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Haem III (HL; NHL) Flashcards

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1
Q
A
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2
Q

Describe what is meant by Hodgkin’s lymphoma

A

Uncontrolled proliferation of B-lymphocytes, causing lymphadenopathy

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3
Q

The infection of which pathogen is linked to / often precedes HL? [1]

A

Epstein-Barr Virus

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4
Q

State 4 risk factors for HL [4]

A

EBV

Immunosuppression:
* Organ transplantation
* Immunosuppressant therapies
* Patients with HIV

Autoimmune conditions
* rheumatoid arthritis
* systemic lupus erythematosus
* sarcoidosis

Familial

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5
Q

Which autoimmune conditions increase the liklihood of HL? [3]

A
  • rheumatoid arthritis
  • systemic lupus erythematosus
  • sarcoidosis
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6
Q

What are the two types of HL? [2]

A

Classical Hodgkin’s lymphoma (95%)

Nodular lymphocyte-predominant Hodgkin’s lymphoma (5%)

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7
Q

Describe the features of nodular lymphocyte-predominant Hodgkin’s lymphoma (5%) [4]

A
  • More commonly affects males (75%)
  • Not associated with EBV
  • Absence of Reed-Sternberg (RS) cells, and is characterised by LP (“popcorn”) cells
  • Presents with peripheral adenopathy, and is the only type of Hodgkin’s lymphoma that affects the mesenteric lymph nodes
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8
Q

Which of the following types of classical HL is the most common?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Nodular sclerosis

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9
Q

What are the 4 subtypes of classical Hodgkins Lymphoma? [4]

A

Nodular sclerosis:
- Most common subtype, accounts for around 70% of cHL.

Mixed cellularity:
- Accounts for around 20% of cHL.

Lymphocyte-rich:
- Accounts for around 5% of cHL. Has the best prognosis.

Lymphocyte-depleted:
- Rare, accounting for < 1% of cHL. Has the the worst prognosis.

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10
Q

Which of the following types of classical HL has the worst prognosis?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Which of the following types of classical HL has the worst prognosis?

Lymphocyte-depleted

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11
Q

Which of the following types of classical HL has the best prognosis?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Which of the following types of classical HL has the best prognosis?

Lymphocyte-rich

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12
Q

Which of the following types of classical HL is most associated with HIV patients?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Lymphocyte-depleted

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13
Q

Which of the following types of classical HL is most associated with older patients

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Which of the following types of classical HL is most associated with older patients

Lymphocyte-rich

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14
Q

Which of the following types of classical HL is most associated with mediastinal lymphadenopathy and bulk nodes?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Nodular sclerosis

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15
Q

Which of the following types of classical HL is most associated with peripheral adenopathy and spleen involvement?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Mixed cellularity

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16
Q

Which of the following types of classical HL is most associated with retroperitoneal adenopathy and abdominal lymphadenopathy?

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Which of the following types of classical HL is most associated with retroperitoneal adenopathy and abdominal lymphadenopathy?

Lymphocyte-depleted

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17
Q

Which of the following types of classical HL are most asscoiated with EBV? [2]

Lymphocyte-depleted
Nodular sclerosis
Lymphocyte-rich
Mixed cellularity

A

Mixed cellularity
Lymphocyte-depleted

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18
Q

How do you stage lymphomas? [1]

Lecture content

A

PET scans

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19
Q

Describe the classical clinical features of HL [5]

A

Lymphadenopathy:
- Painless
- Non-tender and firm / rubbery
- Asymmetrical
- Cervical or mediastinal involvement
- Pain in lymph nodes after drinking alcohol

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20
Q

Describe the additional clinical features of HL than lymphadenopathy [5]

A

Pel-Ebstein fever
- cyclical fever followed by periods of being afebrile for 1-2 weeks (rare)

Abdominal pain (if abdominal lymphadenopathy is involved)

Pruritus (30%)

Clinical hepato/splenomegaly is rare (although liver and spleen involvement determined by laparoscopy/laparotomy occurs in up to 30% of the patients)

Bone marrow involvement (5-8%)

systemic - ‘B symptoms’ (25%)
* weight loss
* pruritus
* night sweats
* fever (Pel-Ebstein)

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21
Q

Describe the Cotswolds-modified Ann Arbor staging system for HL [5]

A

Stage I - limited to a single lymph node region.

Stage II - two or more lymph node regions involved, on the same side of the diaphragm.

Stage III - lymph node regions involved on both sides of the diaphragm.

Stage IV - spread to other organs, such as liver, spleen, or bone marrow, with or without nodal involvement.

Each stage is followed by a letter:

  • A - without B symptoms.
  • B - with B symptoms, including fever, weight loss, night sweats.
  • E - an extra-nodal site involved, that is localised to the known lymph node region.
  • X - bulky disease: mediastinal mass exceeds 1/3 of the intrathoracic diameter or nodal mass >10cm in dimension.
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22
Q

Describe the treatment plan for Stage I/II classical Hodgkin’s lymphoma [2]

and

Stage III/ IV classical Hodgkin’s lymphoma [2]

A

Stage I/II classical Hodgkin’s lymphoma:
- Chemotherapy followed by radiotherapy
- Main treatment regimen: ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) + radiotherapy

Stage III/ IV classical Hodgkin’s lymphoma:
- Chemotherapy alone: ABVD or BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisolone)

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23
Q

Describe the treatment plan for Stage I/ II nodular lymphocyte-predominant Hodgkin’s lymphoma: [1]

and

Stage III/ IV nodular lymphocyte-predominant Hodgkin’s lymphoma [2]

A

Stage I/ II nodular lymphocyte-predominant Hodgkin’s lymphoma:
- Involved-field radiotherapy alone is the main treatment for this group of patients with excellent clinical benefit.

Stage III/ IV nodular lymphocyte-predominant Hodgkin’s lymphoma:
- R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) is administered in symptomatic patients or those with rapid disease progression .
- Regular monitoring is adequate in asymptomatic patients.

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24
Q

Describe the management plan for HL in refractory disease [2]

A

Chemotherapy followed by autologous stem cell transplantation (ASCT)

Immunotherapeutic agents can be considered:
- Brentuximab vedotin
- nivolumab
- pembrolizumab

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25
doxorubicin has a risk of causing which cardiac abnormality? [1]
**doxorubicin** causes a higher risk of developing **cardiomyopathy**.
26
Describe the common complcations of HL [6]
Complications of Hodgkin's lymphoma are **usually chemotherapy or radiotherapy related.** **Thyroid**: - Around 50% of the patients who received radiotherapy experience symptoms of **hypothyroidism.** - **thyroid** **cancer** and **hyperthyroidism** also possible **Chemotherapy drugs**,: especially alkylating agents are associated with **secondary malignancies**: - **acute myeloid leukaemia** - **paraneoplastic syndrome** **Cardiac abnormalities**: - **doxorubicin** are at a higher risk of developing **cardiomyopathy** - **acute pericarditis** shortly after receiving radiotherapy - **valvular heart disease** or **coronary heart disease** in the long-term after radiotherapy **Pulmonary toxicity**: - **bleomycin-related pulmonary toxicity** - **Radiation-induced pneumonitis** **Infertility** :( **Infections**: - **Neutropenia** is common in patients taking chemotherapeutic regimens such as **ABVD**, and almost all patients receiving **BEACOPP** are neutropenic.
27
How do you differentiate between leukaemia and lymphoma from a FBC? [1]
**Leukaemias** tend to have **high circulating serum WCCs** **Lymphomas** tend not to have circulating cells; **have solid tumours; enlarged LN with high WCC**
28
Describe the pathway of where normal B lymphocyte development occurs [4]
**B cells:** - Bone marrow - Blood (as niave B-lymphocytes) - Lymphoid tissue (e.g. spleen / LNs / liver); devell - (back to the) Bone Marrow and become **plasma cells**
29
Which of the following areas during B cell development is where B cells start the ability to make immunoglobulins Bone marrow Blood Lymphoid tissue Marrow
Which of the following areas during B cell development is where B cells start the ability to make immunoglobulins Bone marrow Blood **Lymphoid tissue** Marrow
30
Through which process do T lymphocytes make new TCR for antigens [1]
T cells actively mutate their DNA via **VDJ recombination** to make a unique T cell receptor for new antigens as **immature T cells**
31
Describe the process of somatic hypermutation [2]
B cells transit in peripheral blood to germinal centres May detect an antigen, but often this is not specific, so they undergo **somatic hypermutation**. - Rapid and aggressive mutation of DNA to try and improve specificity and recognition of their receptor for the antigen - Go back to bone marrow, become plasma cells and make specific antibodies
32
During B-lymphocyte development, cells start to make antibodies in the lymphoid tissue, before they move back to bone marrow. What Ig do they make in the lymphoid tissues? IgA IgG IgM IgE IgD
During B-lymphocyte development, cells start to make antibodies in the lymphoid tissue, before they move back to bone marrow. What Ig do they make in the lymphoid tissues? IgA IgG **IgM** IgE IgD
33
Describe the process of normal T cell development [4]
34
State and explain which organs are commonly affected in chronic lymphomas [3]
**Lymphadenopathy** **Splenomegaly** **Hepatomegaly** Because they're all germinal centres - which is and important stage in developement in lymphomas Also get B-symptoms
35
State where the following generally occur: [4] State for the following if they're generally aggressive or slow [4] - ALL - CLL - Lymphomas - Myelomas
ALL: - **Bone marrow** - **Aggressive** CLL: - **Blood** - **Slow** Lymphomas: - **Lymphoid tissue** - **Agrresive (high grade); slow (low grade)** Myelomas: - **BM** - **Slow**
36
Whats the general rules about prognosis and chance of cure for aggressive or slow diseases? [2]
**Aggressive:** - Rapidly fatal - Chance of cure **Low grade:** - Grow slowly - Much harder to cure
37
How can you work out if a lymphoma is aggressive or low grade?
**Low grade lymphomas** quite often have pathological descriptions of the cells (e..g follicular lymphoma) **High grade lymphomas** are named
38
For lymphomas, what type of testing do you normally perform for - Diagnostic test - Prognostic test - Staging test
Diagnostic test: - **Biopsy; morphology; phenotyping tests** - Sometimes supported by cytogenetic / molecular Prognostic test: - **Cytogenetic test** Staging test: - **Usually imaging**
39
40
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
41
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**
42
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.
43
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**.
44
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
45
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**
46
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**
47
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**
48
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**
49
State 5 reasons for NHL oncological emergencies [5]
* Superior vena cava obstruction (SVCO) * Cord compression * Hypercalcaemia * Tumour lysis syndrome * Neutropenic sepsis
50
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
51
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.
52
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.
53
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
54
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**
55
Which of the following is most likley to have cause cardiomyopathy? Rituximab Cyclophosphamide Doxorubicin Vincristine Prednisolone
**Doxorubicin**
56
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
57
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**
58
Which of the following is most likley to have caused bladder atony? Rituximab Cyclophosphamide Doxorubicin Vincristine Prednisolone
**Vincristine**
59
Which of the following is most likley to have caused Hep B reactivation Rituximab Cyclophosphamide Doxorubicin Vincristine Prednisolone
**Rituximab**
60
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
61
Which of the following is most likley to cause an infusion reaction? Rituximab Cyclophosphamide Doxorubicin Vincristine Prednisolone
**Rituximab**
62
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**
63
This patient most likely has Diffuse large B cell lymphoma (DLBCL) Follicular lymphoma Burkitt’s lymphoma
**Burkitt’s lymphoma**
64
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*
65
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**
66
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**
67
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**
68
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**
69
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**
70
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
71
Which lymph nodes does Burkitt's lymphoma typically present in? [1]
**Abdomen and mesenteric** lymph nodes
72
Burkitt's lymphoma typically causes what complication? [1]
**Tumour lysis syndrome**

Yr3 Revision (37 decks)

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