Lymphoma

Question 1

HODGKINS LYMPHOMA OVERVIEW
i) what % of lymphomas does it account for? what is it caused by? what is the age distribution?
ii) name four risk factors
iii) what is the key presenting symptom? what is the characteristic? what may symptoms also be associated with?
iv) what type of symptoms are systemic symptoms of lymphoma? (3)
v) name four other symptoms

Answer 1

i) accounts for 20% all lymphoma
proliferation of lymphocytes
bimodal age distribution (peaks at 20 and 75 yrs)
ii) RF = HIV, EBV, AI conds eg RA, family history
iii) key symptom is lymphadenopathy (neck, axilla, inguinal)
enalarged nodes are non tender and feel rubbery
alcohol may cause pain in LNs
iv) B symptoms - fever, WL, NS
v) fatigue, itching, cough, SOB, abdo pain, recurrent infections

Question 2

INVESTIGATIONS FOR HL
i) what blood marker is often raised? what is they key diagnostic test?
ii) what is the key finding on investigation? what are they?
iii) what three imaging techniques may be used?
iv) what staging system is used? what does it focus on?

Answer 2

i) lactate dehydrogenase is often raised but is non specific
key dx test is LN biopsy
ii) reed-sternberg cell on LN biopsy = abnormally large B cells that have multiple nuclei and nucleoli inside (looks like an owl)
iii) CT, MRI, PET
iv) ann arbor staging - focus on whether the affected nodes are above or below the diaphraghm
stage 1 - confised to one region of LNs
stage 2 - >1 region but same side of dia
stage 3 - LNs above and below dia
stage 4 - involvement of non lymphatic organs eg lungs or liver

Question 3

MANAGEMENT OF HL
i) what are the two key treatments? name a risk of each?
ii) what tx can be given in early stage HL? name three late effects of this
iii) what is ABVD chemo? when is a prolonged course of this given?

Answer 3

i) chemo - increase risk of leuk and infertility
RT - risk of secondary cancer and damage to tissues/hypothyroidism
ii) early stage HD > RT alone (70% OS)
late effects = inc risk of MI, inc risk of solid tumour, post splenectomy sepsis
usually also give a short course of chemo (ABVD)
iii) ABVD = dox, bleomycin, vinblastine, darcarbazine
given a longer coirse in advanced disease

Question 4

NON HODGKINS LYMPHOMA
i) name three types
ii) name two main RFs? name three infections that can cause it
iii) how can patients be differentiated from HL? what staging system is used?
iv) what is the most common subtype?

Answer 4

i) burkitt (assoc EBVm malaria, HIV), MALT (affects mucosa assoc lymphoid tissue in stomach - h pylori). diffuse large B cell (DLBCL - rapid growing seen over 65yrs)
ii) main RFs are immunodeficiency and infections (h pylori, EBV, HTLV-1)
iii) can only be differentiated from HL with LN biopsy
ann arbor staging
iv) follicular NHL is most common

Question 5

MX OF LOW GRADE NHL
i) what treatment is given for localised disease? what other approach may be taken?
ii) when should treatment be started? (4)
iii) what MAB can be used? how does it work?
iv) what combination chemo can be used?

Answer 5

i) RT
may also watch and wait - no OS advatage over RT and W&W
ii) start tx if systemic symptoms, painful nodes, clear PD or organ compromise
iii) rituximab > human murine MAB directed at CD20
cell med toxicity and induction of apoptosis
iv) R-CVP (ritux, cyclo, vinc)

Question 6

HIGH GRADE NHL MX - DLBCL
i) what special tests should be done? (2)
ii) what does the international prognostic index for DLBCL encompass?
iii) what can be given for localised stage I/II disease?
iv) what is given for stage III/IV

Answer 6

i) BM aspirate and trephine
lumbar puncture if high risk sites
ii) ann arbor stage, age, performance status, serum LDH, extra nodal sites
iii) short course of chemo (CHOP/R-CHOP) + RT
iv) longer combination chemo

Question 7

SUMMARY
i) what type of NHL is slow growing, incurable, sensitive to chemo.RT, medial survival 10-15yrs?
ii) what type of NHL is fast growing, curable, sensitive to chemo/RT?
iii) which type experience pain in LNs when drinking ETOH?
iv) which type do B symptoms occur earlier?
v) in which type is extra nodal disease more common

Answer 7

i) follicular
ii) diffuse large B cell
iii) HL
iv) HL
v) NHL

Question 8

COMPLICATIONS AND PROGNOSIS
i) name four complications
ii) does low or high grade have a better prognosis? which has a higher cure rate?

Answer 8

i) BM infiltration (anaemia, neutropenia), SVC obstruction, mets, sp cord compression
ii) low grade has a better prognosis but high grade has a better cure rate