Hematopathology Practice Questions

Q: Working Formulation in classification of NHL is based on:

Morphology of cells. ***Morphology of cells*** - The staging of non-Hodgkin lymphoma (NHL) is primarily based on the **morphological characteristics** of the tumor cells, which helps in classifying the type of lymphoma [1]. - Accurate morphological assessment, including cell size, shape, and arrangement, aids in determining **prognosis** and guiding treatment decisions [1]. *Cells of origin* - While the **origin of the cells** is important, it is not the primary factor in staging NHL. - Cell origin is more relevant for **classification** rather than staging, which focuses on tumor morphology. *None of the above* - This option implies that the correct basis for staging is not listed, which is incorrect since morphology is the appropriate criterion. - Furthermore, choosing this isregards valid and clear factors that do influence staging in NHL. *Survival characteristics of cells* - Survival characteristics primarily relate to **prognosis** and how well a patient might do with treatment, not staging. - Staging involves **anatomical and histopathological** evaluations rather than just survival metrics of the cells. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 596-598.

Q: In the context of extranodal Hodgkin's lymphoma, which of the following sites is most commonly involved?

Bone. ***Bone*** - Among the options listed, **bone is the most frequently involved extranodal site** in Hodgkin's lymphoma, particularly in patients with advanced stage disease. - **Note:** The most common extranodal sites overall in Hodgkin's lymphoma are the **spleen**, **liver**, and **bone marrow** [1]. However, among the specific sites listed in this question, bone involvement is most frequent. - Osseous involvement often manifests as **osteolytic or osteoblastic lesions** visible on imaging and may cause bone pain or pathological fractures. *Thymus* - While the **mediastinum** (including thymus) is a common **nodal site** for Hodgkin's lymphoma (especially nodular sclerosis subtype), extensive thymic involvement as a true **extranodal site** is less common than bone [1]. - Primary thymic lymphomas are more characteristic of **T-cell lymphoblastic lymphoma** rather than Hodgkin's lymphoma. *Thyroid* - **Thyroid involvement** in Hodgkin's lymphoma is rare, typically occurring as secondary extension from adjacent cervical lymph nodes. - Primary thyroid lymphoma is more commonly **non-Hodgkin lymphoma** (particularly MALT lymphoma or DLBCL) associated with Hashimoto's thyroiditis. *Small bowel* - **Gastrointestinal involvement**, including small bowel, is a rare manifestation of Hodgkin's lymphoma. - GI tract lymphomas are predominantly **non-Hodgkin lymphomas** (especially MALT lymphoma, DLBCL, and enteropathy-associated T-cell lymphoma). **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 557-559.

Q: Gandy-Gamma nodules are typically seen in chronic venous congestion of

Spleen. ***Spleen*** - **Gandy-Gamma nodules** (also called **Gamna-Gandy bodies**) are characteristic findings in the spleen, resulting from **chronic passive congestion**. - These nodules are composed of **fibrous tissue**, **hemosiderin**, and **calcium deposits**, reflecting old microhemorrhages and fibrosis due to chronic congestion. - They appear as **rust-brown nodules** on the splenic capsule, typically seen in conditions causing splenic congestion such as **portal hypertension** or **congestive splenomegaly**. *Lungs* - Chronic venous congestion in the lungs typically leads to **pulmonary hypertension** and **hemosiderin-laden macrophages** (heart failure cells). - It does not involve the formation of Gandy-Gamma nodules. *Kidneys* - Chronic venous congestion of the kidneys can lead to **renal dysfunction** and morphological changes like **glomerular sclerosis** or **tubulointerstitial fibrosis**. - Gandy-Gamma nodules are not associated with renal pathology. *Liver* - Chronic venous congestion of the liver, often due to **right-sided heart failure**, results in **nutmeg liver** appearance. - This involves **centrilobular necrosis** and congestion, but not Gandy-Gamma nodules.

Q: Which immunoglobulin is primarily associated with lymphoplasmacytoid lymphoma?

IgM. ***IgM*** - Lymphoplasmacytoid lymphomas are often associated with **elevated serum IgM** levels, indicative of monoclonal gammopathy [1]. - These lymphomas primarily involve **plasma cells** that secrete IgM, leading to conditions such as **Waldenström macroglobulinemia** [2]. *IgA* - IgA is primarily involved in **mucosal immunity** and is not typically associated with lymphoplasmacytoid lymphomas. - These lymphomas do not usually show a **dominance of IgA secreting cells** compared to the IgM type [1]. *IgG* - While IgG is important in immune responses, it is not the hallmark of lymphoplasmacytoid lymphomas, which are characterized by **IgM secretion** [1]. - These lymphomas do not present with **significant IgG monoclonal gammopathy** like other plasma cell disorders. *IgE* - IgE is predominantly associated with **allergic reactions** and parasitic infections, and has no known association with lymphoplasmacytoid lymphomas. - These lymphomas are even less related to **IgE production**, which plays a minimal role in lymphoid malignancies. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 609-610. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 606-607.

Q: Which marker is used to differentiate a thymoma from acute lymphoblastic leukemia (ALL)?

Cytokeratin. ***Cytokeratin*** - **Thymomas** are epithelial tumors and express **cytokeratin**, which is a marker for epithelial cells, while **ALL** (Acute Lymphoblastic Leukemia) does not express this marker. - The presence of **cytokeratin** indicates a **thymic origin**, differentiating it from lymphoid neoplasms like **ALL**. *CD1a* - This marker is primarily associated with **Hodgkin's lymphoma** and some **T-cell neoplasms**, not thymomas [2]. - The lack of expression in **ALL** makes it an unsuitable differentiator for thymomas. *Tdt* - **Tdt** (Terminal deoxynucleotidyl transferase) is a marker typically found in lymphoid progenitor cells, especially in **ALL**. - Its presence would not indicate a **thymoma**, which does not express **Tdt**. *CD3* - While **CD3** is a marker of **T-cells** [2], it is not specific for thymomas, which can be **CD3-positive**, but it is also seen in various **lymphoid proliferations** including **ALL** [1]. - Therefore, it cannot be definitively used to distinguish between a thymoma and **ALL**. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 599-600. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 598.

Q: Cord red blood cells from an infant suspected of having hemolytic disease of the newborn are most likely to be tested by which of the following?

Direct Coombs test. ***Direct coombs test*** - The **direct Coombs test** is utilized to detect antibodies attached to the surface of red blood cells (RBCs), which is a key factor in diagnosing **hemolytic disease of the newborn** [1]. - It specifically identifies **autoantibodies** or **alloantibodies** causing hemolysis in infants due to maternal-fetal blood group incompatibility. *Nephelometry* - Nephelometry is used for measuring **immunoglobulin levels** and not specific for detecting **antibodies on RBCs**. - It does not provide information about hemolysis or the specific conditions related to **hemolytic disease of the newborn**. *Hemagglutination inhibition test* - This test is primarily used for identifying **viral infections** and assessing antibody response rather than detecting antibodies on RBCs. - It is not relevant for diagnosing conditions like **hemolytic disease of the newborn**. *Passive hemagglutination test* - The passive hemagglutination test detects antigens or antibodies but does not specifically identify **coated RBCs** from hemolytic disease. - It is less specific and not the preferred method for determining the cause of **hemolysis in newborns**. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Blood And Bone Marrow Disease, pp. 603-604.

Q: Which malignancy is characterized by a stepwise progression through lymph nodes, making staging an important prognostic factor?

Hodgkin's lymphoma. ***Hodgkin's lymphoma*** - Characteristically spreads in a **stepwise fashion** through lymphatic pathways [1], making **staging critical** for prognosis [1]. - Its localized dissemination and the presence of **Reed-Sternberg cells** help define its distinct clinical behavior [1]. *Multiple myeloma* - Primarily characterized by **disseminated plasma cell proliferation** and typically does not follow a stepwise spread pattern. - Staging is based on **serum markers** rather than anatomical spread, focusing more on paraproteins and organ damage. *Mature T cell NHL* - Often exhibits an **aggressive** nature with various patterns of spread, but not characteristically in a stepwise manner [2]. - Staging relevance is less focused compared to Hodgkin's lymphoma, as many subtypes present differently. *Mature B cell NHL* - More variable in behavior and can disseminate **discontinuously** [2], lacking a uniform stepwise progression. - Staging exists but is often less straightforward compared to **Hodgkin's lymphoma**, which has a more predictable pattern [1][2].

Q: A 17-year-old boy presented with a total leukocyte count of 138 × 10^9/L, with 80% blasts on the peripheral smear. Chest X-ray demonstrated a large mediastinal mass. Immunophenotyping of this patient's blasts would most likely demonstrate:

Markers associated with immature T-cell lineage. ***An immature T cell phenotype (Tdt/CD34/CD7 positive)*** - Given the age of the patient and presentation, the high percentage of blasts along with the mediastinal mass suggests **T-cell acute lymphoblastic leukemia (T-ALL)** [1], which commonly presents with an immature T cell phenotype. - The presence of **Tdt, CD34, and CD7** indicates the immature nature of the T cells, which is characteristic of this condition. *No surface antigens (null phenotype)* - A null phenotype typically indicates a **lack of differentiation**, which is not consistent with the high blast count seen here. - Most leukemias or lymphomas usually express some markers, especially in a case with significant blast population like this one. *Myeloid markers, such as CD13, CD33 and CD15* - These markers are indicative of **myeloid lineage**, which is not relevant in this case as it suggests an **acute myeloid leukemia (AML)**, not T-ALL. - The clinical context and immunophenotyping results would not support myeloid lineage in a patient with such a presentation. *B cell markers, such as CD 19, CD20 and CD22* - These are **characteristic of B-cell lineage** [1], which is not relevant in this scenario, given the presence of a mediastinal mass often associated with T-cell malignancies. - The blast cells in this patient are clearly indicative of a **T-cell disorder**, rather than a B-cell neoplasm. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 598-600.

Q: A 45-year-old female patient presented with painless supraclavicular lymphadenopathy. Biopsy revealed binucleated acidophilic owl eye appearance with floating lymphocytes in empty space, which were CD15 and CD30 positive. What is the most probable diagnosis?

Nodular sclerosis Hodgkin lymphoma (NSHL). ***Nodular sclerosis Hodgkin lymphoma*** - Characterized by a **painless supraclavicular lymphadenopathy** and the presence of **binucleated Reed-Sternberg cells** with the "owl eye" appearance. - **CD15** and **CD30 positivity** confirm the diagnosis, common in this subtype of Hodgkin lymphoma [2]. *Lymphocytic predominant Hodgkin lymphoma* - Typically shows **lymphocyte-rich background** and may present with fewer **Reed-Sternberg cells**, which differ from the described findings [3]. - **CD15** and **CD30 positivity** is generally low, contrasting with the strong positivity seen in this case. *Lymphocytic depleted lymphoma* - Characterized by a **lack of lymphocytes** and high numbers of **Reed-Sternberg cells**, not matching the floating lymphocyte description [1]. - **Usually CD15 and CD30** positive but presents with **more aggressive clinical features** than nodular sclerosis. *Mixed cellularity Hodgkin lymphoma* - This form also presents with Reed-Sternberg cells but typically involves a more **heterogeneous population** of inflammatory cells [2,3]. - Presentation of **painless lymphadenopathy** can occur, but the specific histological findings here are more indicative of nodular sclerosis. **References:** [1] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 559-560. [2] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, pp. 616-618. [3] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Diseases of White Blood Cells, Lymph Nodes, Spleen, and Thymus, p. 618.

Question 1

Working Formulation in classification of NHL is based on:

Accepted Answer

Morphology of cells

Answer

Survival characteristics of cells

Answer

Cells of origin

Answer

None of the options

Question 2

In the context of extranodal Hodgkin's lymphoma, which of the following sites is most commonly involved?

Accepted Answer

Bone

Answer

Thyroid

Answer

Small bowel

Answer

Thymus

Question 3

Gandy-Gamma nodules are typically seen in chronic venous congestion of

Accepted Answer

Spleen

Answer

Lungs

Answer

Kidneys

Answer

Liver

Question 4

Which immunoglobulin is primarily associated with lymphoplasmacytoid lymphoma?

Accepted Answer

IgM

Answer

IgG

Answer

IgA

Answer

IgE

Question 5

Which marker is used to differentiate a thymoma from acute lymphoblastic leukemia (ALL)?

Accepted Answer

Cytokeratin

Answer

CD1a

Answer

CD3

Answer

TdT

Question 6

Cord red blood cells from an infant suspected of having hemolytic disease of the newborn are most likely to be tested by which of the following?

Accepted Answer

Direct Coombs test

Answer

Hemagglutination inhibition test

Answer

Nephelometry

Answer

Passive hemagglutination test

Question 7

Which malignancy is characterized by a stepwise progression through lymph nodes, making staging an important prognostic factor?

Accepted Answer

Hodgkin's lymphoma

Answer

Multiple myeloma

Answer

Mature T cell NHL

Answer

Mature B cell NHL

Question 8

A 17-year-old boy presented with a total leukocyte count of 138 × 10^9/L, with 80% blasts on the peripheral smear. Chest X-ray demonstrated a large mediastinal mass. Immunophenotyping of this patient's blasts would most likely demonstrate:

Accepted Answer

Markers associated with immature T-cell lineage

Answer

Markers associated with myeloid lineage

Answer

Markers associated with B-cell lineage

Answer

A null phenotype (no surface antigens)

Question 9

Which of the following is a false statement regarding disseminated intravascular coagulation (DIC)?

Accepted Answer

Decreased PTT

Answer

Decreased fibrinogen

Answer

Increased PT

Answer

Thrombocytopenia

Question 10

A 45-year-old female patient presented with painless supraclavicular lymphadenopathy. Biopsy revealed binucleated acidophilic owl eye appearance with floating lymphocytes in empty space, which were CD15 and CD30 positive. What is the most probable diagnosis?

Accepted Answer

Nodular sclerosis Hodgkin lymphoma (NSHL)

Answer

Lymphocytic predominant Hodgkin lymphoma

Answer

Mixed cellularity Hodgkin lymphoma

Answer

Lymphocytic depleted Hodgkin lymphoma

Hematopathology — MCQs

Hematopathology — MCQs

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