Lymphoma

Mediastinal mass before anything else - Patients with mediastinal involvement usually have an abnormal chest X-ray, so get the chest film and staging CT chest and look at tracheal caliber and the great vessels yourself. Cough, chest discomfort, dyspnea, stridor or facial edema in a new lymphoma is a mass until imaging says otherwise, and that changes whether you induce at all.

SVC syndrome - Facial and neck edema from SVC compression means the upper body is a poor place to run volume and vasoactives. Site lower-extremity access, and expect airway edema to make laryngoscopy and extubation harder than the Mallampati suggested.

Neck and upper airway disease - Thyroid lymphoma presents with a rapidly enlarging goiter causing dyspnea and stridor from tracheal compression, dysphagia from esophageal compression, and hoarseness from recurrent laryngeal nerve involvement. NHL involves Waldeyer's ring. Ask about hoarseness, positional dyspnea and swallowing, look in the mouth, and have a video laryngoscope and a smaller tube in the room.

Anthracycline cardiomyopathy - Doxorubicin sits in both R-CHOP and ABVD. Ask for the regimen, the cumulative dose and the most recent LVEF before you commit to a plan that leans on preload or a big fluid shift.

Radiation heart disease - Mantle radiotherapy causes pericarditis, valvular disease and coronary artery disease, and produces diffuse myocardial and pericardial fibrosis plus fibrosis of the conduction system, often with a preserved ejection fraction. A normal EF does not rule out a stiff, rate-dependent heart, so look at the ECG for conduction disease and at the echo report for valves and pericardium.

Bleomycin and radiation lung - Both cause pulmonary toxicity. Ask about exertional dyspnea and a bleomycin-containing regimen (ABVD), and run the lowest FiO2 that holds an acceptable saturation rather than defaulting to high oxygen.

Myelosuppression - Get a current CBC. Myelosuppression is managed with red cell and platelet transfusion or colony-stimulating factors, so know the platelet count before a neuraxial or a deep block and the hemoglobin before a case that bleeds.

Neutropenia and infection - Neutropenia raises the risk of bacterial, viral and fungal infection, and these patients are susceptible to varicella and herpes zoster. Treat every line, block and airway manipulation as a sterile procedure and keep the febrile neutropenic patient off an elective list.

Tumor lysis - Burkitt lymphoma can present with tumor lysis syndrome, and it has been reported to declare itself on emergence from general anesthesia. New arrhythmias or oliguria after a case in an untreated high-bulk lymphoma is lysis until the chemistries say otherwise.

Vincristine neuropathy - Vincristine causes neurotoxicity. Document the sensory and motor exam before any regional technique so a pre-existing deficit is not attributed to your block.

Spinal cord compression - Epidural cord compression occurs in aggressive NHL. Ask about back pain, weakness and bowel or bladder change, and record a level before neuraxial anesthesia or prone positioning.

Ascites and effusions - Abdominal NHL can present with massive ascites, and effusions occur across subtypes. Both cut FRC and raise aspiration risk, so plan the induction accordingly.

Renal and hepatic involvement - The kidney is the abdominal organ most often involved by NHL, and renal involvement can raise creatinine and cause hypercalcemia from tumor vitamin D overproduction; hepatic involvement raises alkaline phosphatase. Check a metabolic panel and dose renally and hepatically cleared drugs to the numbers you see.

Lymphoma is a malignant clonal proliferation of lymphoid tissue, split into Hodgkin lymphoma (HL), defined by Hodgkin and Reed-Sternberg cells on a background of non-neoplastic inflammatory cells, and non-Hodgkin lymphoma (NHL), which arises from B or T cell precursors or mature B or T cells. Most NHL patients present with advanced-stage disease, and marrow involvement is common in several subtypes.

Two mechanisms drive the perioperative problem. First, bulk: nodal masses compress whatever is next to them. Mediastinal disease produces cough, chest discomfort and superior vena cava (SVC) syndrome; thyroid lymphoma compresses trachea, esophagus and recurrent laryngeal nerve; NHL can cause epidural spinal cord compression. Second, treatment: anthracyclines cause cardiomyopathy, mantle radiotherapy causes pericardial, valvular and coronary disease, bleomycin and radiation injure lung, and every regimen myelosuppresses and immunosuppresses.