Lymphoma

Question 1

What are the two classes of lymphoma

Answer 1

Hodgkin’s and non-Hodgkin’s

Question 2

What chemotherapy is used for DLBCL-NHL?

Answer 2

R-CHOP

Question 3

Describe how high calcium leads to pre-renal AKI?

Answer 3

High calcium causes water to move out of the cells, causing dehydration, PTH is low, polyuria and polydipsia

Question 4

What is rituximab?

Answer 4

Targets B cells 
Chimeric human-murine monoclonal antibody 
Directed to CD20
Cell mediated toxicity/complement
Induction of apoptosis

Question 5

How does the material from the tumour exit the body when rituximab is given?

Answer 5

Broken down into proteins and amino acids - turns into uric acid
Through the kidney

Question 6

What is a complication of rituximab treating lymphoma

Answer 6

Can develop gout and intrinsic renal failure

Question 7

What is tumour lysis syndrome?

Answer 7

Breakdown of products of cancer affecting the kidney

Question 8

What is the management of tumour lysis syndrome

Answer 8

Anticipate
Hydrate and allopurinol for low/medium risk
Rasburicase (recombinant urate oxidase)
Dialysis

Question 9

What are the causes of NHL?

Answer 9

Immunodeficiency - primary and secondary
Age
Infection - HTLV-1, EBV, H.pylori

Question 10

What happens to the electrolytes in tumour lysis syndrome

Answer 10

Increased uric acid, potassium and phosphorous

Lower calcium due to phosphorous soaking this up

Question 11

Describe the staging of lymphoma

Answer 11

Ann Arbor
1 - single lymph node
2 - >2 sites, same side of diaphragm
3 - both sides of diaphragm
4 - Diffuse/disseminated involvement of >1 extra lymphatic organ
Stage A - no systemic symptoms other than pruitis
Stage B - B symptoms present
Stage E - localised extra-nodal extension - does not advance the stage and denoted by subscript

Question 12

Describe follicular NHL

Answer 12

30-40%
Majority disseminated disease at diagnosis
Median survival 15-20yrs
Not curable

Question 13

When do you start treatment for NHL?

Answer 13

When patient becomes symptomatic

Question 14

Describe the treatment of high-grade lymphoma

Answer 14

Chemo/radiotherapy - potentially curable

R-CHOP - short/long course

Question 15

What are the two main types of NHL?

Answer 15

Follicular - slow growing

Diffuse large B cell - aggressive

Question 16

Which virus is HL associated with?

Answer 16

EBV

Question 17

Which age group does Hodgkin’s most commonly affect

Answer 17

Younger people (15-24yo) but also can affect the elderly - two peaks

Question 18

What are lymphomas?

Answer 18

Disorders caused by malignant proliferations of lymphocytes. These accumulate in the lymph nodes, peripheral blood or infiltrate organs

Question 19

What characteristic cells are found in Hodgkin’s lymphoma

Answer 19

Reed Sternberg cells - Mirror nuclei

Question 20

What are the RF for HL

Answer 20

An affected sibling
EBV
SLE
Post-transplantation

Question 21

List the symptoms of HL

Answer 21

Enlarged, non tender, rubbery superficial lymph node (mostly cervical, but can be axillary or inguinal) - node size may fluctuate and become matted
Constitutional upset - fever, weight loss, night sweats, Pruitus, lethargy
Alcohol induced lymph node pain
Mediastinal lymph node involvement may cause mass effect - bronchial or SVC obstruction or direct extension (pleural effusion)

Question 22

List the signs of HL

Answer 22

Lymphadenopathy
Cachexia
Anaemia
Spleno or hepatomegaly

Question 23

What tests would you do if suspecting lymphoma

Answer 23

Lymph node excision biopsy if possible, image-guided needle biopsy, laparotomy or mediastinoscopy
Bloods - FBC, film, ESR, LFT, LDH, urate, Ca2+
Imaging - CXR, CT/PET CAP

Question 24

What are the B symptoms

Answer 24

Weight loss >10% in last 6 months
Unexplained fever >38%
Night sweats - needing to change clothes

Question 25

Describe the treatment of HL

Answer 25

Chemoradiotherapy - radiotherapy and short course of chemo for stages I-A and II-A (<3 areas of involvement). Longer courses of chemo for II-A with >3 areas of involvement through to IV-B
ABVD - Adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine cures 80%
More intensive regimes if poor prognosis/advanced disease
In relapsed disease, high dose chemo followed by autologous stem cell transplant

Question 26

What are the complications of radiotherapy?

Answer 26

Increased risk of some solid tumours
IHD
Lung fibrosis
Hypothyroidism

Question 27

What is the 5 year survival for HL?

Answer 27

I-A lymphocyte predominant >95%

IV-B lymphocyte depleted <40%

Question 28

Name the different subtypes of HL and state the percentage of cases and prognosis

Answer 28

Nodular sclerosis (70%) - good prognosis
Mixed cellularity (20-25% - good prognosis
Lymphocyte rich (5%) - good prognosis
Lymphocyte depleted (1%) - poor prognosis

Question 29

Which two subtypes of HL have a worse prognosis in a HIV positive patient

Answer 29

Mixed cellularity

Lymphocyte depleted

Question 30

What is NHL?

Answer 30

Group of lymphomas without reed-sternberg cells

Mostly derived from B cell lines

Question 31

What is the most common NHL

Answer 31

Diffuse large B cell lymphoma

Question 32

What causes NHL

Answer 32

Immunodeficiency - drugs and HIV
HTLV-1
H.Pylori
Toxins
Congenital

Question 33

Give some signs and symptoms of NHL

Answer 33

Superficial lymphadenopathy
Extranodal disease - gut (gastric and non-gastric MALT , small bowel lymphoma - diarrhoea, vomiting, abdo pain and weight loss), skin (clonal T cells in mycosis fungiodes), oropharynx (waldeyers ring lymphoma causes sore throat and obstructed breathing), bone, CNS, lung
Fever, night sweats, weight loss
Pancytopenia - anaemia, infection and bleeding (thrombocytopenia)

Question 34

What tests would you request when suspecting NHL?

Answer 34

Blood - FBC,U&Es, LFT, LDH
Marrow and node biopsy - classification 
Staging - Ann Arbor system - CT and PET CAP
Cytology of any effusion
LP for CSF cytology if CNS signs

Question 35

Describe the treatment of high grade NHL

Answer 35

R-CHOP - Rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine and prednisolone

Question 36

Describe how rituximab works

Answer 36

Kills CD20 positive cells by antibody-directed cytotoxicity and apoptosis induction
Also sensitises cells to CHOP