Haematology 12 - Lymphoma 2

Question 1

How do Reed Sternberg cells appear on the blood film?

Answer 1

Giant cell surrounded by reactive eosinophils

Question 2

What is the age distribution of Hodgkin’s lymphoma?

Answer 2

Females 20-29 (typically nodular sclerosing)

M=F, elderly

Question 3

What are the symptoms of Hodgkin’s lymphoma?

Answer 3

Painless lymphadenopathy, that becomes painful on drinking alcohol
Constitutional B symptoms
If advanced lymphadenopathy, may –> obstructive symptoms

Question 4

What is the cause of constitutional B symptoms in lymphoma?

Answer 4

Hyper-catabolic state

Question 5

Which investigation is used to diagnose hodgkin’s lymphoma, and which diagnosis is used for staging?

Answer 5

Diagnosis: LN biopsy
Staging: FDG-PET

Question 6

Recall the different stages of Hodgkin’s lymphoma

Answer 6

I: one group of nodes
II: >1 group of nodes, on one side of the diaphragm
III: Nodes on both sides of the diaphragm
IV: extranodal spread
Then:
A: no B symptoms
B: one/ any of fever/ weight loss/ night sweats

Question 7

Which subtype of lymphoma is most likely to affect young women?

Answer 7

Nodular sclerosing Hodgkin’s

Nodular lymphocyte predominant Hodgkin’s mainly affects the elderly

Question 8

What type of chemotherapy is used in Hodgkin’s lymphoma?

Answer 8

ABVD
All patients started on chemo even if stage1
This drug regimen preserves fertility

Patients considered for rituximab (anti-cd20) or nivolumab (PD1 inhibitor- increases anti-tumour activity of T cells) if they fail ABVD

Question 9

After how many cycles of chemotherapy for Hodgkin’s lymphoma should the FDG-PET be repeated to check response?

Answer 9

After 2 cycles

And at the end of the treatment (outcomes of this will recommend if radiotherapy is needed or not)

Question 10

What is the risk of giving radiotherapy for Hodgkin’s lymphoma?

Answer 10

It produces a lot of collateral damage, and when given alongside chemotherapy increases the risk of secondary malignany significantly

Question 11

Recall 4 prognostic markers in lymphoma

Answer 11

1. LDH
2. Performance status
3. HIV serology- increases risk of b-cell lymphomas due to underactive t-cells
4. Hep B serology-immunotherapy regimens can lead to reactivation of virus and subsequent liver damage

Question 12

How aggressive is diffuse large B cell non-Hodgkin’s lymphoma?

Answer 12

High grade

Question 13

How aggressive is follicular non-Hodgkin’s lymphoma?

Answer 13

Indolent

Question 14

How is diffuse large B cell non-Hodgkin’s lymphoma treated?

Answer 14

R-CHOP
Patients who relapse are considered for autologous stem cell transplantation (25% cure rate)

Aim of treatment is to cure

Question 15

What mutation is commonly associated with follicular non-Hodgkin’s lymphoma?

Answer 15

t(14;18)

Translocation of Bcl2 –> oncogene

Question 16

Which subtype of non-Hodgkin’s lymphoma is associated with chronic H. pylori?

Answer 16

Extra-nodal marginal zone lymphoma

Question 17

What are the symptoms of extra-nodal marginal zone lymphoma?

Answer 17

Epigastric pain, ulceration and bleeding

Question 18

How aggressive is enteropathy-associated non-hodgkin’s lymphoma?

Answer 18

Very aggressive

Question 19

What is the main association of enteropathy-associated non-hodgkin’s lymphoma?

Answer 19

Coeliac

Question 20

What finding on a blood film is typial of CLL?

Answer 20

Smear/ smudge cells

Question 21

Recall the surface markers of intermediate B cells vs mature B cells vs CLL mature B cells

Answer 21

Intermediate B cell: CD5 positive
Mature B cell: CD19 positive
Mature CLL B cell: CD5 positive and CD19 positive

Question 22

What are the 2 staging methods that can be used in CLL?

Answer 22

Rai staging

Binet staging

Question 23

Is CLL a pre- or post-germinal centre malignancy?

Answer 23

50% pre, 50% post

Question 24

How can pre- and post-germinal centre CLL be differentiated?

Answer 24

VDJ sequencing

Pre germinal centre-Unmutated VDJ= much worse prognosis

Question 25

Which mutation is associated with a particularly poor prognosis in CLL?

Answer 25

17p deletion (TP53)

Question 26

What is Richter's syndrome?

Answer 26

Rare transformation of CLL to high grade lymphoma

Question 27

Recall 3 classes of targeted therapy that can be given to treat CLL

Answer 27

1. BCR kinase inhibitors (eg ibrutinib and idelalisib)- BCR Kinase important in B Cell signalling, blocking this results in B cell depletion 2. BCL2 inhibitors (eg venetoclax)- promotes apoptosis 3. CAR-T and other experimental cell-based therapies

Question 28

What type of lymph node biopsy will help you diagnose lymphomas

Answer 28

Excision biopsy or core biopsy Fine needle aspirate is useless- while not tell you anything because wont show you the structure of the lymph node. All the cells will just be smeared on the slide

Question 29

Which of the Classical Hodgkin's has a poor prognosis?

Answer 29

Lymphocyte depleted cHL

Question 30

How to differentiate symptoms of HL and NHL

Answer 30

HL will have more contiguous spread with patients often presenting with mediastinal masses. NHL will be more widespread Both will present with painless lymphadenopathy, B symptoms (except MZL) and compression symptoms, but in HL there might be painful lymph nodes after drinking

Question 31

How is follicular non-Hodgkin's lymphoma treated?

Answer 31

R-COP Treatment is not curative Watch and wait recommended first, only treat if clinically indicated (compression symptoms, painful nodes, recurrent infections)

Question 32

Laboratory findings of CLL

Answer 32

Lymphocytosis (5-300 x 10^9) Smear cells Normocytic normochromic anaemia Thrombocytopaenia Cancer of mature b lymphocytes (pre and post germinal follicle)

Question 33

Poor prognostic markers of CLL

Answer 33

CD38 pre-GC, IgH unmutated 17p(TP53) deletion