Hematological malignancy

Hematological malignancies are the types of cancer that affect blood, bone marrow, and lymph nodes. As the three are intimately connected through the immune system, a disease affecting one of the three will often affect the others as well: although lymphoma is technically a disease of the lymph nodes, it often spreads to the bone marrow, affecting the blood and occasionally producing a paraprotein.
While uncommon in solid tumors, chromosomal translocations are a common cause of these diseases. This commonly leads to a different approach in diagnosis and treatment of hematological malignancies.
Hematological malignancies are malignant neoplasms ("cancer"), and they are generally treated by specialists in hematology and/or oncology. In some centers "Hematology/oncology" is a single subspecialty of internal medicine while in others they are considered separate divisions (there are also surgical and radiation oncologists). Not all hematological disorders are malignant ("cancerous"); these other blood conditions may also be managed by a hematologist.
Hematological malignancies may derive from either of the two major blood cell lineages: myeloid and lymphoid cell lines. The myeloid cell line normally produces granulocytes, erythrocytes, thrombocytes, macrophages and mast cells; the lymphoid cell line produces B, T, NK and plasma cells. Lymphomas, lymphocytic leukemias, and myeloma are from the lymphoid line, while acute and chronic myelogenous leukemia, myelodysplastic syndromes and myeloproliferative diseases are myeloid in origin.

Classification and incidence

Taken together, hematological malignancies account for 9.5% of new cancer diagnoses in the United States. Within this category, lymphomas are more common than leukemias.
Historically, hematological malignancies have been most commonly divided by whether the malignancy is mainly located in the blood (leukemia) or in lymph nodes (lymphomas).
However, the influential WHO Classification (published in 2001) emphasized a greater emphasis on cell lineage.

Classic classification

Relative proportions of hematological malignancies in the United States:

Type of hematological malignancy	Percentage	Total
Leukemias	—	30.4%
Acute lymphoblastic leukemia (ALL)	4.0%
Acute myelogenous leukemia (AML)	8.7%
Chronic lymphocytic leukemia (CLL) sorted under lymphomas according to current WHO classification; called small lymphocytic lymphoma (SLL) when leukemic cells are absent.	10.2%
Chronic myelogenous leukemia (CML)	3.7%
Acute monocytic leukemia (AMOL)	0.7%
Other leukemias	3.1%
Lymphomas	—	55.6%
Hodgkin's lymphomas (all four subtypes)	7.0%
Non-Hodgkin's lymphomas (all subtypes)	48.6%
Myelomas		14.0%
Total		100%

Diagnosis

For the analysis of a suspected hematological malignancy, a complete blood count and blood film are essential, as malignant cells can show in characteristic ways on light microscopy. When there is lymphadenopathy, a biopsy from a lymph node is generally undertaken surgically. In general, a bone marrow biopsy is part of the "work up" for the analysis of these diseases. All specimens are examined microscopically to determine the nature of the malignancy. A number of these diseases can now be classified by cytogenetics (AML, CML) or immunophenotyping (lymphoma, myeloma, CLL) of the malignant cells.

Treatment

Treatment can occasionally consist of "watchful waiting" (e.g. in CLL) or symptomatic treatment (e.g. blood transfusions in MDS). The more aggressive forms of disease require treatment with chemotherapy, radiotherapy, immunotherapy and - in some cases - a bone marrow transplant. The use of rituximab has been established for the treatment of B-cell–derived hematologic malignancies, including follicular lymphoma (FL) and diffuse large B-cell lymphoma (DLBCL).

Follow-up

If treatment has been successful ("complete" or "partial remission"), a patient is generally followed up at regular intervals to detect recurrence and monitor for "secondary malignancy" (an uncommon side-effect of some chemotherapy and radiotherapy regimens - the appearance of another form of cancer). In the follow-up, which should be done at pre-determined regular intervals, general anamnesis is combined with complete blood count and determination of lactate dehydrogenase or thymidine kinase in serum.

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Posted in: Health

Laparoscopic procedure can help to treat infertility

Amin Milki

BY MICHELLE L. BRANDT
A study from medical school researchers demonstrates that a minimally invasive procedure to diagnose and treat a common gynecologic disorder may be a useful way for women to combat infertility problems.
During the study, which appeared in the December issue of the Journal of Fertility and Sterility, 22 of 29 women who had previously undergone unsuccessful in vitro fertilization were able to conceive following laparoscopic treatment of endometriosis.
"If you fail IVF, it's not the end of the story," said Amin Milki, MD, professor of obstetrics and gynecology and a co-author, explaining the significance of the study's findings. "You might have a chance to conceive if you treat your endometriosis."
endometriosis is a condition in which endometrium tissue, normally found lining the uterus, spreads to other areas within a woman's pelvic cavity and abdomen, usually the fallopian tubes, ovaries and intestines. The condition is known to interfere with fertility; as many as 25 to 50 percent of infertile women have endometriosis.
In many cases, treating a woman's endometriosis can pave the way for a pregnancy. The researchers note in their paper that other studies have shown a 20 to 65 percent pregnancy rate following laparoscopic treatment. Milki noted that most pregnancies occur within the first six months after surgery.
Although checking for endometriosis was once the standard for women with fertility problems, it is increasingly common for these women to undergo hormonal treatments, artificial insemination and even IVF without being evaluated—or treated—for endometriosis. Among the reasons that these steps are skipped: The diagnosis and treatment of endometriosis require surgery, and some women and physicians worry about the risks of undergoing a surgical procedure.
The average patient's age is also a factor, according to Milki. Some older women are hesitant about doing the procedure and taking a wait-and-see approach, especially considering IVF yields more immediate results.
"More than one-third of our patients are over 40," said Milki, who directs Stanford's IVF clinic. "Although we suspect some women might have endometriosis and could benefit from laparoscopy, we don't have much time to wait. These patients want an immediate answer."
If initial IVF treatments fail, patients and their partners tend to choose additional IVF treatment, egg donation or even adoption over endometriosis treatment. "It is not unusual for patients and health-care providers to perceive IVF as the final treatment for infertility," the authors noted in their paper.
The researchers launched this study to further evaluate the benefit of laparoscopy—a procedure in which specialized tools with cameras attached are inserted through small holes in the body—for women with unexplained infertility. The retrospective study looked at patients in their mid-30s who had failed IVF treatment and were offered laparoscopic evaluation and management as an alternative to additional IVF treatments, egg donation or adoption.
Twenty-nine women underwent the laparoscopy, while 35 chose not to. Camran Nezhat, MD, an adjunct clinical faculty member of surgery and obstetrics and gynecology who was a pioneer in the field of laparoscopic surgery, performed each procedure.
Nezhat and the team found that all 29 laparoscopy patients had endometriosis. After the treatment, more than three-fourths of the women (22) conceived; seven of these pregnancies came after subsequent IVF treatments. Thirty-seven percent—13 of 35—of women in the non-laparoscopy group conceived, and 11 of the pregnancies came after IVF.
"The study shows there is hope for these couples, even when they've experienced failed IVF," said Nezhat.
Milki said the fact that Nezhat performed each procedure could be the reason the pregnancy rate in this study is higher than the rates in past studies. "We believe the remarkably high pregnancy rate achieved in the patients who underwent laparoscopic evaluation is a reflection of the thorough surgical technique," the researchers said in the paper.
Do the encouraging results mean every woman should get a laparoscopy before undergoing IVF? "Not necessarily," said Milki. "But even being biased by the success of IVF and the promptness to which it can lead to pregnancy, I can see the wisdom of doing a laparoscopy."
The researchers say a multicenter, randomized clinical trial is now needed to further evaluate the procedure.
Other study authors include Stanford's Eva Littman, MD, and Ruth Lathi, MD; Linda Guidice, MD, now at UCSF, and Bulent Berker, MD, now at Ankara University in Turkey.

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Posted in: Endometriosis,Health,Laparoscopy

For women caution for Endometriosis

Symptoms

The most common symptom of endometriosis is pelvic pain. The pain often correlates to the menstrual cycle, however a woman with endometriosis may also experience pain at other times during her monthly cycle.

For many women, but not everyone, the pain of endometriosis can unfortunately be so severe and debilitating that it impacts on her life so that she may not be able to carry out day to day activities.

Pain may be felt:

·  before/during/after menstruation

·  during ovulation

·  in the bowel during menstruation

·  when passing urine

·  during or after sexual intercourse

·  in the lower back region

Other symptoms may include:

·    diarrhoea or constipation (in particular in connection with menstruation)

·    abdominal bloating (in particular in connection with menstruation)

·    heavy or irregular bleeding

·    fatigue

The other well known symptom associated with endometriosis is infertility. It is estimated that 30-40% of women with endometriosis are subfertile.

Endometriosis from Endometriosis.org on Vimeo.

Causes

There are different hypotheses as to what causes endometriosis. Unfortunately, none of these theories have ever been entirely proven, nor do they fully explain all the mechanisms associated with the development of the disease.

Thus, the cause of endometriosis remains unknown.

Most scientists working in the field of endometriosis do agree, however, that endometriosis is exacerbated by oestrogen. Subsequently, most of the current treatments for endometriosis attempt to temper oestrogen production in a woman’s body in order to relieve her of symptoms.

At the moment there are no treatments, which fully cure endometriosis.

Several theories have become more accepted, and reality is that it may be a combination of factors, which make some women develop endometriosis.

Metaplasia

Metaplasia means to change from one normal type of tissue to another normal type of tissue. It has been proposed by some that endometrial tissue has the ability in some cases to replace other types of tissues outside the uterus.

Some researchers believe this happens in the embryo, when the uterus is first forming. Others believe that some adult cells retain the ability they had in the embryonic stage to transform into reproductive tissue.

Retrograde menstruation 

This theory was promoted by Dr John Sampson in the 1920s. He surmised that menstrual tissue flows backwards through the fallopian tubes (called “retrograde flow”) and deposits on the pelvic organs where it seeds and grows.

However, there is little evidence that endometrial cells can actually attach to women’s pelvic organs and grow. Years later, researchers found that 90% of women have retrograde flow. But since most women don’t develop endometriosis, some doctors have concluded that something else (perhaps an immune system problem or hormonal dysfunction) may be the trigger for endometriosis.

The Retrograde Menstruation Theory also doesn’t explain how endometriosis develops in women who’ve had a hysterectomy or a tubal ligation nor why, in rare cases, men have developed endometriosis when they’ve been treated with oestrogen after prostate surgery.

Genetic disposition

It has been demonstrated that first-degree relatives of women with this disease are more likely to develop endometriosis. And when there is a hereditary link, the disease tends to be worse in the next generation.

There are ongoing worldwide studies investigating the blood samples from sisters with endometriosis in hopes of isolating an endometriosis gene.

This is what we know so far about genetics:

·    Significant evidence of one or more susceptibility loci for endometriosis with near-Mendelian inheritance on chromosome 7p13-15

·    Researchers identify one gene’s critical role in the human embryo implantation process

·    First report of linkage to a major locus for endometriosis

·    Genome-wide association study identifies variations in the DNA of women that predispose them to developing endometriosis

Lymphatic or vascular distribution

Endometrial fragments may travel through blood vessels or the lymphatic system to other parts of the body. This may explain how endometriosis ends up in distant sites, such as the lung, brain, skin, or eye.

Immune system dysfunction

Some women with endometriosis appear to display certain immunologic defects or dysfunctions. Whether this is a cause or effect of the disease remains unknown.

Environmental influences

Some studies have pointed to environmental factors as contributors to the development of endometriosis, specifically related to the way toxins in the environment have an effect on the reproductive hormones and immune system response, though this theory has not been proven and remains controversial.

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Posted in: Endometriosis,Health,Laparoscopy