General Management

Management of Intrathoracic Lesions

Always maintain patient in an inclined or sitting position and avoid use of general anesthesia. Diagnostic procedures should include:

• Chest radiograph to evaluate:

Size of the mass

Degree of airway compression

Presence of significant amounts of pleural and/or pericardial effusions

• Echocardiogram for evaluation of pericardial effusion and cardiac function

• Biopsy of a clinically involved peripheral lymph node under local anesthesia or from the cytology of pleural effusion aspirate when present.

If the disease is present exclusively in the anterior mediastinum, a biopsy (under local anesthesia) through a small suprasternal incision should be performed or, if possible, obtain a core-needle biopsy.

It is possible that all of the preceding procedures may be prohibitive because of the patient's poor clinical condition. Under this circumstance, the patient should be treated with corticosteroids with or without a limited radiation field until the mass is sufficiently small to permit safe biopsy under general anesthesia. Corticosteroid and/or local radiotherapy can bring about rapid resolution of SVC obstruction.

Management of Pericardial Effusion

Pericardial effusion can cause life-threatening cardiac tamponade. A pericardial rub, S-T segment elevation on EKG, a globular-shaped heart on a chest radiograph, and cardiac ultrasonography establish the diagnosis. When signs of cardiac tamponade (pulsus paradoxus, elevated venous pressure or hypotension) are present, pericar-diocentesis should be performed. The cytology of the fluid should be examined. Prompt treatment with chemotherapy is necessary to prevent reaccumulation of fluid.

Management of Gastrointestinal Complications

Abdominal disease is more commonly observed in patients with BL or BLL. The following complications are of immediate significance:

• Small bowel obstruction: NHL of the gastrointestinal (GI) tract commonly involves the terminal ileum and the cecum. The tumor can cause bowel obstruction, either by compression of the bowel lumen, or by intussusception. In about 25% of the patients, the tumor can be resected completely. Chemotherapy should begin within a few days of surgery.

• Gastric bleeding or perforation: Endoscopic examination should be performed to identify patients at high risk of massive bleeding and/or perforation by noting extent of involvement of the stomach wall and the degree of ulceration and necrosis. High-risk patients should be treated with resection of the tumor

(involving total or partial gastrectomy depending on the extent of the tumor) before starting chemotherapy.

Management of Tumor Lysis Syndrome

Management of tumor lysis syndrome and its metabolic complications is detailed in Chapter 26.

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