Lymphoma Flashcards
What is lymphoma?
Lymphoma is a cancer of lymphocytes in the lymphatic system, causing lymph node enlargement due to abnormal cell proliferation
What are the key features of Hodgkin lymphoma?
- Reed-Sternberg cells
- bimodal age distribution
(peaks at 20 and 75 years) - Painful lymphadenopathy after alochol consumption. Uusally painless
- Systemic symptoms - B (fever, night sweats, weight loss)
- Good prognosis
- accounts for 1/5 of lymphomas
Name risk factors for Hodgkin lymphoma
(1) Immunosuppression (e.g., HIV)
(2) Autoimmune diseases (e.g., rheumatoid arthritis)
(3) EBV infection, and family history
(4) Male sex
What is Burkitt lymphoma associated with?
Epstein-Barr virus
Malaria
HIV
t(8;14) translocation.
What infection is commonly associated with MALT lymphoma?
H. pylori infection
Name risk factors for non-Hodgkin lymphoma
(1) Infections (HIV, EBV, H. pylori)
(2) Hepatitis B/C
(3) Exposure to pesticides, and trichloroethylene.
What is the hallmark symptom of lymphoma?
Lymphadenopathy
= enlarged, non-tender, rubbery lymph nodes.
What are “B symptoms” in lymphoma?
Fever, night sweats, and weight loss.
How does lymphadenopathy differ between Hodgkin and non-Hodgkin lymphoma?
Hodgkin lymphoma usually presents with localised lymphadenopathy that is painless and has a continuous spread, whilst non-Hodgkin lymphoma typically has generalised lymphadenopathy that is painless and does not have a continuous spread
What unusual symptoms might some Hodgkin lymphoma patients experience?
Pain in the lymph nodes after drinking alcohol
What is the key diagnostic test for lymphoma?
Lymph node biopsy
What is the characteristic finding on lymph node biopsy in Hodgkin lymphoma?
Reed-Sternberg cells – large B cells with bilobed nuclei and an “owl’s eye” appearance
What imaging is used to stage lymphoma?
CT, MRI, and PET scans
Describe the Ann-Arbor staging system for lymphoma
I: Single lymph node region.
II: Multiple regions, same side of the diaphragm
III: Both sides of the diaphragm
IV: Spread beyond lymph nodes (e.g., liver, bone marrow)
A = No systemic symptoms
B = Systemic symptoms
(weight loss, fever, night sweats)
What is the main treatment regimen for Hodgkin lymphoma?
ABVD – adriamycin, bleomycin, vinblastine, and dacarbazine
What side effect is associated with bleomycin in ABVD treatment?
Pneumonitis
What are the long-term risks of Hodgkin lymphoma treatment?
Secondary cancers, cardiovascular disease, and infertility (with intensive treatment)
What is the main treatment regimen for non-Hodgkin lymphoma?
R-CHOP
R - rituximab
C - cyclophosphamide
H - hydroxydaunorubicin (doxorubicin)
O - Oncovin®
P - Prednisolone
How is MALT lymphoma treated?
Triple therapy with a PPI
(omeprazole)
and two antibiotics
(e.g., amoxicillin and clarithromycin)
What is Richter transformation in lymphoma?
Transformation of a low-grade lymphoma (eg, CLL) into a high-grade lymphoma (eg, DLBCL)
Why should steroids be used cautiously before a biopsy in suspected lymphoma?
They can cause cell necrosis and distort tissue architecture, complicating the diagnosis
What is the significance of lactate dehydrogenase (LDH) in lymphoma?
Elevated LDH is often seen in Hodgkin lymphoma but is non-specific
What is a poor prognostic factor in Hodgkin lymphoma?
Elevated ESR or decreased haemoglobin
What factors indicate a poor prognosis in Hogkin’s lymphoma?
Advanced stage > stage 4
B symptoms
Large mediastinal mass
High ESR
Older age (>45 years)
Male sex
Low albumin
What are the types of Hogkin’s lymphoma?
(1) Nodular Sclerosing
(2) Mixed cellularity
(3) Lymphocyte rich
(4) Lymphocyte deplete
Which type of Hogkin’s lymphoma is the most common?
Nodular Sclerosing (about 70% )
A 25-year-old male patient presents to the general practitioner with a 4-week history of an enlarging non-tender left neck mass. He also reports feeling generally unwell with fever, night sweats and a 2kg weight loss in the last month.
Excisional lymph node biopsy reveals Reed-Sternberg cells. A PET-CT scan reveals the involvement of cervical, mediastinal, and inguinal lymph nodes.
What is the Lugano stage of this disease?
Stage III (B)
The patient is not asymptomatic and presents with B symptoms
When does Lymphocyte-depleted occur?
Rare
Typically presents in older patients or those with HIV
Poorer prognosis
When does Nodular Sclerosis occur?
Most Common
Often affecting young adults and presenting with mediastinal involvement.
Although it has a good prognosis, especially in early-stage disease, it is not as favourable as lymphocyte-predominant Hodgkin lymphoma
When does Mixed Cellularity occur?
More common in older adults
May present with a more advanced disease.
It has an intermediate prognosis
When does Lymphocyte-predominant occur?
Rare subtype that typically has a very favorable prognosis compared to other subtypes.
It is often diagnosed at an early stage and responds well to treatment
A 25-year-old male patient presents to the general practitioner with a 4-week history of an enlarging left neck mass. He reports the mass is generally painless, but he notices it is sometimes painful after he drinks alcohol. He denies any other symptoms. He has epilepsy and takes carbamazepine.
Physical examination reveals non-tender cervical lymphadenopathy. Excisional lymph node biopsy reveals large cells with bilobed nuclei and eosinophilic nucleoli.
Given the likely diagnosis, which subtype has the best prognosis?
Lymphocyte-predominant
= characterised by
(1) Predominance of lymphocytes
(2) Fewer Reed-Sternberg cells
(3) Typically occurs in younger males
A 20-year-old male presents to his General Practice with persistent cervical lymphadenopathy fever weight loss and night sweats. He is referred for a biopsy which shows Reed-Sterberg cells. On further investigation, it is noted that he has inguinal lymphadenopathy that also shows Reed-Sterberg cells on biopsy. There is no evidence of liver, spleen or marrow involvement.
Given his likely diagnosis, what stage is his disease?
3 B
A 70-year-old woman with a two-month history of fatigue, weight loss, shortness of breath and painless neck swelling is urgently referred to haematology for further investigations. These include a chest x-ray which shows a mediastinal lesion, a lymph node biopsy which shows infiltrating lymphocytes and the absence of Reed-Sternberg cells, and a CT TAP which shows multi-organ involvement
Which classification is the most appropriate to stage this type of cancer?
Lugano classification
A 27-year-old male has presented with a non-tender supraclavicular lump which has gradually increased in size over the last 3 months. On direct questioning, he admits having night sweats and 10 kg unintentional weight loss.
He has no significant past medical history. An urgent ultrasound reported abnormal cervical lymph nodes in the neck and supraclavicular fossae.
What is the next best investigation?
Excisional node biopsy
What translocation is commonly found in Burkitt’s Non-Hodgkins lymphoma?
t(8;14) IgH-Myc translocation
What are the poor prognostic markers in non-Hodgkin’s lymphoma?
- Presence of B symptoms (weight loss, night sweats, and fever)
- lymphadenopathy/organomegaly
- Advanced tumour stage
- Advanced age >60
- Anaemia
- Raised serum LDH
- Bulky disease (large tumor masses)
What translocation is commonly found in Follicular Non-Hodgkins lymphoma?
t(14;18)
An 18-year-old man is undergoing chemotherapy for lymphoma.
His past medical history includes Epstein-Barr Virus (EBV) infection.
Histology of a lymph node aspirate shows a ‘starry sky appearance’ typical of his type of lymphoma.
Which chromosomal translocation is associated with this type of lymphoma?
Translocation between chromosomes 8 and 14
= The question describes Burkitt’s lymphoma. It is associated with EBV infection
A 71-year-old woman is undergoing treatment for non-Hodgkin’s lymphoma, specifically a high-grade B cell lymphoma.
In addition to CHOP chemotherapy, what targeted therapies is the patient likely to receive?
Rituximab
An 84-year-old man is referred to Oncology with weight loss, night sweats and lymphadenopathy. A lymph node biopsy confirms the diagnosis of mantle cell lymphoma.
Which chromosomal translocation is associated with this diagnosis?
t(11;14)
A 24-year-old female is referred to haematology by her GP. She had presented with night sweats, fatigue, and weight loss and was found to have cervical lymphadenopathy. She has no medical history of note.
What investigation will give a definitive diagnosis?
Lymph node biopsy
What are the Low-Grade Non-Hodgkin Lymphomas (Indolent) ?
- Follicular lymphoma
= t(14;18), increased BCL-2 transcription. - MALT lymphoma
= Associated with H. pylori infection. - Small lymphocytic lymphoma (SLL)
= Similar to CLL, slow progression.
What are the High-Grade Non-Hodgkin Lymphoma (Aggressive)
- Diffuse large B-cell lymphoma
= Most common, rapidly growing painless mass, typically in older adults. - Burkitt lymphoma
= Associated with EBV, malaria, HIV, t(8;14). - Mantle cell lymphoma
= t(11;14), cyclin D1 overexpression, poor prognosis.
A 40-year-old male presents to the GP with a swollen neck, night sweats and weight loss.
He has a past medical history of hyperthyroidism, gout, and HIV for which he takes carbimazole, allopurinol, and antiretrovirals, respectively. Several years ago he was involved in a road traffic accident where he received two units of packed red blood cells for treatment of blood loss. His sister has just received a diagnosis of breast cancer.
He is investigated and later receives a diagnosis of lymphoma.
What subtypes is this patient most likely to have?
Burkitt’s lymphoma
= Burkitt’s lymphoma is strongly associated with immunosuppression, particularly in HIV-positive individuals
A 65-year-old male presents with fever, night sweats, and fatigue. On examination, he has generalised lymphadenopathy. A biopsy of the enlarged lymph nodes reveals the presence of atypical lymphoid cells with an irregular nucleus and a high mitotic rate
What is the most likely diagnosis?
Non-Hodgkin’s lymphoma
Diffuse large B-cell lymphoma (DLBCL)
The presence of
(1) atypical lymphoid cells
(2) irregular nuclei
(3) high mitotic rate on biopsy
= characteristic features of DLBCL
What are the additional staging variables in the Ann Arbor staging system?
(A) Asymptomatic
(B) Presence of B symptoms (fever, night sweats, weight loss)
(X) Bulky disease (>10 cm or >1/3 of intrathoracic diameter)
(S) Splenic involvement
(E) Extranodal disease
t(14;18)
Follicular lymphoma - Non Hodgkins lymphoma.
Involves the BCL2 gene
t(8;14)
Burkitt lymphoma - Non Hodgkins lymphoma.
Involves the MYC gene
t(11;14)
Mantle cell lymphoma - Non-Hodgkins Lymphoma
Involves the cyclin D1 gene
t(9;22)
Chronic myeloid leukemia
A 25-year-old man has presented to his general practitioner after noticing a lump in his neck a few days ago. He is not sure how long this has been there. It is not currently painful but he reports it became painful when he went out for some alcoholic drinks with his friends last Saturday. He has no other symptoms. On examination, a 2-cm rubbery, nontender lymph node is noted in the right anterior cervical chain. There is no evidence of any other lymphadenopathy
Where in the above statement indicates to us that the disease is Hodgkins lymphoma and not non-Hodgkins lymphoma
Painful whilst drinking
What is the target of action of rituximab?
CD20
A 61-year-old female patient presents to the general practitioner with a left-sided neck lump. The lump has been enlarging over the last 12 months and is non-tender. She denies any other symptoms.
Physical examination reveals bilateral cervical and axillary non-tender lymphadenopathy. There is mild splenomegaly. Excisional lymph node biopsy reveals uniform densely packed follicles with loss of nodal architecture. What does this suggest and why?
Follicular lymphoma, a type of non-Hodgkin lymphoma
= (1) The uniform densely packed follicles
(2) Loss of nodal architecture on biopsy
(3) Occurs more often in this 60+
(same as mantle)
Bilateral cervical and axillary lymphadenopathy and splenomegaly also point to a non-Hodgkin lymphoma rather than Hodgkin lymphoma, which typically has more localised involvement
What are the nodes called below the diaphragm?
- Abdominal lymph nodes
- Para-aortic lymph nodes
- Lliac lymph nodes
- Inguinal lymph nodes
A 26-year-old male patient receives his second cycle of chemotherapy for Hodgkin’s lymphoma. 48 hours later he presents to the emergency department feeling unwell, with abdominal pain and weakness. He also reports reduced urine output. The patient is tachycardic but vital signs are otherwise normal.
Given the most likely diagnosis, which investigations should be ordered immediately?
ECG, U&E, calcium, uric acid
= The patient presents with clinical features consistent with tumour lysis syndrome
A 60-year-old male patient is admitted to the hospital due to an enlarged rubbery neck lymph node that is starting to cause stridor. The lymph node biopsy confirms high-grade diffuse large B-cell Lymphoma. The patient is due to be started on the R-CHOP chemotherapy regimen.
What should be prescribed before starting chemotherapy?
Rasburicase
(recombinant xanthine oxidase)
A 65-year-old man is receiving chemotherapy for a high-grade non-Hodgkin lymphoma. He has a past medical history of hypertension and gout, for which he takes amlodipine and allopurinol. Since starting chemotherapy, he has been prescribed a higher dose of allopurinol compared to what he usually takes.
What is the indication for allopurinol here?
To prevent a complication of tumour lysis syndrome
A 77-year-old man with a recent diagnosis of chronic myeloid leukaemia undergoes chemotherapy. Soon after commencing treatment, he developed acute renal failure with a markedly raised uric acid.
What other electrolyte abnormality is most likely to be observed?
(1) Hyperphosphatemia (↑ phosphate) – most significant due to kidney damage and calcium precipitation.
(2) Hypocalcemia (↓ calcium) – secondary to phosphate binding, can cause tetany/seizures.
(3) Hyperkalemia (↑ potassium) – dangerous due to risk of cardiac arrhythmias.
(4) Hyperuricemia (↑ uric acid) – leads to acute kidney injury but is usually managed with allopurinol/rasburicase
Lymphocyte sheets interspersed with macrophages containing dead apoptotic tumour cells in a question is most likely to indicate what?
Burkitt’s lymphoma
