early, because once that protein gets deposited there, you can’t get rid of it. Treatment will help it, so it doesn’t get worse, but you can’t undo the damage that’s done. unfortunately, a lot of these patients are found at an advanced stage cause it is something that’s kind of hard to diagnose.
Lydia Popichak: And the workup is interesting. So for heart, you do a heart cardiac MRI. They do fat pad biopsies to look for it. They’ve done [00:24:00] kidney biopsies on patients. So a lot of it’s biopsy driven or they can do special stains on a bone marrow biopsy also to look for it.
Professor Hare: Are they looking at peripheral tissue at all and elsewhere in the body? Or looking for signs and symptoms of an amyloid plaque for these folks?
Professor Hare: if
Lydia Popichak: If there’s other areas.
Lydia Popichak: Like
Lydia Popichak: if they have myeloma or symptoms of something else going on, if they’re having GI symptoms, they could do a colonoscopy and biopsy the tissue there. I’ve had a patient that had it in his tongue and he presented with swallowing issues.
Lydia Popichak: he had a prolonged workup and it took him a long time, but eventually. they Did biopsy his tongue and he was found to have amyloidosis in his tongue and he needed to get a peg tube because he couldn’t swallow.
Professor Hare: It sounds like this is all kind of playing back into that picture of odd symptoms, fevers of unknown origin, things of that nature that, from family medicine perspective, it can be scary, right?
Professor Hare: These are must not misdiagnoses. If we allow these to go on too long in the community without sending them to your services then we risk that patient having a more advanced [00:25:00] case and more advanced staging as they move forward. tell me about the staging when it comes to these.
Professor Hare: We talk a lot about the Ann Arbor staging when it comes to lymphomas, especially can you tell me a little bit about that Ann Arbor staging and how that really plays into your decision-making with those patients?
Lydia Popichak: So Anarbor staging is the general staging that they use for most of the lymphomas, slightly different in non-Hodgkin’s versus Hodgkin’s lymphoma.
Lydia Popichak: Hodgkin’s lymphoma is what you think of when you think of lymphoma, that’s more treatable. So James Connor and Mario Lemieux are two people that have had Hodgkin’s lymphoma and it follows a more predictable pathway pathway. And that’s why it’s easier to treat because usually you can figure out where it’s going to go.
Lydia Popichak: non-Hodgkin’s lymphoma is an umbrella term
Lydia Popichak: many, many different types of lymphoma. So like diffuse large B cell follicular lymphoma, marginal zone lymphoma, mantle cell lymphoma. So it makes up a lot of things. It’s not as easy [00:26:00] to treat. And each different type has its own subset of treatments, but for staging.
Lydia Popichak: There is a slight difference between non-Hodgkin’s and Hodgkin’s. generally you want to look at wherever the involved areas of the lymphoma are to determine where it is on the staging and how many areas are involved. So if it’s one single site, one node or one organ site, it’s going to be a stage one.
Lydia Popichak: And in a Hodgkin’s lymphoma, that one spot can be the spleen. If they have two or more lymph nodes or two or more areas on the same side of the diaphragm, that would make it stage two
Professor Hare: and that’s above or below.
Lydia Popichak: Yes. So if it’s two spots above the diaphragm or two spots below the diaphragm, that stage two.
Lydia Popichak: And then if it’s stage three, if they have areas, on both sides of the diaphragm in Non-Hodgkin’s lymphoma. The spleen makes it stage three and then stage four is usually disseminated disease. So like widespread disease, over different areas. we also we’ll break it into stage a or B.
Lydia Popichak: So a is no systemic symptoms. And [00:27:00] B is presence of B symptoms. B symptoms are sometimes what people do present with. weight loss that was unintentional,
Lydia Popichak: night sweats, fatigue, our constitutional symptoms, weakness fevers again. some of the big presenting factors.
Lydia Popichak: So that plays a role in that B symptoms are worse in the staging Versus not having B symptoms.
Professor Hare: I’ve had patients who came to my family medicine service to the psych hospital. And when they came in they were depressed and having a lot of difficulty dealing with their diagnoses.
Professor Hare: one of the things that we would always look for in that scenario was the presence of those B symptoms and deciding, how advanced is this? are they miserable for one thing with their symptoms the symptomatology that fevers and things of that nature that we’re going to have to keep an eye on that in a different patient might be addressed differently those B symptoms are always something to watch for in, general medicine internal medicine and then there’s an X, right? We can have an ex associated with these.
Professor Hare: An ex is [00:28:00] bulky disease.
Professor Hare: So bulk of greater than 10 centimeters. Although a space occupying lesion in the mediastinum or anywhere really in the body that is close to a nerve close to major vessel, an artery a nervous system structure is going to be a major concern for that individual, regardless of the size of it more than its proximity to those areas in the body.
Professor Hare: Certainly the lymph nodes.
Professor Hare: have a lot of proximity to to some of those areas in the body to be concerned about. backing up just a little bit to the leukemia side of things, leukemias are coming from the bone marrow and your current position, you are doing more treatment of leukemia with bone marrow transplants.
Professor Hare: And so tell us how that process works from the beginning of that treatment through to when you are replacing bone marrow in those patients,
Lydia Popichak: so there’s different types of transplants. You can do an auto stem cell transplant, which is when you use your own cells versus an Allo stem cell transplant, which is when you use someone else’s. cells. And then within that type there’s [00:29:00] different types, so you can get a half match, you can get a full match, and then it depends on who matches with you.
Lydia Popichak: So a family member, or sometimes they do matched unrelated donors. And then the auto transplants are usually in the lymphoma and multiple myeloma patients. And that is a way for them to give really high doses of chemotherapy, which,
Lydia Popichak: cleans out your marrow from your disease, but then they rescue you by giving your stem cells back in the cases of leukemia or myelodysplastic syndrome.
Lydia Popichak: The issue is the bone marrow. So you can’t give yourself your cells. So what they do is use someone else’s cells. they give you that really high dose chemotherapy, but then they have to rescue by giving you someone else’s cells then you have to go through the process of your body, accepting those cells and you can get stuff like graft versus host disease
Lydia Popichak: Yeah. So it it’s the way of the graft rejecting your body because it seeing you as not itself.
Professor Hare: Foreign. Yeah, not self.. You mentioned the treatments involving chemotherapy often [00:30:00] clean out the bone marrow. So that’s destroying the capability of that bone marrow the native bone marrow from actually producing red blood cells and white blood cells in that scenario.
Professor Hare: that’s a pretty significant treatment Resetting of that ability in the body. When you do a bone marrow transplant? Where do you replace and transplant that to
Lydia Popichak: the areas you can get bone marrow transplants so they can use peripheral blood. So that’s like kind of like a blood transfusion The actual bone marrow donation or a cord donation.
Lydia Popichak: So the most commonly used one now is peripheral blood. when they give it to the patient, it’s through an I.V.. So it’s like a blood transfusion. And then the chemo is systemic, so it goes through the whole body. So then the transfusion will eventually go, hopefully go through the whole body.
Professor Hare: It doesn’t sound as if it’s quite as invasive as the biopsy itself, the initially occurs, which is going directly
Lydia Popichak: It just goes through a pheresis line.
Professor Hare: let’s move on to Possible referrals. you mentioned a couple of these and really a lot of this is intended to be family medicine, [00:31:00] right?
Professor Hare: So the PA education way of doing things is to talk about things from a family medicine perspective. And then you guys go out into the community as new PAs and work in specialty services. And that’s why I bring you back. Cause I know you’ve got the basis that’s for sure. And I know that, but I do, I am curious about things that you think family medicine needs to pay close attention to in the community for a potential referral let’s talk about some of those elements,
Lydia Popichak: a big thing that can catch a lot of the issues is getting the lab work. So when someone comes in for their yearly physical and you get the lab work, you might know that. some of these abnormalities. such as abnormalities in the CBC, or when you’re thinking of myeloma, you’re looking at their protein levels.
Lydia Popichak: So just your normal yearly checkup could show you some abnormalities if you get there.
Professor Hare: and typically looking at sending them along for a more specific as you mentioned, in the case of the proteins, looking at albumin and total protein. that may be indicating a more significant [00:32:00] plasma phoresis, where we’re looking at, what kind of proteins are present in the body.
Professor Hare: And if any of those are present at a level that would be concerning like our IgG and IgM and IGA is the screening lab in those scenarios, that preventative medicine side of things where we’re looking at basic lab, That give us a good bit of information, and it’s always good to keep some of those things in the back of your mind when you’re looking at those complete blood count for CBC or a complete metabolic panel for a CMP would give you more information about that patient and then might give you a reason to send them along That’s that aspect of family medicine that we’ve talked about in a previous episode with Tony Wilson, that there are, must not misdiagnoses everywhere when you start to look at those kinds of conditions at times. How about talking about new lymphadnopothy?
Professor Hare: So in other words, what kind of lymph nodes are we really concerned about in those patients on physical exam?
Lydia Popichak: you wanted. Routine physical, you can do a good physical exam on the patient. and You want to feel for lymph nodes. You want to feel along the front and the back of their [00:33:00] neck, around their clavicles, their armpit their groin in front and behind their ears.
Lydia Popichak: Or if they notice any lumps or bumps, obviously feel those cause that can lead to other diagnoses.
Professor Hare: what do those lymph nodes usually look like or act like when they present in that fashion?
Lydia Popichak: they’re, usually from their non-mobile, they’re not going to be moving around a lot,
Lydia Popichak: and they’re usually Not tender,
Professor Hare: not tender. So in other words, no pain from it, but enlargement and fixated with a very firm lymph node would be one of our big concerns there. And then leukocytosis. Another one of those big lab findings on CBC. So what do those usually look like on the labwork.
Lydia Popichak: So if they have a high, white count or low white count, so leukopenia could be a sign that something is going on. A lot of times in a leukemia, they’re going to have a high white count because you have all those bad white blood cells in their body. And that will show because there’s cells in the peripheral that are getting out of the bone marrow, or if they have really bad disease in their marrow, they could have a low white count, meaning you’re [00:34:00] not even getting a chance to make those white blood cells because there’s so many bad cells in the marrow.
Professor Hare: And then pancytopenia is something you have listed here. Pancytopenia being all cell lines red cell white cells are being decreased in the periphery. And so what’s that usually a sign of,
Lydia Popichak: so that can be a sign of leukemia
Lydia Popichak: those leukemia cells are packed in the marrow so much. that Your body isn’t able to make those cells like in the leukopenia situation, but you’re not making red blood cells or platelets either.
Professor Hare: we also have listed FUO the fever of unknown origin, and that goes along with that relapsing and remitting fever And with, or without a specific cause. How often do you see full sepsis in those patients? Full on sepsis,
Lydia Popichak: Oh, we see septic patients all the time.
Lydia Popichak: So no matter if we think it’s a fever of unknown origin or not, we always work up a full infectious workups. So we do blood cultures, urine cultures, chest x-ray or anything else that we need. If they have sinus pain, we’ll do a CT of their maxillofacial. If they have cellulitis, we’ll do a scan of their legs.
Lydia Popichak: So we’ll do a full workup of any [00:35:00] symptomatic areas or just our routine things to look for infection. Cause we don’t ever want to miss an infection. Or more invasive testing. Sometimes people need bronchoscopies or biopsies of different areas, but you never want to miss an infection. So you have to prove it, not an actual infection before you can call it a fever of unknown origin.
Professor Hare: I find that interesting again, back to the family medicine side of things and the generalist perspective fevers caused by something. Again, you have to look back at the trend. Is there something else going on here with this patient? Is there a consistent fever presenting in this patient or are they just having multiple infections in the community and you know, either one could be possible, but again, those are going to raise a red flag for a lot of practitioners to move along to the next level.
Professor Hare: And then the last one on that list is the crab criteria. I always have to remind myself what the crab criteria are. So crab is hypercalcemia the next one is renal function and the a is anemia and the B
Professor Hare: the B is [00:36:00] bone symptoms. Okay. So a bone Lytec lesions and changes in the bone and presumably possibly a pathologic fracture so the calcium levels are generally speaking increased. So that’s more calcium being released into the bloodstream from the bones in that scenario.
Lydia Popichak: Crab criteria it goes with multiple myeloma. So these are the big things you want to look out for. If you suspect someone has multiple myeloma. the kidney stems from the myeloma proteins are very bulky, they can clog up the renal tubules.
Lydia Popichak: And they can cause a lot of kidney damage because they’re so big. So some patients present in full renal failure and some have needed dialysis before you’ve even fully diagnosed them because their myeloma was so bad that it destroyed their kidneys. Sometimes it’s reversible, sometimes it’s not.
Professor Hare: those are very big proteins. those immune proteins that are being dumped into the system are really clogging up the works in the kidneys at the very least The anemia side of multiple myeloma.
Lydia Popichak: the issue with multiple myeloma is the [00:37:00] plasma cells.
Lydia Popichak: So the immunoglobulins, IgG, M, and A are the big ones and then the light chain disease. So Lambda and Kappa. those can also replace your bone marrow. So if you have really bad myeloma, you’re not making the proper cells that you should be, or it could be a sign of renal failure also because when you have renal failure, you don’t make EPO, which causes anemia.
Lydia Popichak: So it can be two-sided in some of the cases,
Professor Hare: Multifactorial and the causes for that particular anemia. And then lytic lesions would presumably be a later presenting issue,
Lydia Popichak: not necessarily.
Lydia Popichak: When you think of high calcium, you think of the stones, bones, abdominal moans, and psychotic groans. sometimes these people will present With altered mental status and you check their labs and their calcium is 14, which is over the normal limit. So this lady had a high calcium, she was confused.
Lydia Popichak: She came in with bilateral broken knees. She had a creatinine of four and she had a hemoglobin of seven when she came in.
Professor Hare: Wow.
Lydia Popichak: So she had [00:38:00] all four of the crab criteria is, and she was in the hospital for a very long time because she needed two surgeries. We had to give her chemo and that’s a lot to figure out when you’re trying to reverse all of those different areas and help all of those different areas all at the same time,
Lydia Popichak: just working on one area helps the other.
Lydia Popichak: So if you fix the calcium, you might help the kidneys, hopefully
Professor Hare: Two broken knees, So let me just kind of back up to that, just a second, where those femoral fractures
Lydia Popichak: one was femur and one was tibial.
Professor Hare: Wow. in pathologic, fractures are things that really cause us a lot of concern in medicine in general orthopedic, certainly, but family medicine, when someone has a fracture that really doesn’t have a cause that is significant, you know, falling from one’s feet and someone who doesn’t have significant osteoporosis, for instance, shouldn’t cause a major fracture.
Professor Hare: So these fractures are occurring stepping off of a curb or with normal muscular contractions at times when those occur then backing up to things like multiple myeloma as a potential causative for that weak area in the [00:39:00] bone, and this causes focal lesions in the bone that allow those fractures to occur in those spots.
Professor Hare: what kind of. Imaging do we do to look for those kinds of lytic lesions in the bone?
Lydia Popichak: So if you’re just generally looking like, say their arms hurt, you would scan that area. But if you’re concerned for myeloma, you want to do a skeletal survey. So that looks at all the long bones in the body and also their skull to look for lytic lesions.
Professor Hare: I do recall skull being one of those areas that has that light potential, and that can cause some changes in the shape of the skull, as well as I recall, . Can we talk for a second about the ID consults that go along with being on your services. Tell me, so what kind of infections might you find that really pull in the ID folks and make you want to get a more, specialized look at their infections.
Lydia Popichak: a lot of our patients have ID consults most of them so oftentimes if, even if they just have a neutropenic fever, we’ll get them onboard, but you’re not usually taught to look for zebras in school, but we do see zebras.
Lydia Popichak: there are expected [00:40:00] ones that we can find, but we also get some less common things than other people, because in the general population, people aren’t usually as immunocompromised. So these people are susceptible to a lot of different things like,
Lydia Popichak: I’ve seen Mac infections
Professor Hare: Can you define Mac for us?
Lydia Popichak: So that’s mycobacterium avium complex, which can cause severe lung disease. I’ve also seen PJP pneumonia, which is pneumocystis, jurovechi which can be very rare. We get people with weird fungal infections and mucore, which can invade into your sinuses and your brain.
Lydia Popichak: Seeing necrotizing fasciitis that has eaten away at a wound or a bed sore. And unfortunately these people can get that from very minor things outside.
Professor Hare: So the same way that HIV may be presents with some characteristic infections. We can see some of those, some characteristic infections that go along with this..
Professor Hare: So as you said, the MAC and the new pneumocystis jurovecii versus the pneumocystis carinii , which is one of the characteristic [00:41:00] infections of HIV patients. Is that a concern for you in that setting? Is an HIV test, a part of your screening and discussion in those moments? Or is that a differential for you?
Lydia Popichak: Usually on everyone, we send an HIV and hepatitis panel, to make sure that’s not also concurrently happening or especially if they’re going to get something called ritoxin, which is a monoclonal antibody, it can reactivate viral infections. it usually as part of our workup, when we’re diagnosing someone, we send those off.
Professor Hare: I’m guessing that the differential diagnosis list for your service is as broad as it could possibly be because you’re covering so many different things. And we talked about all the things that you think might be possible so far there, are there common differentials that pop up in your patients?
Lydia Popichak: Well, just in diagnosing, just from the very beginning, it could just be an infection. So mono
Lydia Popichak: Or EBV, but that can reactivate causing lymphoma down the road or just strep throat. So some people just have swollen lymph nodes because they have a sickness, a viral illness which can cause that
Professor Hare: I did notice that [00:42:00] EBV is listed a lot in the reference material about the differential, the early differentials and some of the causatives actually have some of these conditions in hem-onc.
Professor Hare: So I would assume that EBV testing is pretty early for you. Epstein-Barr virus and mononucleosis.
Lydia Popichak: Not usually. They can send EBV off the tissue if they biopsy it. But if someone comes into the ER, they can do a rapid mono test. But if they see other imaging they’re most likely going to send them for more
Professor Hare: so you’re, you’re seeing EBV, you’re not seeing EBV as a primary condition. You’re seeing it as, as a next step. For most of those folks, they’re getting it diagnosed elsewhere. And then you’re seeing those make their way to you. As in orthopedic surgery, we would often know the diagnosis before the patient walked in the door because family medicine or an emergency room had already seen them.
Professor Hare: When we knew that this was a fracture of a certain bone or a very lax joint caused by a traumatic or non-traumatic injury. And so we knew what was coming when it walked in the door for the most part. So it sounds like you have often gotten [00:43:00] past the point where EBV is really on your significant list of differentials there
Lydia Popichak: for a lot of times, it’s what kind of cancer. Is this.
Professor Hare: Well I appreciate you coming back and and hanging out and talking about this. Again, it’s nice to be able to ask you the questions instead of you sitting across the desk from me and asking me all the questions like you did when you were in PA school. But it is fun to have you back.
Professor Hare: of course, I really appreciate your time today. Thanks for coming in.
Lydia Popichak: Thanks for having me
Professor Hare: so many thanks to our esteemed guest, Lydia Popichak. That’s it for now, be sure to check out the podcast website at www.beexcitedhq.com for more episodes, show notes and full transcripts of every show. Email us at [email protected] with questions, comments, or future show suggestions. And of course, follow us on Facebook and Instagram at be excited podcast for news new episode notifications and maybe a picture or two. Thanks for listening and Remain Excited!
