3.2: Lumps and Bumps (Increased Lymph Nodes)

Question 1

Lymphadenopathy (enlarged _______________) may be a result of various causes:

Infections

• Acute infections: bacterial, viral (e.g. HIV, ________________), parasitic (toxoplasmosis)
• Chronic infections (e.g. EBV)

Malignancies: ________________, metastasis from other cancers

Autoimmune: -

Other: Sarcoidosis, ___________ (when lymph nodes drain an area of diseased skin), snake bites

Answer 1

lymph nodes;

infectious mononucleosis;

Primary lymphoid malignancies;

dermatopathic

Question 2

The clinical presentation of the patient can point to the cause of the lymphadenopathy, or certain investigations to undertake:

• Isolated lymphadenopathy: Tissues draining to that set of lymph nodes must be considered (e.g. ________________ should be considered when looking at cervical nodes)
• Widespread lymphadenopathy (with ____________): Glandular fever (infectious mononucleosis)

If the cause of the lymphadenopathy is not obvious, a ___________ is required (via fine needle aspirate or lymph node biopsy):
• Architecture of the lymph node can be observed on biopsy (important in diagnosis of lymphomas)

Answer 2

throat, chest, ear;

swinging fevers and sore throat;

tissue diagnosis

Question 3

[Lymphoma]
Lymphomas are cancers beginning in the cells of the ________________ (tumour of lymphoid tissue):

The risk factors for lymphoma include viral infections, family history, radiation, drugs, autoimmune disorders and immunosuppressive therapy:
• Immunocompromised patients have increased likelihood of lymphoma as they are more susceptible to viral infections (linked to lymphoma development) and loss of immune surveillance
• Lymphoid neoplasms also cause secondary disruption of normal functioning immune system, causing some patients with lymphoma to develop immunodeficiency

SIGNS
The typical signs which point towards lymphoma includes:
1. ______________ lymphadenopathy (unexplained)
2. Fevers, ____________ (drenching), weight loss
3. On basis of routine investigations: abnormal CXR (e.g. _________________), FBC (increased ________________ in low grade lymphomas)

Answer 3

immune/lymphoreticular system;

Painless;

night sweats;

hilar lymph nodes/thymic mass;

peripheral blood lymphocytes

Question 4

Lymphomas are classified into Hodgkin’s lymphoma (20%) and non-Hodgkin’s lymphoma (80%) based on whether the ____________ is present:
• Most cases of non-Hodgkin’s lymphoma are ________________

Hodgkin’s lymphoma: Classical (4 types)

• Mixed cellularity
• Lymphocyte-depleted
• Lymphocyte-rich
• ________________
• Nodular lymphocyte-predominant

Non-Hodgkin’s lymphoma

• B cell: Low grade (e.g. ____________ lymphoma); High grade (e.g. ______________ lymphoma)
• T cell: Precursor T cell neoplasms; _____________ T cell neoplasms

Answer 4

Reed-Sternberg cell;

high grade B cell lymphomas;

Nodular sclerosing;

follicular; diffuse large B cell;

Peripheral

Question 5

LYMPH NODE ARCHITECTURE

• Germinal centre: B cells, APCs (site of B cell selection and activation)
• _______________: Naïve unstimulated B cells
• Paracortex: T cells, APCs

Different types of cells in the lymph nodes give rise to different malignancies:

• Naïve B cells: ___________________
• GC B cells: _____________, follicular lymphoma, ______________, diffuse large B cell lymphoma (DLBCL)
• Mantle zone B cells: ______________
• Memory B cells: Diffuse large B cell lymphoma (DLBCL)
• Plasma cells: ____________

Answer 5

Mantle zone;

Acute lymphoblastic leukaemia (ALL);

Hodgkin’s lymphoma; Burkitt’s lymphoma;

Mantle cell lymphoma ;

Myeloma

Question 6

HODGKIN’S LYMPHOMA
Patients with Hodgkin’s lymphoma present with __________, __________ and ____________ pain, and asymmetric lymph nodes in the neck (typically painless, non-tender, rubbery) and splenomegaly upon examination:
• Characterised by the Reed-Sternberg cell (large bi nucleated cell with _________________ nucleoli)

Test results

• FBC: _______________________
• ESR: __________
• LDH: _________
• LFTs: -
• Bone marrow: Infiltration
• CT staging: -

Answer 6

fever; pruritus (itch); alcohol-induced;

prominent eosinophilic inclusion-like;

Neutrophilia and eosinophilia; Raised; Raised

Question 7

[Ann-Arbor’s Classification]
Staging of the lymphoma in Hodgkin’s disease is important as it tends to start in only one group of lymph nodes before spreading to other nodes:
• Patient with involvement of only one group of lymph nodes is considered to have a less severe case of lymphoma compared to those with multiple groups
- Stage I: Only affects one group of lymph nodes
- Stage II: Affects multiple groups of lymph nodes (confined to one side of the ___________)
- Stage III: Affects multiple groups of lymph nodes on _____________________
- Stage IV: Affects ____________ (e.g. bone marrow, liver)

Answer 7

diaphragm;

both sides of the diaphragm;

extranodal tissues

Question 8

[Types of Hodgkin’s Lymphoma]

Classical

• Patients are young
• Cellular origin: _____________ cells
• EBV association: ____
• Histology: _____ with mixed cell population (scattered Reed- Sternberg and Hodgkin’s cells with ______)
• Clinical course: moderately aggressive

Nodular lymphocyte- predominant

• patients have _______
• cellular origin: _____ cells
• EBV association: _____
• Histology: ________
• Clinical course: Indolent (but may transform to ______________)

Answer 8

GC/ Post GC B:

present;

sclerosis;

eosinophilia;

isolated lymphadenopathy;

GC B cells;

no;

Distinct B cell rich nodules;

High grade B cell lymphoma

Question 9

Non-Hodgkin’s lymphoma includes high-grade diffuse large B cell lymphomas (37%) and low-grade follicular lymphomas (29%).

Follicular lymphoma often presents with lymphadenopathy and originates from a _____________ germinal centre cell:
• Median age of presentation is 60 years of age with median survival of 10 years
• Involves a classical __________________ (causing constitutive activation of the bcl-2 gene) → decreased cellular apoptosis
• Clinical course tends to be indolent (causing little/no pain), but may transform to a high-grade B cell lymphoma
• No cure with chemotherapy (only treatment for any complications and symptoms)

Diffuse large B cell lymphoma is a classical high grade non-Hodgkin’s lymphoma presenting with rapidly progressive lymphadenopathy and originates from GC/post-GC B cells:
• Mainly affects the elderly
• Histology reflects the lymphadenopathy as __________________
• Treated with combination chemotherapy and radiotherapy → mixture of rituximab and _____________________
• One third of patients are cured, one third respond to treatment and relapse, and one third do not respond

Answer 9

CD10+ and bcl-6+;

14;18 translocation involving the bcl-2 gene;

sheets of large lymphoid cells;

CHOP (cyclophosphamide, doxorubicin hydrochloride, oncovin, prednisolone)

Question 10

BURKITT’S LYMPHOMA
Burkitt’s lymphoma is an aggressive tumour with dramatic presentations like an enlarging mass in the ___________________
• Typically affects young children and young adults
• Associated with ___________ and may be divided into 3 subtypes (endemic, sporadic, immunodeficiency) • Shows a characteristic ____________ appearance on histology (with CD10+ and bcl-6+ cells), with _____________________ involved

Answer 10

jaw or abdomen:

EBV infections;

starry-sky;

c-myc oncogene translocation (8;14, 2;8, 8;22)

Question 11

Some special forms of T cell lymphomas include:

• Adult T cell leukaemia/lymphoma: Common in the _____________ (associated with HTLV-1 infections)
• Enteropathy-associated T cell lymphoma: Occurs in some patients with ____________
• Cutaneous T cell lymphomas: E.g. __________
• Anaplastic large cell lymphoma: Rare type (1% of all lymphomas)

Answer 11

Caribbean and Japan;

longstanding coeliac disease ;

mycosis fungoides