Lymphoma Cases

Question 1

What lymphoma is a medical emergency?

Answer 1

Burkitts Lymphoma! These kids die in days-weeks!!

Question 2

What was the disease that created oncologists?

Answer 2

Hodgkin lymphoma!!

Question 3

What are the four stages of lymphomas? (Ann Arbor Staging)

Answer 3

I. Single LN region
II. One side of diaphragm
III. Both sides of diaphragm
IV. Disseminated

Question 4

What is the immunohistochemistry consistent with a Reed Sternberg cell?

Answer 4

CD15+, CD30+, EBER+, CD20-, CD79a-, CD45-

Question 5

What must you do if you think something is lymphoma?

Answer 5

EXCISIONAL BIOPSY

Question 6

What translocation is associated with follicular lymphoma?

Answer 6

t(14;18)

Question 7

What is cyclin D1 positive in?

Answer 7

Mantle Cell Lymphoma

Question 8

What is MALT lymphoma often associated with?

Answer 8

Helicobacter pylori - stomach

Question 9

What is the treatment for PTLPD (post-transplant lymphoproliferative disorder)?

Answer 9

Backing off immune suppression (ex: anti-kidney rejection medication - treated with chemo)

Question 10

What should you do if someone has hemolysis??

Answer 10

JUST TRANSFUSE THEM - don’t take time to blood type them

Question 11

What should you do if some has a lot of anemia with heart trouble/ischemia?

Answer 11

Transfuse them

Question 12

What are B symptoms?

Answer 12

> 10% weight loss, drenching night sweats, fever >38.5

Question 13

What three side things should you check for with potential lymphoma?

Answer 13

• Hepatitis B (reactivation of chronic infection)
• Ask about fertility counseling - treatment may make them infertile
• HIV - much higher rates of lymphoma in HIV tests

Question 14

What is important to remember about Hodgkin’s Lymphoma?

Answer 14

• Malignant cell is Reed Sternberg Cell (owl eyes)
• Now recognized as a B-cell, some are CD20+
• Bulk of tumor is reactive tissue
• Spreads contiguously from node to node

Question 15

What are common hodgkin’s lymphoma symptoms?

Answer 15

It typically presents with enlarging, rubbery, but not tender lymphadenopathy. Typically in the NECK or CHEST.
Can also have:
-Fatigue
-Fever
-Weight loss
-Nigh sweats
-Pain with EtOH
-Symptoms of cytopenias
-Hepatosplenomegaly

Question 16

HL is a rare cancer, but in . . .

Answer 16

. . .young people with cancer, its common

-Most cases occur 15-19 years or 70-74 years

Question 17

What is the best treatment for Hodgkin lymphoma?

Answer 17

• ABVD - used since 1970s. - Adriamycin, Bleomycin, Vinblastine, Dacarbazine
• Autotransplant - can be curative - transplant for relapsed/refractory lymphoma
• Rituximab - Targeted therapy

Question 18

What is the classification of HL by WHO?

Answer 18

• Classical HL (CD30+)
• –Nodular sclerosis (grades I and II)
• –Lymphocyte-rich classical
• –Mixed cellularity
• –Lymphocyte depleted
• Nodular lymphocyte predominant (CD20+)

Question 19

What does E and S mean in the staging of lymphomas?

Answer 19

E- extralymphatic site

S- Splenic disease

Question 20

What are four late (bad) effects of therapy?

Answer 20

1. Second malignancy
   - Solid tumors (risk continues to increase beyond 15 years)
   - -Lung cancer most common (1/3 of all cancers)
   - -Breast cancer
   - Secondary leukemia (rare beyond 10-15 years)
2. Heart disease
   - Distant third cause of death after HL and second malignancies
   - Most common is acute MI secondary to CAD
   - Associated with radiation to the mediastinum
3. Lung disease
   - Acute interstitial pneumonitis - chronic lung injury
   - Most common in bleomycin containing regimens, esp. when combined with chest radiation
   - Significant complication in transplant patients
4. Impaired fertility
   - - infections (herpes, sepsis)

Question 21

Where does testicular cancer metastasize to?

Answer 21

Parasitical nodes

Question 22

For non-hodgkin lymphoma, what do you use other than stage for diagnosis?

Answer 22

IPI Scoring System
Prognostic factors: 
-Age over 60
-Stage III/IV
-ECOG 3 (need help grocery shopping) or 4 (need help with everything)
-Elevated LDH
-Two or more extra nodal sties

Question 23

What is the treatment for Diffuse Large B-cell lymphoma (non-hodgkin)?

Answer 23

R-CHOP (rituximab, adriamycin, cyclophosphamide, vincristine & prednisone), followed by field radiation

Question 24

What are important things to remember about Diffuse Large B-cell Lymphoma?

Answer 24

• Prototype aggressive NHL
• Accounts for 40% of lymphomas
• Average age = 67
• 75.3% cases are over age 55
• Quickly fatal if left untreated
• Treated with CHOP and R (rituximab) - with rituximab we now cure about 50% with no added toxicity

Question 25

What is the most common T-cell lymphoma on boards?

Answer 25

Usually cutaneous lymphoma, with mycosis fungicides as the prototype.

Question 26

What are the general principles of T cell lymphomas?

Answer 26

Ex: mycosis fungicides

• Not curable
• Frequently relapse, but systemic involvement is uncommon
• Treatment is UV radiation, topical or systemic

Question 27

What is the only lymphoma you don’t treat? (and it isn’t curable)

Answer 27

Non-Hodgkin Indolent Lymphoma (ex: follicular, MALT, marginal zone, SLL, etc.)

Question 28

What are the aggressive non-hodgkin lymphomas?

Answer 28

DLBC, Mantle Cell

Question 29

What are the very aggressive non-hodgkin lymphomas?

Answer 29

Lymphoblastic, Burkitt, AIDs related

Question 30

How does PTLPD (post-transplant lymphoproliferative disorder) usually occur?

Answer 30

• Solid organ transplant patients, patients with immune suppression, particularly calcineurin inhibitors (tacrolimus & cyclosporine) or ATG, who develop lymphoma
• EBC induced, poly-clonal, expansion of B cells. It occurs bc suppression of T-cells lead to loss of suppression of B-cell proliferation

Question 31

What to know about systemic T cell lymphoma?

Answer 31

These behave badly and don’t end well!!

• Again, CHOP is often first line treatment
• No rituximab
• CD30+, then brentuximab vedotiin as targeted therapy