Intro:
-true oncological emergency❗️
-up to 6% of cancer patients
-annual incidence of hospitalizations secondary to MSCC among patients with advanced cancer ~3.5%
-multiple myeloma and non-Hodgkin lymphoma with highest cancer-specific incidence
-prognosis poor
2/11
Definition of MSCC:
-any radiologic evidence of indentation of the thecal sac or spinal cord compression, whether or not there are neurologic signs and symptoms associated with compression
-grading using the "epidural spinal cord compression (ESCC) scale" (Bilsky scale)
3/11
Pathophysiology:
-mostly due to metastases to vertebral bodies
👉erode into spinal canal & encroach on spinal cord
-paravertebral tumors can extend through neural foramina 👉cord compression
-intramedullary & meningeal rare
-Most locations: thoracic>lumbar>cervical spine
4/11
Clinic:
-back pain
-paralysis, sensory loss, bladder and bowel dysfunction can evolve rapidly
-Cauda equina syndrome👉compression in lumbosacral spine
-20% do not have a known cancer diagnosis at the time the MSCC is diagnosed❗️
-know your dermatomes❗️
5/11
Diagnosis:
-method of choice is MRI
-if possible, important to image ENTIRE spine because up to 40% have multiple levels of compression or cord impingement
-CT, with or without myelography, if MRI is contraindicated or not available
-assess ESCC and instability
6/11
Treatment:
-initiate without delay
-assess motor function before
-consider high-dose dexamethasone for severe deficits in whom small potential gain may outweigh the risks
-almost all patients should be evaluated urgently for a decompressive surgical procedure
8/11
Radiation:
-most patients, whether or not get decompressive surgery
-conventional external beam radiation therapy (cEBRT)
👉~70% pain improvement, 50% without instability with resolution
👉variety of schedules: single (8 Gy), protracted (30-40 Gy in 10-20 fractions)
9/11
Stereotactic body radiotherapy (SBRT):
-cEBRT limited by proximity of spinal cord
-SBRT with precisely targeted high dose to tumor (even separated by 2 to 3 millimeters from spinal cord)
BUT
-less useful for relatively radioresistant tumors
10/11
Summary for MSCC:
❗️Emergency
❗️Myeloma & non-Hodgkin lymphoma
❗️Thoracic>lumbar>cervical
❗️Pain, sensory & motor dysfunction, in ~40% first sign even before cancer diagnosis
❗️scales: ESCC & instability score
❗️MRI
❗️Treat immediately: dexamethasone, surgery +/- radiation
Rule 1: Lead by example
As a mentor, your actions speak louder than words. Demonstrate the ethics, dedication, and passion you wish to instill in your mentees.
Practice what you preach🙏
Rule 2: Listen actively
Effective mentoring starts with listening. Understand your mentee's needs, fears, and aspirations. This builds trust and opens up more honest communication.
Short intro to sickle cell disease (SCD):
-group of inherited red blood cell disorders
-affects ~ 1 in 500 African American and 1 in 36,000 Hispanic American children
-results in anemia
-main clinical feature is acute painful crisis
👉 often requires hospitalization
2/15
Acute pain:
-one of the most common types of vaso-occlusive events in SCD
BUT
-not all patients are in true crisis
BUT
-pain shouldnt be allowed to progress to crisis
AND
-most patients grow with pain, so ask them how severe it is❗️
-do not to delay analgesia
3/15
Intro:
-rare but underestimated bleeding disorder
-lab and clinic similar to inherited form
-usually occurs more frequently in adults with no history of bleeding
-renewed interest
👉association with 🫀disorders (eg aortic stenosis), cancer, autoimmune disease...
2/14
History I - (inherited) VWS:
-1924
-5-year-old girl from 🇫🇮 brought to hospital in Helsinki, seen by physician Erik Adolf von Willebrand
-assessed 66 members of her family
-reported in a 1926 a previously undescribed bleeding disorder, called "Hereditary pseudohemophilia"
3/14
😱Gastrointestinal (GI) manifestations in hematology😱
A short visual 🧵with diagnosis
1/19
Intro:
-lympho-/myeloproliferative disorders
-nodal and/or extranodal
-GI tract one of the most common extranodal sites
-diagnosis of GI hematologic malignancy challenging
👉esp in absence of documented nodal/extranodal disease
👉due to higher incidence of other pathologies
2/19
Importance of imaging:
-although tissue biopsy is often required to reach the definitive diagnosis, imaging plays a crucial role in raising suspicion of underlying hematologic malignancy
-imaging also guides biopsies, staging, and evaluating response to treatment
3/19
History part I:
-1928, Maurice Richter reported generalized swelling of lymph nodes, liver + spleen in a patient with chronic lymphocytic leukemia (CLL)
-due to infiltration by rapidly growing cells
👉termed it generalized reticular cell sarcoma
-patient died after 22 days
2/20
History part II:
-1964, Lortholary described case series of 14 patients with CLL developing malignant reticulopath
👉occurrence of diffuse large B cell lymphoma (DLBCL)
👉named it Richter's transformation (RT)
-DLBCL most common
-also Hodgkin lymphoma, T cell lymphoma
3/20
When I started med school, I subscribed to the New England Journal of Medicine. Apart from published trials, case records are the world's treasure for education & help navigate clinical courses & differentials better than any class.
A visual 🧵of selected cases #MedTwitter #MedX
50-year-old man with back pain, fatigue, weight loss, and knee swelling
Final diagnosis: Ankylosing spondylitis
-affects 0.5% of population
-strongly associated with HLA-B27 allele
-90% of patients with ankylosing spondylitis are positive for HLA-B27 nejm.org/doi/full/10.10…
60-year-old man with bone pain and skeletal lesions on imaging
Final diagnosis: epithelioid hemangioendothelioma
-affects <300 patients per year in US, ~1% of all vascular neoplasms nejm.org/doi/full/10.10…