Clinical Management of Lymphomas

Question 1

What is a lymphoma

Answer 1

Malignant growth of white blood cells in the lymph nodes

Question 2

Where else can lymphomas be found

Answer 2

Liver
Spleen
Blood
Marrow

Question 3

Causes of lymphomas

Answer 3

1. Primary immunodeficiency
2. Secondary Immunodeficiency (HIV)
3. Infection (Heliicobacter pylori, EBV)
4. Autoimmunity

Question 4

How does EBV cause lymphoma

Answer 4

Immunosurveillance of EBV infected cells is impaired

Infected B cells escape regulation + proliferate autonomously

Question 5

How is a lymphoma diagnosed

Answer 5

Blood film and bone marrow

Lymph Node biopsy (to confirm)

Immunoophenotyping

Cytogenetics (karyotype analysis - FISH)

PCR

Question 6

What is HODS

Answer 6

Haemato Oncology DIagnostic Service

Question 7

How do we build up a case for lymphomas

Answer 7

1. Staging (how bad)
2. Assessment of patients (How good is the patient)
3. MDT (Have we got our facts right)

Question 8

What investigations involve staging

Answer 8

1. Blood tests
2. CT Scan Chest/abdo/pelvis
3. Bone Marrow Biopsy
4. PET

Question 9

How is a patient assessed for lymphomas

Answer 9

History + Examination 
Bloods (FBC, /Es/Viral serology)
CXR
ECHO
PFTs
Performance status

Question 10

What is the WHO performance status

Answer 10

0 - Asymptomatic
1 - Symptomatic but completely ambulatory
2 - Symptomatic (<50% in bed during the day)
3 - Symptomatic - more than 50% in bed but not bed bound
4 - Bedbound
5 - Death

Question 11

How does a CXR help with lymphoma diagnosis

Answer 11

Mediastinal widening

Question 12

What gender does Hodgkin’s lymphoma effect

Answer 12

Males

Question 13

Two sub-categories of Hodgkin’s lymphoma

Answer 13

1. Classical Hodgkin’s lymphoma (Reed-sternberg cells present)
2. Nodular lymphocyte predominant HL (Popcorn cell present)

Question 14

Clinical feature of Hodgkin’s lymphoma

Answer 14

1. Painless cervical lymphadenopathy (rubbery sensation)

Coughs due to mediastinal lymphadenopathy

Sweats, weight loss

Pancpcytopenia if effecting bone marrow

Raised lactose dehydrogenase = worse prognosis as increased cell turnover

Question 15

How is Hodgkin’s lymphoma treated

Answer 15

1. Close surveillance
2. Moderate chemotherapy (ABVD)
3. Irradiation

Question 16

How many stages of Hodgkin’s lymphoma are there

Answer 16

4 
1 - Neck
2 - Neck and mediastinum
3- Neck, axilla, spine
4 - Neck, axilla, spine, pelvis

Question 17

How is stage 1-2A Hodgkin’s treated

Answer 17

Chemotherapy followed by radiotherapy

Question 18

How is stage 2B-4 Hodgkin’s treated

Answer 18

Combination chemotherapy

Question 19

What drugs are used in chemotherapy

Answer 19

1. Adriamycin
2. Bleomycin
3. Vinblastine
4. Dacarbazine

Question 20

What is the future of Hodgkin’s treatment

Answer 20

PET scanning to identify (and reduce amount of treatment given)

Question 21

How would a PET scan be implemented in treatment

Answer 21

1. PET scan -> ABVD - > PET SCAN

If PET (+ve) - Escalated BEACON

If PET (-ve) Randomise ABVD v AVD

Question 22

Late effects of hodgkin’s lymphoma ABVD treatment

Answer 22

1. Infertility
2. Cardiomyopathy (from anthracyclines)
3. Lung Damage (Bleomycin)
4. Vinca alkaloid - peripheral neuropathy
5. Second Cancers

Question 23

Name a low grade NHL

Answer 23

Follicular

Question 24

Name a high grade NHL

Answer 24

Large B cell lymphoma

Question 25

Name a very high grade NHL

Answer 25

Burkitt’s Lymphoma

Question 26

How fast do low grade NHLs grow

Answer 26

Slow

Question 27

Are Low grade NHL curable

Answer 27

No

Question 28

What is the median survival rate of low grade NHL

Answer 28

9-11 years

Question 29

How do we treat Indolent NHL

Answer 29

Nothing
Alkylating Agents
Combination Chemotherapy 
Purine analogues
Monoclonal Antibodies
Oral targeted agents
Bone Marrow transplants

Question 30

Where are high grade NHLs presented

Answer 30

Nodes

Question 31

How often is extra nodal involvement in high grade NHL

Answer 31

1/3 of cases

Question 32

How is High grade NHl treated

Answer 32

Early:
Short course chemotherapy + RT (R-CHOP + IFRT)

Advanced:
Combo chemotherapy + monoclonal antibodies (R-CHOP)

Question 33

What monoclonal antibody do we give patents

Answer 33

Rituximab

Question 34

What does Rituximab target

Answer 34

CD20 expressed on B-cells

Question 35

What compound is given during radio-immunotherapy

Answer 35

Zevalin (Yttrium)

Question 36

What is T-cell engaging therapy

Answer 36

Bi-specific antibodies

Target CD19 on B cells
CD3 on T cells

Directs immune system

Question 37

Name a compound used in T cell engaging therapy

Answer 37

Blinatumomab

Question 38

What does A/B mean in staging

Answer 38

A - No systemic symptoms other than pruritus

B - Systemic symptoms: Feber, weight loss and night sweats

Question 39

Ann arbour classification of staging

Answer 39

I - confined to single lymph node
II - Involvement of two or more lymph nodes on the same side of diaphragm
III - Involvement of nodes on both sides
IV - spreads beyond lymph nodes (bone marrow)

Question 40

Side effects of CHEMOTHERAPY

Answer 40

Myelosuppresion
Nausea
Alopecia
Infection
Infertility

Question 41

Complications of radiotherapy

Answer 41

Increased risk of secondary malignancies in lung,breast, stomach

Increased tosk of IHD, hypothyroidism and lung fibrosis

Question 42

Stage I vs Stage 2 hodgkins

Answer 42

1 is less than 3 areas involved

2 is more than 3 areas involved

Question 43

Extranodal clinical presentations

Answer 43

Skin

Gut, bowel, bone, cns and lung

Question 44

Why is biopsy done

Answer 44

To determine whether it is hodgkins or non-hodgkin’s