How To Approach LYMPHADENOPATHY In Adults

Dr Joshua Richmond MBBS (Hons), FRACGP, FRACP. FRCPA
Clinical Haematologist

Lymphadenopathy is a common presentation in general practice and understanding the red flag symptoms and signs can improve treatment outcomes. The patients’s clinical history and examination can be very helpful in identifying patients who need urgent assessment. The following symptoms and signs  give guidance on when to refer patients with lymphadenopathy

  1.  Unexplained night sweats, fevers and weight loss
  2.  Persistent palpable enlarged lymph nodes >1.5cm (greater than 6 weeks)
  3.  Rapid growth in a lymph node site
  4.  Unexplained cytopenias and/or elevated LDH in association with lymphadenopathy
  5. Generalised lymphadenopathy
  6. Splenomegaly

The initial workup of these patients should include the following initial tests

  1. Excision biopsy of the lymph node for histology, flow cytometry and cytogenetics is the preferred diagnostic test. In some cases, the ability to access tissue is limited by the location of the nodes. With these cases, core biopsy via radiology guidance is appropriate. I would not suggest fine needle aspiration due to it’s poor specificity in lymphoma diagnosis workup
  2. PET/CT is the preferred staging radiology investigation as it has enhanced sensitivity in lymphoma staging and allows better assessment of extranodal involvement. CT scans of the neck,chest abdomen and pelvis are also appropriate in some low grade lymphoma patients
  3. FBC, ELFTS including LDH, serum EPP, Beta-2 microglobulin and  serum immunoglobulins

If the patient has a past history of malignancy, then collaboration with the treating haematologist or oncologist can also help streamline the patient’s assessment.

Capsule endoscopy in the diagnosis of small intestinal pathology

Mark W A Norrie BHB, MBChB, FRACP, PhD

Capsule with Sensor array

Since its introduction in 2000, capsule endoscopy has allowed us to investigate and diagnose pathology in the small intestine, a previously arcane area of the gastrointestinal tract.

Presently it is funded by Medicare to investigate overt GI bleeding or occult bleeding with iron deficiency anaemia where a source has not been disclosed after gastroscopy and colonoscopy or for the surveillance of PeutzJeghers syndrome.

The procedure requires the patient to fast overnight and then swallow a capsule equipped with a light source and camera that tumbles through the small intestine and transmits two images per second to a recording device worn by the patient over an 8 hour time period. There is no anaesthetic involved, nor does the patient need to remain within the facility during this time thus ensuring minimal disruption. . The capsule is excreted normally with defaecation

The only significant risk with this procedure is capsule retention that occurs in about 1% of cases that may require surgical or endoscopic removal. This rate is higher (up to 8%) in patients with Crohns disease. In patients with a swallowing disorder, the capsule may need to be placed with a gastroscopy

Capsule endoscopy has a sensitivity of 47% and 66.6% respectively for the detection of pathology in occult bleeding or iron deficiency anaemia. Where pathology is detected, the patient may then need to be referred for enteroscopy to obtain a tissue diagnosis or for interventional procedures.

The most commonly diagnosed conditions include small bowel tumours in 5-7% cases as well as Crohns disease, NSAID injury and angioectasia.

Capsule endoscopy is available at Montserrat Day hospitals at our Indooroopilly facility and can be performed after the patient has had an antecedent gastroscopy and colonoscopy and following a brief consultation
Small bowel tumour that presented with severe iron deficiency anaemia in a 27 year old male

The Battle against ovarian Cancer

Great effort to the Montserrat Cancer Care Team: The Full Montyserrat
The Battle is the signature event for the Cherish Women’s Cancer Foundation which helps to fund research into more effective, less invasive and gentler treatment options for gynaecological cancer sufferers.

A special thanks to the following Montserrat staff for showing of some skills on the sand and the amazing team spirit and support.
Montserrat IT manager- James Bowman, Business Development Manager- Ken Hilliard, Dr Hong Shue -Oncologist, CFO-Shane Kosanic,SCHOC Nurse Manger Kim McCullough and SCHOC Manger- Gayle Dowsett

The event raised over $100,000 for the research team at QLD Centre for Gynaecological Cancer Research

ENDOCUFF VISION

Rebecca Ryan BMBS (Hons) FRACP

Endocuff Techonology now being offered to patietns at all Montserrat Facilites across Queensland

One of the major indications for colonoscopy is for Polyp follow up or for a Family history of Colorectal carcinoma/colonic polyps.

Performance of a high quality colonoscopy examination requires careful visualisation of the colonic mucosa which requires

1/ Adequate Bowel Preparation

“Split bowel preps” refers to the administration of half of the bowel prep the evening prior to the colonoscopy and the second half the morning of the colonoscopy, allowing for adequate fasting .

Since the introduction of split bowel preps at Montserrat in (insert date here) our rate of incomplete colonoscopies due to poor/incomplete bowel preparation has (insert data).

2/ Quality Measures

Quality indicators such as

  • Acceptable caecal intubation rate,
  • At least 95% to the caecum or terminal ileum in patients with intact colons.
  • Withdrawal times
  • Should be 6 minutes  (not including biopsy or polyp removal time)
  • Adenoma detection rates (ADR)
  • The finding of at least one adenoma  during colonoscopy
  • At least 25% in eligible patients.

“Eligible patients” are 50 years or older, have intact colons, do not have a finding of acute IBD and were intubated to the caecum or terminal ileum.

serve as surrogate, though imperfect markers of careful mucosal visualisation. These targets have been set by GESA (Gastroenterological Society of Australia for re-certification of colonoscopists in Australia) as of April 2016.

At Montserrat we routinely record all our procedures, a selection of which are routinely audited by a independent senior experienced colonoscopist. We also document our caecal intubation rate, withdrawal time and ADR, for all our gastroenterologists to ensure we are meeting the above targets. These are viewed and discussed quarterly at our quality assurance meetings.

Despite implementation of these measures, we know we miss adenomas.

6 studies of 465 patients who underwent tandem colonoscopy showed

The overall missed adenoma rate was 22%and proportional to size  (Ref 1)

  • 1 to 5 mm: 26 percent miss rate
  • 5 to 10 mm: 13 percent miss rate
  • ≥10 mm: 2 percent miss rate

Higher ADR has been demonstrated in multiple studies to decrease the rates of interval cancers (ie, cancer that developed between the time of the screening colonoscopy and the time scheduled for follow-up colonoscopy)

In a study of 45,026 patients who underwent screening colonoscopy, interval colorectal cancer (ie, cancer that developed between the time of the screening colonoscopy and the time scheduled for follow-up colonoscopy) was detected in 42 patients. (Ref 2)

The endoscopists’ adenoma detection rates were associated with the risk of developing an interval colorectal cancer. The rates of interval colorectal cancer were

  • 34 per 100,000 person-years for endoscopists with an ADR <11%,
  • 22 per 100,000 person-years for endoscopists with an ADR 11 – 14.9 %
  • 26 per 100,000 person-years for endoscopists with an ADR of 15 -19.9 %,
  • 2 per 100,000 person-years for endoscopists with an ADR ≥20 percent.

In another study, each 1% increase in the ADR was associated with a 3% decrease in the risk of colorectal cancer. Ref 3

How can we increase the Adenoma Detetion Rate (ADR)?

ENDOCUFF VISION ®

Put in pretty picture and link to online brochure

Endocuff Vision ®  is a ‘cap’ designed to fit securely around the tip of the colonsocope and is comprised of soft projection s (arms) which remain flattened during insertion in the bowel. When the colonoscope is withdrawn the soft arms project out to spread the folds of the colon. This allows for improved visibility of the bowel wall and more opportunity to find hidden or harder to see polyps.

In observational studies to date ENDOCUFF VISION ®  has been shown to

Increase ADR

Increase mean number of Adenomas per procedure

Relative decrease in the mean time to caecal intubation Ref 3

Montserrat will be, as of (insert date), routinely using ENDOCUFF VISION ® in ALL patients that are

  • over the age of 50
  • Have a personal or family history or polyps or CRC.

Don’t know if you ant to put in the that we are absorbing the cost etc.)

Ref 1

Polyp miss rate determined by tandem colonoscopy: a systematic review. van Rijn JC, Reitsma JB, Stoker J, Bossuyt PM, van Deventer SJ, Dekker E, Am J Gastroenterol. 2006;101(2):343.

Ref 2

Quality indicators for colonoscopy and the risk of interval cancer. Kaminski MF, Regula J, Kraszewska E, Polkowski M, Wojciechowska U, Didkowska J, Zwierko M, Rupinski M, Nowacki MP, Butruk E, N Engl J Med. 2010;362(19):1795.

Ref 3

Tsiamouulos Z, et al. gastrointestinal Endoscopy 2015; 81 (5s): AB209 Abstract Sa 1423

Bowel Cancer Statistics

Colorectal cancer incorporates ICD-10 cancer codes C18 (Malignant neoplasm of colon), C19 (Malignant neoplasm of rectosigmoid junction) and C20 (Malignant neoplasm of the rectum).

Estimated number of new cases of colorectal cancer diagnosed in 2017

16,682 =  9,127 males +  7,555 females

 

Estimated % of all new cancer cases diagnosed in 2017

12.4% 

 

Estimated number of deaths from colorectal cancer in 2017

4,114 =  2,136 males +  1,978 females

 

Estimated % of all deaths from cancer in 2017

8.6% 

 

Chance of surviving at least 5 years (2009–2013)

69%

 

 

People living with colorectal cancer at the end of 2012 (diagnosed in the 5 year period 2008 to 2012)

52,630

 

New cases of colorectal cancer

Colorectal cancer was the third most commonly diagnosed cancer in Australia in 2013. It is estimated that it will become the second most commonly diagnosed cancer in 2017 (Table 1). This is because the incidence of prostate cancer (which was the most commonly diagnosed cancer in 2013) is expected to continue to decline.

In 2013, there were 14,962 new cases of colorectal cancer diagnosed in Australia (8,214 males and 6,748 females). In 2017, it is estimated that 16,682 new cases of colorectal cancer will be diagnosed in Australia (9,127 males and 7,555 females).

In 2013, the age–standardised incidence rate was 58 cases per 100,000 persons (68 for males and 49 for females). In 2017, it is estimated that the age–standardised incidence rate will remain at 58 cases per 100,000 persons (67 for males and 49 for females). The incidence rate of colorectal cancer is expected to generally increase with age for both males and females (Figure 1).

In 2017, it is estimated that the risk of an individual being diagnosed with colorectal cancer by their 85th birthday will be 1 in 13 (1 in 11 males and 1 in 15 females).

The number of new cases of colorectal cancer diagnosed increased from 6,986 (3,524 males and 3,462 females) in 1982 to 14,962 in 2013. Over the same period, the age–standardised incidence rate increased steadily from 58 cases per 100,000 persons (67 for males and 52 for females) in 1982 to a peak of 66 cases per 100,000 (81 for males and 55 for females) in 2000 and 2001 before decreasing to 58 cases per 100,000 in 2013 (Figure 2).

 

Table 1: Estimated most common cancers diagnosed in 2017
Cancer type New cases 2017 % of all new cancers 2017
Breast 17,730 13.2
Breast (among females) 17,586 28.4
Colorectal (bowel) 16,682 12.4
Prostate (among males) 16,665 23.1
Melanoma 13,941 10.4
Lung 12,434 9.3

Deaths from colorectal cancer

In 2014, colorectal cancer was the second leading cause of cancer deaths in Australia. It is estimated that it will remain the second most common cause of death from cancer in 2017 (Table 2).

In 2014, there were 4,071 deaths from colorectal cancer in Australia (2,236 males and 1,835 females). In 2017, it is estimated that this will increase to 4,114 deaths (2,136 males and 1,978 females).

In 2014, the age–standardised mortality rate was 15 deaths per 100,000 persons (18 for males and 12 for females). In 2017, it is estimated that the age–standardised mortality rate will be 14 deaths per 100,000 persons (16 for males and 12 for females). The mortality rate of colorectal cancer will generally increase with age (Figure 1).

In 2017, it is estimated that the risk of an individual dying from colorectal cancer by their 85th birthday will be 1 in 54 (1 in 47 males and 1 in 63 females).

The number of deaths from colorectal cancer increased from 2,500 (1,218 males and 1,282 females) in 1968 to 4,071 in 2014. Over the same period, the age–standardised mortality rate decreased from 31 deaths per 100,000 persons (36 for males and 28 for females) in 1968 to 15 deaths per 100,000 in 2014 (Figure 2).

 

Table 2: Estimated most common cancers deaths in 2017
Cancer type Number of deaths 2017 % of all cancer deaths 2017
Lung 9,021 18.9
Colorectal (bowel) 4,114 8.6
Prostate (among males) 3,452 12.7
Breast 3,114 6.5
Breast (among females) 3,087 14.9
Pancreatic 2,915 6.1

Figure 1: Estimated age-specific incidence and mortality rates for colorectal cancer, by sex, 2017

Figure 2: Age-standardised incidence rates for colorectal cancer 1982–2013 and age-standardised mortality rates for colorectal cancer 1968–2014, by sex

Survival from colorectal cancer

In 2009–2013, individuals diagnosed with colorectal cancer had a 69% chance (68% for males and 69% for females) of surviving for 5 years compared to their counterparts in the general Australian population.

Between 1984–1988 and 2009–2013, 5-year relative survival from colorectal cancer improved from 50% to 69%.

Figure 3: 5-year relative survival from bowel cancer, 1984–1988 to 2009–2013

Survivorship population for colorectal cancer

The survivorship population is measured using prevalence data. Prevalence refers to the number of people alive who have previously been diagnosed with colorectal cancer.

The prevalence for 1, 5 and 31 years given below are the number of people living with colorectal cancer at the end of 2012 who had been diagnosed in the preceding 1, 5 and 31 years respectively.

At the end of 2012, there were 13,078 people living who had been diagnosed with colorectal cancer that year, 52,630 people who had been diagnosed with colorectal cancer in the previous 5 years (from 2008 to 2012) and 129,497 people who had been diagnosed with colorectal cancer in the previous 31 years (from 1982 to 2012).

Data notes

International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD–10)

Cancer is classified by the International Statistical Classification of Diseases and Related Health Problems Version 10 (ICD–10). This is a statistical classification, published by the World Health Organization, in which each morbid condition is assigned a unique code according to established criteria.

Estimations

Future estimations for incidence and mortality are a mathematical extrapolation of past trends. They assume that the most recent trends will continue into the future, and are intended to illustrate future changes that might reasonably be expected to occur if the stated assumptions continue to apply over the estimated period. Actual future cancer incidence and mortality rates may vary from these estimations. For instance, new screening programs may increase the detection of new cancer cases; new vaccination programs may decrease the risk of developing cancer; and improvements in treatment options may decrease mortality rates.

Incidence

Cancer incidence indicates the number of new cancers diagnosed during a specified time period (usually one year).

The 2013 national incidence counts include estimates for NSW because the actual data were not available. Note that actual data for the Australian Capital Territory do not include cases identified from death certificates.

The 2017 estimates are based on 2004–13 incidence data. Due to rounding of these estimates, male and female incidence may not sum to person incidence.

Mortality

Cancer mortality refers to the number of deaths occurring during a specified time period (usually one year) for which the underlying cause of death is cancer.

The 2017 estimates are based on mortality data up to 2013. Joinpoint analysis was used on the longest time series of age–standardised rates available to determine the starting year of the most recent trend.

Prevalence

Prevalence of cancer refers to the number of people alive with a prior diagnosis of cancer at a given time. It is distinct from incidence, which is the number of new cancers diagnosed within a given period of time. The longest period for which it is possible to calculate prevalence using the available national data (from 1982 to 2012) is currently 31 years so this is used to provide an estimate of the ‘total’ prevalence of cancer as at the end of 2012, noting that people diagnosed with cancer before 1982 aren’t included.

Age standardised rates

Incidence and mortality rates expressed per 100,000 population are age–standardised to the Australian population as at 30 June 2001.

References

  1. Australian Institute of Health and Welfare 2017. Australian Cancer Incidence and Mortality (ACIM) books: Colorectal cancer. Canberra: AIHW. www.aihw.gov.au/acim-books.
  2. AIHW 2017. Cancer in Australia 2017. Cancer series no. 101. Cat. No. CAN 100. Canberra: AIHW.

Alarming Rise In Bowel Cancer Fuels Calls For Renewed Testing

The forecast adds urgency to calls for the federal government to restart the stalled national screening program.

Australia’s peak cancer organisation said new calculations also showed nearly 20 per cent of bowel cancers were already at stage four when diagnosed — the most advanced grade, when the disease has spread and often proves fatal.

Ian Olver, chief executive of the Cancer Council Australia, said the new figures “show the extent of the problem”. “It’s one of our high-incidence cancers. Because that incidence is continuing to increase it seems prudent to prevent that from happening by introducing a screening program,” Professor Olver said. “This would only be the third population screening program introduced, behind breast and cervical cancer, and the first that involved men.”

The Howard government launched a national bowel cancer screening program in 2006, but it was mired in controversy from the start.

After immediate criticisms of underfunding, the program was suspended for six months in 2009 after it was found nearly half a million people had been sent faulty test kits, supplied by a Japanese company, that were prone to returning false negative results after hot weather.

The program was restarted in January last year, but created an immediate capacity problem as thousands of people who had previously tested negative, then tested positive, requiring immediate follow-up to find out if cancer was present.

The program has now stopped after its funding came to an end in December. Cancer experts have long criticised the scheme as inadequate, despite new evidence showing that a proper rollout could save up to 500 lives every year for an overall annual outlay of about $50 million. The program initially offered one-off screening to people as they turned 55 or 65, sending them a kit allowing them to take a stool sample and send it away for analysis. Those whose samples were found to contain minute flecks of blood were referred for further testing, usually involving a colonoscopy.

In 2008, the Rudd government extended the program to include people turning 50, but experts say this remains well short of the recommended model that invites every Australian over 50 to be screened every two years. Professor Olver called on the federal government to resume funding the program, and to “announce a plan over the next three years for a full implementation” for biennial screening for the over-50s.

Graeme Young, co-director of the Flinders University Centre for Cancer Prevention and Control, wrote in the online newsletter MJA InSight yesterday that a full program would cut deaths by 15 to 25 per cent.