Non-Hodgkin's Lymphoma Flashcards
Which is the most common form of NHL? [1]
Diffuse large B cell lymphoma (DLBCL) is the most common form of NHL.
Describe the clinical presentation of NHL
- NHL is typically disseminated at presentation, with two-thirds of patients presenting with painless lymphadenopathy: cervical, axillary, inguinal, and femoral lymph nodes are the most commonly involved
- Extranodal involvement is also common, and may affect any organ; the most common sites are the GI tract (stomach, in particular), skin, and bone marrow
- Fever
- Night sweats
- Weight loss (unexplained, > 10% in the last 6 months)
- Pruritus
- Splenomegaly
- Hepatomegaly
Describe how you differentiate betwen NHL and HL with regards to:
Cells; Age; Extra-nodal disease; Systematic symptoms; contigoius spread [5]
Cells:
* HL: Reed-Sternberg cells (mature B cells) PRESENT
* NHL: Reed-Sternberg cells NOT present; instead get B or T cells at all stages of maturation
Age:
* HL: Bimodal
* NHL: More common with increasing age
Extra-nodal disease:
* HL: Extranodal disease uncommon
* NHL: Extranodal disease common
Contiguous spread:
* HL: Contiguous spread
* NHL: Non-contiguous spread
Systematic symptoms:
* HL: Systemic symptoms common
* NHL: Systemic symptoms not common
Describe the common presentation of the following types of NHL [3]
- Diffuse large B cell lymphoma (DLBCL) [3]
- Follicular lymphoma [1]
- Burkitt’s lymphoma [1]
Diffuse large B cell lymphoma (DLBCL):
- rapidly enlarging mass, commonly in the neck, abdomen or mediastinum
- Extranodal is common in GI tract
- Disease in the mediastinum may lead to SVCO
Follicular lymphoma:
- insidious manner with gradually worsening, painless lymphadenopathy
Burkitt’s lymphoma:
- rapidly enlarging tumour in the jaw of a child
- associated with EBV
Describe the treatments for the following types of NHL [3] (in both local and advanced stages diseases)
- Diffuse large B cell lymphoma (DLBCL) [2]
- Follicular lymphoma [2]
- Burkitt’s lymphoma [1]
Diffuse large B cell lymphoma (DLBCL):
* Limited stage disease: R-CHOP; Combined modality therapy (CMT) may be used where chemoimmunotherapy is combined with radiotherapy.
* Advanced stage disease: Treatment may involve R-CHOP or other regimens such as (da)-EPOCH-R.
Follicular lymphoma:
- Limited stages: local radiotherapy
- Advanced disease: immunotherapy with rituximab if asymptomatic. If
symptomatic: RCHOP
Burkitt’s lymphoma
- Intensive chemotherapy
Which areas of the body are most commonly affected by NHL (aside from lymphadenopathy) [3]
GI tract (stomach, in particular)
skin
bone marrow
* If bone marrow involvement: cytopenia - anaemia, infections or purpura.
Describe some implications of enlarged LNs due to lymphadenopathy [5]
Enlarging nodes can cause symptoms due to mass effect:
* Compression of the superior vena cava: shortness of breath and facial oedema
* Compression of the external biliary tree: jaundice
* Compression of the ureters: hydronephrosis
* Bowel obstruction: vomiting and constipation
* Impaired lymph drainage: chylous pleural or peritoneal fluid, or lymphoedema of the lower limbs
State 5 reasons for NHL oncological emergencies [5]
- Superior vena cava obstruction (SVCO)
- Cord compression
- Hypercalcaemia
- Tumour lysis syndrome
- Neutropenic sepsis
What is the name for this skin condition related to NHL? [1]
Mycosis fungoides: skin lesions including an eczematous reaction which proceeds to form plaques, tumours, and fungating ulcers.
Describe the initial investigations used to investigate NHL [5]
FBC:
- anaemia
- thrombocytopenia
- neutropenia
- lymphocytosis
U&Es:
- acute kidney injury from obstructive nephropathy
LDH:
- Often elevated in high grade lymphomas
Chest x-ray:
- mediastinal adenopathy
- pleural or pericardial effusions and parenchymal involvement
MRI brain / spinal cord if neurological symptoms
Describe the definitive tests for NHL? [2]
Biopsy:
* If the lesion is easily palpable, an excisional biopsy is preferred.
* If the lesion is in the lung or abdomen, a core needle biopsy is preferred
Bone marrow aspirate and biopsy may also be indicated
When would a lumbar puncture be indicated as a biospy in a NHL patient? [1]
What is meant by Fluorescence in situ hybridisation (FISH) and when is it used? [1] What further tests would you perform if positive? [1]
Lumbar puncture:
- In patients with suspected CNS disease, cytology and flow cytometry may be required.
Fluorescence in situ hybridisation (FISH):
- NICE advise using FISH to identify MYC rearrangement (Burkitt lymphoma) in those with high-grade B-cell lymphoma.
- If found, further testing to identify BCL2 and BCL6 rearrangements and the immunoglobulin partner should be arranged.
Which type of NHLs (stage 1) are indicated FDG-PET-CT imaging to confirm staging? [3]
- Stage I diffuse large B-cell lymphoma by clinical and CT criteria
- Stage I or localised stage II follicular lymphoma if disease is thought to be encompassable within a radiotherapy field
- Stage I or II Burkitt lymphoma with other low-risk features
Describe the staging
What does the term ‘B symptoms’ relate to? [1]
‘B’ symptoms: ‘B’ symptoms refer to fever, night sweats and weight loss (unexplained, >10% in 6 months). ’B’ denotes presence and ‘A’ denotes absence.
What is the commonly used chemotherapy regimen used in NHL? [5]
Describe the MoA of each [5]
R-CHOP:
Rituximab:
* A monoclonal antibody with activity against CD20 - an antigen found on the surface of B-cells.
Cyclophosphamide:
- An alkylating agent, inhibits DNA synthesis through cross linking of DNA.
Doxorubicin:
- An anthracycline that inhibits topoisomerase II leading to inhibition of DNA and RNA synthesis.
Vincristine:
- Inhibits microtubule formation by binding to tubulin.
Prednisolone
- a glucocorticoid steroid.
State common side effects of each of R-CHOP [5]
R-CHOP:
Rituximab:
* infusion reactions
* hepatitis B reactivation
* mucocutaneous reactions
Cyclophosphamide:
- transitional cell carcinoma of the bladder
- bone marrow suppression
- infertility.
Doxorubicin:
- cardiomyopathy
- myelosuppresion
- skin reactions.
Vincristine:
- peripheral neuropathy
- bladder atony.
Prednisolone
- steroid effects
Which vaccines are recommended for patients of NHL [4]
Meningococcal group C conjugate vaccine
and
Haemophilus influenzae type b (Hib)
and
Polyvalent pneumococcal vaccine
and
influenza vaccine
Any patient suffering from NHL who exhibits neutropenia should be given what treatment? [1]
Any patient with severe neutropenia should be given antibiotic prophylaxis with chemotherapy
Describe what is meany by tumour lysis syndrome [1]
What electrolyte disturbances may this cause? [5]
Tumour lysis syndrome commonly occurs after treatment of high-grade lymphomas; when tumor cells release their contents into the bloodstream, either spontaneously or in response to therapy
- hyperuricaemia
- hyperkalaemia
- hyperphosphataemia
- hypocalcaemia
- acute kidney injury
Describe the pathological consequence of NHL undergoing bone marrow infiltration [3]
Neutropenia, anaemia, thrombocytopenia:
- Bleeding secondary to thrombocytopenia
A patient is undergoing treatment for NHL. They are subsequently diagnosed as having transitional bladder cancer. You suspect this is because of their treatment used for their NHL.
Which of the following is most likley to have caused this?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Cyclophosphamide
Describe some complications of NHL pertaining to the following systems:
- Cardiac [3]
- Vascular [3]
- Resp. [1]
- Neurological [2]
- GI [3]
Cardiac:
- Pericardial effusion
- Arrythmias (secondary to cardiac metastases)
- SVCO (secondary to large mediastinal tumour)
Vascular:
- disseminated intravascular coagulation
- direct vascular invasion by the tumour
- bleeding secondary to thrombocytopeni
Resp:
- Pleural effusions
Neurological:
- spinal cord compression
- lymphomatous meningitis
Gastrointestinal:
- obstruction
- perforation
- bleeding
Which of the following is most likley to have cause cardiomyopathy?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Doxorubicin
Which of the following is most likley to have caused bone marrow suppression?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Which of the following is most likley to have caused bone marrow suppression?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Which of the following is most likley to have caused peripheral neuropathy?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Which of the following is most likley to have caused peripheral neuropathy?
Vincristine
Which of the following is most likley to have caused bladder atony?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Vincristine
Which of the following is most likley to have caused Hep B reactivation
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Rituximab
Which of the following is most likley to cause infertility?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Which of the following is most likley to cause infertility?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Which of the following is most likley to cause hypogammaglobulinaemia?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Which of the following is most likley to cause hypogammaglobulinaemia?
Rituximab
Which of the following is most likley to cause an infusion reaction?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisolone
Rituximab
Which of the following are associated with large abdominal mass and symptoms of bowel obstruction
Lymphoblastic lymphoma
Burkitt’s lymphoma
Adult T-cell leukaemia-lymphoma
Anaplastic large cell lymphoma
Burkitt’s lymphoma
Which of the following are associated with large mediastinal mass, SVC syndrome and cranial nerve palsies
Lymphoblastic lymphoma
Burkitt’s lymphoma
Adult T-cell leukaemia-lymphoma
Anaplastic large cell lymphoma
Lymphoblastic lymphoma
Which of the following are associated with:
fulminating clinical course with skin infiltrates, lymphadenopathy, hepatosplenomegaly, and leukaemia. May also be associated with symptoms of hypercalcemia
Lymphoblastic lymphoma
Burkitt’s lymphoma
Adult T-cell leukaemia-lymphoma
Anaplastic large cell lymphoma
Adult T-cell leukaemia-lymphoma
Which symptoms help differentiate between HL and NHL? [3]
- Alcohol-induced pain at sites of nodal disease is specific to HL, but only occurs in < 10% of patients.
- Pruritis is common in HL
- Lymph node involvement occurs in a contiguous manner in HL, but is non-contiguous in NHL
This patient most likely has
Diffuse large B cell lymphoma (DLBCL)
Follicular lymphoma
Burkitt’s lymphoma
Burkitt’s lymphoma
This patient most likely has
Diffuse large B cell lymphoma (DLBCL)
Follicular lymphoma
Burkitt’s lymphoma
Diffuse large B cell lymphoma (DLBCL)
suffering from SVCO
A patient undergoes a biopsy of a mass in their ceceum. It exhbitis a ‘starry sky’ pattern. What is the most likely infection? [1]
EBV: causes Burkitt’s lymphoma
Which lymph nodes does Burkitt’s lymphoma typically present in? [1]
Abdomen and mesenteric lymph nodes
Burkitt’s lymphoma typically causes what complication? [1]
Tumour lysis syndrome
