Question

12. What is disseminated intravascular coagulation (DIC)? Briefly describe the cause, typical signs, symptoms and what the potential adverse outcomes might be if this condition cannot be treated 13. What is a reason that non-Hodgkin's lymphomas are often more difficult to harder to treat than Hodgkin's lymphomas? Give an idea as to how you might overcome this issue and include how you might effectively apply the difference in using PET imaging versus Gallium- scintigraphy as well as staging concepts in diagnosis and treatment of these types of lymphomas based on the publication by Friedberg and Chengazi (2003) that is included for further reading on Blackboard

Answer 1

Disseminated intravascular coagulation (DIC) is a serious disorder in which the proteins that control blood clotting become overactive.

Causes

When you are injured, proteins in the blood that form blood clots travel to the injury site to help stop bleeding. If these proteins become abnormally active throughout the body, you could develop DIC. The underlying cause is usually due to inflammation, infection, or cancer.

In some cases of DIC, small blood clots form in the blood vessels. Some of these clots can clog the vessels and cut off the normal blood supply to organs such as the liver, brain, or kidneys. Lack of blood flow can damage and cause major injury to the organs.

In other cases of DIC, the clotting proteins in your blood are consumed. When this happens, you may have a high risk of serious bleeding, even from a minor injury or without injury. You may also have bleeding that starts spontaneously (on its own). The disease can also cause your healthy red blood cells to fragment and break up when they travel through the small vessels that are filled with clots.

Risk factors for DIC include:

• Blood transfusion reaction
• Cancer, especially certain types of leukemia
• Inflammation of the pancreas (pancreatitis)
• Infection in the blood, especially by bacteria or fungus
• Liver disease
• Pregnancy complications (such as placenta that is left behind after delivery)
• Recent surgery or anesthesia
• Severe tissue injury (as in burns and head injury)
• Large hemangioma (a blood vessel that is not formed properly)

• Sign and symptoms of disseminated intravascular coagulation (DIC) depend on its cause and whether the condition is acute or chronic.

  Acute DIC develops quickly (over hours or days) and is very serious. Chronic DIC develops more slowly (over weeks or months). It lasts longer and usually isn't recognized as quickly as acute DIC.

  With acute DIC, blood clotting in the blood vessels usually occurs first, followed by bleeding. However, bleeding may be the first obvious sign. Serious bleeding can occur very quickly after developing acute DIC. Thus, emergency treatment in a hospital is needed.

  Blood clotting also occurs with chronic DIC, but it usually doesn't lead to bleeding. Sometimes chronic DIC has no signs or symptoms.

  Signs and Symptoms of Excessive Blood Clotting

  In DIC, blood clots form throughout the body's small blood vessels. These blood clots can reduce or block blood flow through the blood vessels. This can cause the following signs and symptoms:

• Chest pain and shortness of breath if blood clots form in the blood vessels in your lungs and heart.
• Pain, redness, warmth, and swelling in the lower leg if blood clots form in the deep veins of your leg.
• Headaches, speech changes, paralysis (an inability to move), dizziness, and trouble speaking and understanding if blood clots form in the blood vessels in your brain. These signs and symptoms may indicate a stroke.
• Heart attack and lung and kidney problems if blood clots lodge in your heart, lungs, or kidneys. These organs may even begin to fail.

• Signs and Symptoms of Bleeding

  In DIC, the increased clotting activity uses up the platelets and clotting factors in the blood. As a result, serious bleeding can occur. DIC can cause internal and external bleeding

• DIC may present as acute, subacute or chronic disease. ... Acute DIC may develop primarily (e.g. caused by sepsis), or secondary to decompensation of chronic DIC. Acute DIC is often fatal with multiorgan failure and circulatory collapse.p erson can die if it is not treated on time.

• 2- The aggressive non-Hodgkin's lymphomas (NHL) are a clinically heterogeneous group of lymphomas with disparate responses to standard chemotherapy regimens. Aggressive NHL includes diffuse large B-cell lymphoma (DLBCL), mantle cell lymphoma (MCL) and peripheral T-cell lymphomas (PTCL), among others. Significant advances have been made in the last decade in the initial treatment of DLBCL and MCL, but the treatment of relapsed or refractory disease remains difficult. The addition of rituximab to the treatment of DLBCL and MCL has improved clinical outcomes and is now a critical component of initial therapy and treatment of relapsed disease. The PTCLs, not having a similar agent to significantly change the treatment approach to these diseases, remain a difficult therapeutic problem. Hodgkin's lymphoma is treatable, especially in its early stages. The one-year survival rate for all patients diagnosed with Hodgkin's lymphoma is about 92 percent. The five-year survival rate is about 86 percent. For people with stage 4 Hodgkin's lymphoma, the survival rate is lower.

• BY Friedberg and chengazi-

  Accurate staging of Hodgkin lymphoma (HD) allows for minimization of therapy and reduction of long-term toxicities. The present study prospectively compares FDG-PET with gallium/SPECT scintigraphy at time of diagnosis and in follow-up of 36 patients with HD. Prior to therapy, whole body FDG-PET and gallium/SPECT were performed. Follow-up scans were obtained after 3 cycles of chemotherapy (n = 22), and at the end of chemotherapy (n = 32). Two nuclear medicine physicians independently interpreted scans in blinded and random order and a consensus was obtained. Baseline scans revealed a greater number of supradiaphragmatic disease sites detected by PET, and 5 patients had splenic involvement on PET not noted by gallium (P = 0.05); 3 patients were upstaged on PET. Midway through therapy, 5 patients had positive PET (4 of whom relapsed), and 3 had positive gallium (1 relapsed). At conclusion of chemotherapy, 8 patients had a positive PET (4 relapsed) and 3 had a positive gallium (2 relapsed). In conclusion, diagnostic PET and gallium are largely concordant, with the exception of unique detection of splenic disease by PET. However, more patients have persistently positive PET at the end of chemotherapy compared with gallium (P = 0.04), although only half of these patients have relapsed

  Comparison of gallium and PET scans at diagnosis

  BACKGROUND: Positron emission tomography (PET) and gallium scans facilitate diagnosis and staging, evaluation of response to therapy, and monitoring for relapse in Hodgkin lymphoma (HL), but have not been compared in pediatric HL.

  PROCEDURE: We performed concurrent PET and gallium scans on 44 pediatric HL patients at diagnosis, early response, off chemotherapy, and off-therapy evaluations. PET and gallium scans were compared to each other and to computed tomography (CT) alone to determine whether either modality led to a change in stage or modified the results of the early response evaluation, which was used to determine the radiation dose.

  RESULTS: PET upstaged four patients at diagnosis (2 from stage I to II, one II to III, and one III to IV), but did not lead to a change in therapy in any of them. It changed response category in two patients at early response evaluation, leading to a change in radiation dose for 1 patient (25.5 Gy instead of 15 Gy to the spleen). Gallium did not change the stage of treatment for any patient. The negative predictive values for eventual lymphoma relapse of PET and gallium scans at off therapy were 89% and 83%, respectively; the positive predictive value of PET at off therapy is 29%.

  CONCLUSION: PET appears to be superior to gallium in pediatric HL; future studies will determine the optimal timing of PET to assess early response and the utility of quantitative interpretation of the avidity of specific nodal sites.

• Diagnosis

• Physical exam. Your doctor checks for swollen lymph nodes, including in your neck, underarm and groin, as well as a swollen spleen or liver.
• Removing a lymph node for testing. Your doctor may recommend a lymph node biopsy procedure to remove all or part of a lymph node for laboratory testing. Advanced tests can determine if lymphoma cells are present and what types of cells are involved.
• Blood tests. Blood tests to count the number of cells in a sample of your blood can give your doctor clues about your diagnosis.
• Removing a sample of bone marrow for testing. A bone marrow aspiration and biopsy procedure involves inserting a needle into your hipbone to remove a sample of bone marrow. The sample is analyzed to look for lymphoma cells.
• Imaging tests. Your doctor may recommend imaging tests to look for signs of lymphoma in other areas of your body. Tests may include CT, MRI and positron emission tomography (

• Tests and procedures used to diagnose lymphoma include: