Lymphomas and Multiple Myeloma

Question 1

____ are dense collections of
immune cells that filter antigens from extracellular fluid passing through

Answer 1

Lymph nodes

Question 2

_____: disease of a lymph node

Answer 2

Lymphadenopathy

Question 3

Lymphadenopathy:

Answer 3

disease of a lymph node
○ It reflects disease secondary to an increase in normal lymphocytes and macrophages in response to an antigen

Question 4

Enlarged Lymph Node causes

Answer 4

● Lymphadenopathy
● Most often due to benign, self-limited conditions, such as viral
infections
● Other causes include accumulation of cells in response to an infection in the node itself (lymphadenitis), metastatic malignancy, or neoplastic
lymphocytes (lymphoma)

Question 5

Tenderness of lymph nodes suggests _____

Answer 5

acute inflammation, the kind that
comes with localized or acute infections

Question 6

If your patient reports lymphadenopathy of a few days or even a couple of weeks, it is appropriate to _____

Answer 6

wait for 3-4 weeks to see if it
resolves before arranging further workup

Question 7

f your patient comes in reporting a swollen lymph node
that is _____, assess for signs concerning for malignancy

Answer 7

non-tender and has been present for a couple of
weeks

Question 8

Lymph nodes ____ cm or greater are more concerning for malignancy

Answer 8

2

Question 9

Good initial imaging for lymphadenopathy

Answer 9

Ultrasound

Question 10

Types of biopsy on lymphadenopathy if malignancy is possible

Answer 10

○ Fine Needle Aspiration Biopsy: Less invasive but has the potential to miss the pathology within the node itself
○ Excisional Biopsy: Most ENT and General Surgeons prefer to remove the entire node to establish a more certain diagnosis

Question 11

The lymphomas are often referred to as the “wet cancers” because ____

Answer 11

they can infiltrate any tissue

Question 12

Lymphomas are generally categorized as

Answer 12

● Hodgkin Lymphoma: A specific type of cancer
● Non-Hodgkin Lymphomas: A large group of several types of Lymphoma

Question 13

Hodgkin Lymphoma age distribution

Answer 13

bimodal age distribution: 20s and 50s

Question 14

About 85% of children who develop Hodgkin’s are ____

Answer 14

male

Question 15

Inheritance pattern of hodgkins?

Answer 15

No consistent chromosomal or hereditary pattern of inheritance
has been established
Also called “Hodgkin’s Disease”

Question 16

Hodgkin Lymphoma Pathophysiology

Answer 16

● A malignant disease of the lymph tissue (lymph cancer)
● Characterized by the presence of
Reed-Sternberg cells
● The disease tends to start in a localized region of lymph nodes and then spreads in an orderly, predictable fashion to adjacent sites
of lymph tissues

Question 17

S/S of hodgkins lymphoma

Answer 17

● Painless lump in neck area
● Fevers/chills
● Night sweats
● Weight loss
● Anorexia
● General malaise
● Intermittent pruritus

Question 18

Some people with Hodgkin will experience pain/soreness at lymph node with ____ ingestion

Answer 18

ETOH (alcohol)

Question 19

Pel-Ebstein pattern is sometimes seen with

Answer 19

Hodgkin lymphoma
Days or weeks of febrile period alternating with days or weeks of afebrile period

Question 20

Excisional biopsy is
____ over FNA for diagnosis of _____

Answer 20

preferred; hodgkin lymphoma

Question 21

Laboratory tests in hodgkin lymphoma may show:

Answer 21

○ Normocytic anemia (if bone marrow infiltration)
○ Elevated erythrocyte sedimentation rate (ESR)
○ Mild leukocytosis with decreased lymphocytes

Question 22

Other imaging for hodgkin lymphoma

Answer 22

● Chest X-ray may show mediastinal lymphadenopathy
● CT chest/abdomen/pelvis required for staging
○ PET scan often used in the initial staging too

Question 23

Hodgkin lympoma treatment

Answer 23

● General surgeon or ENT surgeon for biopsy
● If diagnosis is established, contact oncology right away to set up
consultation
● Treatment could include chemotherapy, chemo and radiation combo, and possible stem cell transplant

Question 24

Ann arbor staging

Answer 24

○ Stage I - one nodal area/region
○ Stage II - two areas on one side of diaphragm
○ Stage III - both sides of diaphragm
○ Stage IV - disseminated; disease within bone marrow or liver
○ Addition of A - lacks constitutional symptoms
○ B- 10% weight loss over 6 months, fever, and night sweats

Question 25

General treatment guidelines and prognosis by stage for Hodgkin lymphoma

Answer 25

■ Stages I, II, and IIIA - Radiation therapy
■ Stages IIIB, IV - Combination chemo, with or without
radiation therapy
■ 5 year survival rate for Stage I is >95%
● For Stage IV, about 65%

Question 26

Non-Hodgkin Lymphomas (NHLs)

Answer 26

A group of dozens of forms of Lymphoma all
classified as Non-Hodgkin Lymphomas
(Non-Hodgkin’s Disease)
○ Classified functionally as B-cell or T-cell

Question 27

Median age of diagnosis for NHLs

Answer 27

Median age at diagnosis is 50 years of age
○ Does occur fairly often in pediatric
population
○ Incidence possibly increases with age as well

Question 28

Non-Hodgkin is much ____
common than Hodgkin

Answer 28

more

Question 29

S/S NHLs

Answer 29

painless, peripheral lymphadenopathy
○ Unlike Hodgkin’s, NHL
lymphadenopathy seems to be more generalized rather than localized to one region
○ ⅔ have retroperitoneal, mesenteric, or pelvic nodal involvement
● Extranodal involvement can occur (GI, skin, CNS, etc)

Question 30

Constitutional symptoms (fever, chills, night sweats, weight loss)
can occur, but are much ____ common in NHL

Answer 30

less

Question 31

Non-Hodgkin Lymphoma diagnosis

Answer 31

● Tissue biopsy is required for definitive diagnosis
● Peripheral blood smear is usually normal, even with extensive bone
marrow involvement
● Disease is usually already disseminated at time of diagnosis

Question 32

Plasma Cells are specialized Lymphocytes that simply excrete large amounts of ____ at their activation

Answer 32

whatever antibody they were programmed to create

Question 33

When a B-Lymphocyte is activated, it differentiates into a
_____

Answer 33

more specialized, mature version of B-Lymphocyte

Question 34

Multiple Myeloma

Answer 34

● MM is malignant proliferation of a
single clone of Plasma Cell
○ Resulting in excess monoclonal
paraproteins (M protein)

Question 35

MM epidemiology

Answer 35

● Most commonly seen in older adults
○ Most are in their 60s or 70s
● More common in men than women
● Exposure to radiation, benzene, and pesticides may play a role based on recent research

Question 36

Multiple Myeloma pathophysiology

Answer 36

● One rogue Plasma Cell starts it off
The malignant cells secrete
● Osteoclast Activating Factor (OAF) which stimulates inappropriate bone breakdown
● The cells also secrete excessive amounts of monoclonal Immunoglobulin protein (M-Protein), and these sometimes form chains that block glomeruli, causing kidney injury

Question 37

Common triad of MM

Answer 37

○ Bone pain
○ Anemia
○ Kidney injury

Question 38

Skull or other X-rays may show
punched out lytic lesions in

Answer 38

Multiple myeloma

Question 39

Occasionally, clumps of Plasma Cells aggregate in various locations
and become a _____ in ___

Answer 39

Plasmacytoma; MM

Question 40

S/S of Multiple Myeloma

Answer 40

● Bone pain - 70%
○ Can develop pathologic fractures
● Normocytic anemia
● Thrombocytopenia
● Leukopenia
● Osteopenia
● Hypercalcemia
● Fatigue
● Recurrent Infection

Question 41

BREAK mnemonic for S/S of Multiple Myeloma

Answer 41

○ Bone pain: Osteolytic destruction
○ Recurrent infections: From the leukopenia
○ Elevated calcium
○ Anemia
○ Kidney failure

Question 42

Multiple Myeloma on CBC

Answer 42

shows normocytic anemia in 80-90% of cases

Question 43

MM CMP findings

Answer 43

shows hypercalcemia, possibly elevated BUN/Creatinine,
and elevated total protein
○ High protein because of excess immunoglobulin circulating in
serum

Question 44

Serum Protein Electrophoresis (SPEP) and Urine Protein
Electrophoresis (UPEP) findings for MM

Answer 44

show monoclonal protein spike
(M-spike) - Classic, essentially pathognomonic

Question 45

Bone marrow biopsy findings with MM

Answer 45

Shows 20-30% Plasma Cells

Question 46

Multiple Myeloma PBS findings

Answer 46

may show Rouleaux formation (coin-stacking formation), but not always

Question 47

24 hour urine electrophoresis findings for MM

Answer 47

May show Bence-Jones Proteins
(excess free light chains;
M-proteins)

Question 48

Multiple Myeloma Treatment

Answer 48

● Although MM is presently incurable, treatment often involves
immunomodulatory agents, chemotherapy, autologous stem cell
transplant, and/or radiation
● Supportive treatments (i.e. Bisphosphonates) have shown some
improvement in delaying skeletal disease and improving bone pain

Question 49

Median survival of Multiple Myeloma

Answer 49

● Median survival is 7 years after diagnosis
○ Eventual bone marrow failure