Lymphoma - Non-Hodgkin Lymphoma Flashcards
Non-hodgkin lymphoma (NHL) is a group of cancers that are derived from lymphocytes, specifically B and T cells. What is the incidence of NHL?
1 - 21 / 100,000
2 - 21 / 10,000
3 - 21 / 1000
4 - 21 / 100
1 - 21 / 100,000
- doubled since 1970
Slightly more common in men 1.2:1 ratio
Non-hodgkin lymphoma (NHL) is a group of cancers that are derived from lymphocytes, specifically B and T cells. What age does the incidence of NHL peak?
1 - 10-20
2 - 30-40
3 - 40-50
4 - 60-70
4 - 60-70
Is Non-hodgkin lymphoma (NHL) or Hodgkin lymphoma more common?
- NHL
Five times more likely than Hodgkin lymphoma
NHL account for >90% of lymphoid cancers
Is Non-hodgkin lymphoma (NHL) more common in developed or less developed countries?
- developed countries
Although the exact cause of Non-hodgkin lymphoma (NHL) is unknown, which of the following infections is NOT associated with causing NHL?
1 - tuberculosis
2 - HIV
3 - human T-lymphotropic virus 1
4 - Epstein–Barr virus
5 - Helicobacter pylori infection
6 - Hepatitis C
1 - tuberculosis
Linked with immunosuppression and viruses
Although the exact cause of Non-hodgkin lymphoma (NHL) is unknown, which of the following immunosuppressive conditions is NOT associated with causing NHL?
1 - rheumatoid arthritis
2 - lupus
3 - type 2 diabetes
4 - Sjögren syndrome
5 - coeliac disease
6 - Hashimoto’s thyroiditis
3 - type 2 diabetes
Which of the following can Non-hodgkin lymphoma (NHL) arise from?
1 - mature lymphocytes
2 - immature lymphocytes
3 - mature and immature lymphocytes
4 - mature, immature and pre-cursor lymphocytes
4 - mature, immature and pre-cursor lymphocytes
The point of differentiation of for the lymphocyte determines the type of lymphoma that will occur
Non-hodgkin lymphoma (NHL) can be due to progressive acquisition of DNA alterations caused by mutation, amplifications, deletions or chromosomal translocation. Particular subtypes of lymphoma are associated with specific acquired genetic abnormalities. Translocation of the BCL2 oncogene is found in which of the following types of NHL?
1 - mantel cell lymphome
2 - follicular lymphoma
3 - burkitt lymphoma
4 - diffuse large cell lymphoma
2 - follicular lymphoma
The WHO have classified Non-hodgkin lymphoma (NHL) based on a histological classification. Which of the following is NOT a classification of NHL according to the WHO?
1 - mature B-cell neoplasms
2 - immature B cell neoplasms
3 - mature T-cell and NK-cell neoplasms
4 - immature NK neoplasms
1 - mature B-cell neoplasms
3 - mature T-cell and NK-cell neoplasms
These can also be high or low grade
Non-hodgkin lymphoma (NHL) account for aprox 90% of all lymphoid cancers. Which of the following is the most common type of NHL?
1 - B cells
2 - T cells
3 - NK cells
4 - all equally likely
1 - B cells
- Diffuse Large B cell Lymphoma (DLBCL) is most common
In both acute lymphoid leukaemia (ALL) and non-Hodgkin lymphoma, the lymphocytes (B, T and NK cells) are involved. Which originates from bone and which originates from lymph nodes?
ALL = bone marrow origin and spread through the blood
non-Hodgkin lymphoma = originate in lymph nodes and spread through lymphatics
When comparing leakaemia and lymphoma, which is a solid and which is a liquid tumour?
- leukaemia = liquid (blood)
- lymphoma = solid (lymph nodes)
B cells are the most common cause of Non-hodgkin lymphoma (NHL). Which of the following receptors on the B cell is involved in NHL?
1 - CD10
2 - CD20
3 - CD4
4 - CD8
2 - CD20
- medication can target CD20
Although T cell and natural killer cell lymphomas are rare, which ethnicity are more at risk of developing these?
1 - Caucasian
2 - Irish and Welsh
3 - Asia and Caribbean
4 - South East Asian
3 - Asia and Caribbean
Enteropathy associated T cell lymphomas are a rare form of Non-hodgkin lymphoma (NHL), but which ethnicity are more susceptible to this?
1 - Caucasian
2 - Irish and Welsh
3 - Asia and Caribbean
4 - South East Asian
2 - Irish and Welsh
- gut associated
- shared HLA types and coeliac risk
Burkitt’s lymphoma is a high-grade B-cell non-Hodgkin’s lymphoma that is rapidly growing and aggressive. There are 3 main types:
- endemic
- sporadic
- immunodeficiency associated BL
However, they are all caused by which gene?
1 - MYC gene
2 - BCR-ABL gene
3 - BRAF gene
4 - HER2 gene
1 - MYC gene
- c-MYC
- myelocytomatosis oncogene
- Ch 8q24
Burkitt’s lymphoma is a high-grade B-cell non-Hodgkin’s lymphoma that is rapidly growing and aggressive. There are 3 main types:
- endemic
- sporadic
- immunodeficiency associated BL
Which of the above subtypes of Burkitt’s lymphoma are all the following associated with?
1 - Equatorial Africa, Papua New Guinea, most common malignancy in childhood in these areas
2 - Epstein–Barr virus in all patients
3 - Jaw/other facial bones site for presentation in 50%
4 - Geographical distribution of endemic malaria a factor in pathogenesis (associated with chronic co-infection)
- endemic
This type of Burkitts lymphoma is constantly present in a region or country, but has a slow spread
Burkitt’s lymphoma is a high-grade B-cell non-Hodgkin’s lymphoma that is rapidly growing and aggressive. There are 3 main types:
- endemic
- sporadic
- immunodeficiency associated BL
Which of the above subtypes of Burkitt’s lymphoma are all the following associated with?
1 - seen throughout the world
2 - majority present with abdominal masses (ileo-caecal)
3 - Epstein–Barr virus in 30%
4 - commonly affects children (30-50% of childhood lymphoma) and adults (1-2% of adult lymphomas)
- sporadic
Burkitt’s lymphoma is a high-grade B-cell non-Hodgkin’s lymphoma that is rapidly growing and aggressive. There are 3 main types:
- endemic
- sporadic
- immunodeficiency associated BL
Which of the above subtypes of Burkitt’s lymphoma are all the following associated with?
1 - associated with HIV, can be a manifestation of AIDS
2 - Epstein–Barr virus 25-40%
- immunodeficiency associated BL
Burkitt’s lymphoma is a high-grade B-cell non-Hodgkin’s lymphoma that is rapidly growing and aggressive. There are 3 main types:
- endemic
- sporadic
- immunodeficiency associated BL
Which virus is commonly associated with all 3 subtypes of Burkitt’s lymphoma?
1 - HIV
2 - influenza
3 - EBV
4 - HPV
3 - EBV
Burkitt’s lymphoma is a high-grade B-cell non-Hodgkin’s lymphoma that is rapidly growing and aggressive. There are 3 main types:
- endemic
- sporadic
- immunodeficiency associated BL
Which of the following would be a common finding on histology in Burkitts lymphoma?
1 - reed-sternberg cells
2 - hodgin cells
3 - starry sky appearance
4 - all of the above
3 - starry sky appearance
- very aggressive and highly proliferative disease so when packed together they appear like stars
To distinguish between Non-hodgkin lymphoma (NHL) or Hodgkin lymphoma we use a specific cell, what is this cell?
1 - reed sternberg cells
2 - cytomegalovirus
3 - aeur rods on blood smears
4 - raised basophils
1 - reed sternberg cells
Only present in Hodgkin Lymphoma
Non-hodgkin lymphoma (NHL) is an umbrella term, but which of the following is required to reach a definitive diagnosis of the NHL sub category?
1 - MDT
2 - Morphology
3 - Immunophenotyping
4 - Genetic features (increasingly)
5 - Clinical features and stage
6 - all of the above
6 - all of the above
Typically in Non-hodgkin lymphoma (NHL), where do the tumours grown?
1 - deep lymph nodes
2 - mucosa-associated lymphoid tissue (MALT)
3 - superficial lymph nodes
4 - bone marrow
3 - superficial lymph nodes
This is why they are called nodal lymphomas
75% of patients present with this
Can occur in any of the other types as well
Typically in Non-hodgkin lymphoma (NHL) tumours grow in the lymph nodes. However, when they grow elsewhere is called extra-nodal disease, which occurs in 50% of patients. All of the following are extra-nodal sites where lymphomas can occur. Which is the most common?
1 - skin
2 - sinuses
3 - GIT
4 - waldeyer ring
3 - GIT
50% of patients will have lymphoma in GIT
May cause GIT symptoms and obstruction
Most common in stomach and is associated with Helicobacter pylori
Common in cervical, axilla, inguinal and femoral lymph nodes
Does Non-hodgkin lymphoma (NHL) typically cause a purpura or petechiae rash?
- purpura
Leaking of small blood vessels due to low platelets.
Patients at increased risk of bleeding
Which of the following is NOT typically a systemic B symptom of Non-hodgkin lymphoma (NHL)?
1 - fever
2 - weight gain >10%
3 - night sweats
4 - pancytopenia
2 - weight gain
Typically >10% weight loss and is a sign of disseminated disease
pancytopenia = low RBC, WBC and platelets
There are 2 subcategories of Hodgkin lymphoma:
- Nodular lymphocyte predominant Hodgkin Lymphoma (NLPHL)
- Classical Hodgkin Lymphoma (cHL)
Do both of these need to be treated immediately?
- no
- NLPHL is treated like a mild non-hodgkin lymphoma
- essentially a monitor and see approach
Mediastinal lymphadenopathy can be dangerous and is a medical emergency. Why can mediastinal lymphadenopathy cause a medical emergency?
1 - cardiomegaly
2 - obstruct pulmonary arteries
3 - superior vena cava obstruction
4 - increased afterload
3 - superior vena cava obstruction
Collateral veins are prominent on the chest in an attempt to overcome blockage
Superior vena cava obstruction (SVCO) can be a medical emergency in patients with mediastinal lymphadenopathy. Which of the following can occur due to SVCO?
1 - collateral veins are prominent to overcome blockage
2 - SOB and cough
3 - oedema (brain, neck, chest)
4 - headaches, confusion
5 - raised JVP
6 - facial plethora
7 - all of the above
7 - all of the above
When trying to diagnose hodgkin and non-Hodgkin lymphoma, which of the following would NOT routinely be performed?
1 - FBC
2 - full lymph node examination
3 - renal/liver/bone profiles
4 - MRI
5 - lactate dehydrogenase (LDH)
6 - Erythrocyte sedimentation rate (ESR) (typically raised)
4 - MRI
- typically perform a chest X-ray 1st to assess for mediastinal masses
- LDH is a tumour marker in hodgkin lymphoma and cell turnover
Which imaging modality is typically 1st in a patient with suspected non-Hodgkin lymphoma?
1 - ultrasound
2 - whole body MRI
3 - chest X-ray
4 - whole body PET scan
3 - chest X-ray
Looking for mediastinal masses
MRI is neurological symptoms are present, especially of the spine and/or brain
When performing a FBC in a patient with suspected non-Hodgkin lymphoma, which of the following would NOT typically be present?
1 - anaemia (RBCs)
2 - thrombocytopenia (platelets)
3 - neutropenia (neutrophils)
4 - lymphopenia (lympocytes)
4 - lymphopenia (lympocytes)
Typically see lymphocytosis (lots of lymphoblasts)
Patients may have bleeding
If the U&Es are abnormal in a patient with suspected non-Hodgkin lymphoma (NHL), which of the following would be the likely cause?
1 - hepato-renal syndrome
2 - AKI due to renal obstruction
3 - glomerulonephritis
4 - all of the above
2 - AKI due to renal obstruction
Typically this is stage 4 NHL as the lymphoma has spread to other organs
Which of the following is NOT a differential for lymphadenopathy, other than Hodgkin and non-Hodgkin lymphoma?
1 - infection (EBV, HIV, etc.)
2 - COPD
3 - tuberculosis
4 - metastatic
5 - chronic lymphocytic leukaemia
2 - COPD
Image shows bilateral lymphadenopathy
What tests is used to make a definitive diagnosis in a patient with suspected Hodgkin lymphoma or non-Hodgkin lymphoma?
1 - core nodal biopsy, or whole node
2 - CT scan
3 - tumour markers in blood
4 - blood smear
1 - nodal biopsy
- used to confirm the presence or lack of reed-sternberg cells
Hodgkin and non-Hodgkin lymphoma need to be staged using either chest CT with PET or FDG-PET/CT scans. There are 4 stages, stage I - IV based on the Lugano staging. Which of the following matches stage I?
1 - nodes on both sides of the diaphragm or nodes above the diaphragm with spleen involvement
2 - 1 node or a group of adjacent nodes
3 - additional non-contagious extralymphatic involvement
4 - >2 nodal groups on the same side of the diaphragm
2 - 1 node or a group of adjacent nodes
A or B is given with the stage
- A = no symptoms
- B = weight loss, fever and/or drenching night sweats
Hodgkin and non-Hodgkin lymphoma need to be staged using either chest CT with PET or FDG-PET/CT scans. There are 4 stages, stage I - IV based on the Lugano staging. Which of the following matches stage I?
1 - nodes on both sides of theI diaphragm or nodes above the diaphragm with spleen involvement
2 - 1 node or a group of adjacent nodes
3 - additional non-contagious extralymphatic involvement
4 - >2 nodal groups on the same side of the diaphragm
> 2 nodal groups on the same side of the diaphragm
- can also include bulky disease
- A = no symptoms
- B = weight loss, fever and/or drenching night sweats
Hodgkin and non-Hodgkin lymphoma need to be staged using either chest CT with PET or FDG-PET/CT scans. There are 4 stages, stage I - IV based on the Lugano staging. Which of the following matches stage III?
1 - nodes on both sides of theI diaphragm or nodes above the diaphragm with spleen involvement
2 - 1 node or a group of adjacent nodes
3 - additional non-contagious extralymphatic involvement
4 - >2 nodal groups on the same side of the diaphragm
1 - nodes on both sides of theI diaphragm or nodes above the diaphragm with spleen involvement
- A = no symptoms
- B = weight loss, fever and/or drenching night sweats
Hodgkin and non-Hodgkin lymphoma need to be staged using either chest CT with PET or FDG-PET/CT scans. There are 4 stages, stage I - IV based on the Lugano staging. Which of the following matches stage IV?
1 - nodes on both sides of theI diaphragm or nodes above the diaphragm with spleen involvement
2 - 1 node or a group of adjacent nodes
3 - additional non-contagious extralymphatic involvement
4 - >2 nodal groups on the same side of the diaphragm
3 - additional non-contagious extralymphatic involvement
- A = no symptoms
- B = weight loss, fever and/or drenching night sweats
You are in a GP and you perform a history and examine a patient and suspect non-Hodgkin lymphoma. Which of the following should you do?
1 - standard haematology referral
2 - prescribe corticosteroids and wait and see approach
3 - direct to A&E
4 - fast track referral to haematology
4 - fast track referral to haematology
If the patient is a child, this should be <48h
In Non-Hodgkins lymphoma where the symptoms are insidious but are not causing the patient any symptoms, would we aim to cure these patients?
- no
- often wait and see approach
In Non-Hodgkins lymphoma, typically if a patient has no symptoms we do not aim to cure and monitor instead. However, if the patient develops symptoms, we aim to address the symptoms. Which of the following are examples of this approach?
1 - if related to infection e.g. Mucosa-associated lymphoid tissue (MALT) lymphoma and H.Pylori, antibiotics to eradicate the infection is sufficient
2 - bulky disease (e.g. pressing on important organs) or symptoms then SACT with chemotherapy/targeted therapy/immunotherapy
3 - occasional role for radiotherapy
4 - surgery to relieve symptoms (SVC and GIT obstructions)
5 - all of the above
5 - all of the above
In patients with high grade non-hodgkins lymphoma, do we always aim to cure?
- yes
In patients with high grade non-hodgkins lymphoma, we always aim to cure using Systemic Anti-Cancer Therapy (SACT). Which of the following is NOT typically part of the SACT therapy?
1 - surgery
2 - chemotherapy
3 - targeted therapy
4 - immunotherapy
1 - surgery
All the others enter the systemic circulation.
In patients with high grade non-hodgkins lymphoma, we always aim to cure using Systemic Anti-Cancer Therapy (SACT). Which includes:
- chemotherapy
- targeted therapy
- immunotherapy
Sometimes combined therapy is used which includes radiotherapy and chemotherapy. Which of the following are 2 examples of this?
1 - elderly patients who may not withstand the standard SACT
2 - if SACT is not available at tertiary centre
3 - if patient fails to meet the criteria for SACT
4 - earlier/limited stage disease
1 - elderly patients who may not withstand the standard SACT
4 - earlier/limited stage disease
Typically chemotherapy is given as a pre-adjuvant followed by radiotherapy, where radiotherapy is the main treatment
We can also do an adjuvant, where the main treatment is given 1st, followed by another treatment
In patients with Burkitts lymphoma, do we always aim to cure?
- yes
- aggressive form that can impact upon the CNS
In patients with Burkitts lymphoma, we always aim to cure. Which 2 of the following treatment modalities are often used in Burkitts lymphoma?
1 - immune therapy
2 - chemotherapy
3 - radiotherapy
4 - targeted therapy
1 - immune therapy
2 - chemotherapy
- chemotherapy that crosses the BBB and is injected directly into spinal fluid
Which of the following is NOT routinely checked prior to giving treatment for non-Hodgkins lymphomas?
1 - echocardiogram
2 - EEG
3 - creatine clearance (CrCl)
4 - advise on tumour lysis risk and risk in uric acid
5 - may need to take medications to clear uric acid
6 - hydrate
2 - EEG
Tumour lysis initially causes:
- high uric acid
- hyperphosphataemia
- hyperkalaemia
- hypocalcaemia
Tumour lysis can cause acute nephropathy and AKI
Patients receiving treatment for non-hodgkin lymphoma may experience tumour lysis, a process where lots of tumour cells are killed releasing their contents. Which of the following would we NOT expect to see if this occurs?
1 - hypokalemia
2 - hypocalcemia
3 - hyperphosphatemia
4 - hyperuricemia
1 - hypokalemia
Causes hyerkalaemia
Patients receiving treatment for non-hodgkin lymphoma may experience tumour lysis, a process where lots of tumour cells are killed releasing their contents. Which of the following are patients at high risk of?
1 - seizures
2 - cardiac arrhythmias
3 - AKI
4 - all of the above
4 - all of the above
Patients receiving treatment for non-hodgkin lymphoma may experience tumour lysis, a process where lots of tumour cells are killed releasing their contents. Which 2 of the following are used to treat tumour lysis syndrome?
1 - calcium gluconate
2 - corticosteroids
3 - allopurinol
4 - naproxen
1 - calcium gluconate
3 - allopurinol
Patients with non-hodgkin lymphoma may go into relapse following treatment. Which of the following would be used following the 1st relapse?
1 - palliative care
2 - enrol onto clinical trials for new treatments
3 - 2nd round of chemo, CAR-T or
autologous stem cell transplant
3 - 2nd round of chemo, CAR-T or
autologous stem cell transplant
CAR-T and autologous stem cell transplant BOTH have specific inclusion criteria
Patients with non-hodgkiun lymphoma may go into relapse following treatment. Which of the following would be used following the 2nd relapse?
1 - palliative care
2 - enrol onto clinical trials for new treatments
3 - 2nd round of chemo, CAR-T or
autologous stem cell transplant
2 - enrol onto clinical trials for new treatments
- anything beyond a 2nd relapse patients should receive palliative care
Patients with Non-Hodgkins lymphoma will receive chemotherapy in an attempt to cure them. However, this can cause which of the following that is classed as a medical emergency?
1 - cardiogenic shock
2 - neutropneic sepsis
3 - hypovolaemic shock
4 - obstructive shock
2 - neutropneic sepsis
Chemotherapy wipes out all haemopoetic stem cells, the body is defenceless against infection and sepsis
Neutropneic sepsis is a medical emergency in patients who may have received chemotherapy, such as Non-Hodgkins lymphoma. Are gram + or gram - most dangerous during neutropneic sepsis?
- gram - bacteria
- examples such as Escherichia coli, Klebsiella sp, Enterobacter sp, and Pseudomonas aeruginosa
Neutropneic sepsis is a medical emergency in patients who may have received chemotherapy, such as Non-Hodgkins lymphoma. Gram - are the most dangerous during neutropneic sepsis. Which of the following should be implemented immediately in neutropneic sepsis?
1 - blood cultures
2 - fluid resuscitation
3 - broad spectrum antibiotics immediately
4 - inotropes based on ITU input
5 - all of the above
5 - all of the above
What is the 5 year survival rate for Non-Hodgkin lymphoma?
1 - 24%
2 - 40%
3 - 74%
4 - 100%
3 - 74%
Which type of Burkitts lymphoma is most strongly associated with Epstein Barr Virus?
1 - endemic Burkitts lymphoma
2 - sporadic Burkitts lymphoma
3 - immunodeficiency associated Burkitts lymphoma
1 - endemic Burkitts lymphoma
All patients with this have EBV
However, EBV is associated with all types of Burkitts lymphoma
Which type of lymphoma is associated with a biomodal age distribution?
1 - Hodgkins lymphoma
2 - Natural Killer cell lymphoma
3 - Non-Hodgkin lymphoma
4 - T cell lymphoma
1 - Hodgkins lymphoma
A starry sky histological appearance is seen in which of the following?
1 - Burkitts lymphoma
2 - Follicular lymphoma
3 - HIV
4 - Hodkins lymphoma
5 - T cell lymphoma
1 - Burkitts lymphoma
Lymphoma staging is best performed using which of the following?
1 - bone marrow biopsy
2 - CT scan
3 - MRI scan
4 - FDG-PET/CT scan
5 - ultrasound
4 - FDG-PET/CT scan
A 50 year old man is diagnosed with follicular lymphoma after a CT scan is done for other reasons. Lymph nodes are noted, but he has no other symptoms. How would you manage this patient?
1 - active surveillance
2 - CAR-T
3 - chemotherapy
4 - immunotherapy
5 - radiotherapy
1 - active surveillance
Which of the following vaccinations are recommended in patients who have Non-Hodgkins lymphoma (NHL)?
1 - Polyvalent pneumococcal vaccine
2 - Influenza vaccine
3 - Meningococcal group C
4 - all of the above
4 - all of the above
Which of the following is NOT a common side effect of chemotherapy?
1 - Hair loss
2 - Change in taste and loss of appetite
3 - Nausea
4 - Weight gain
5 - Pancytopenia
6 - Neutropaenic sepsis
7 - Tumour lysis syndrome
4 - Weight gain
