Lymphomas — MCQs
The most common subtype of Non-Hodgkin's lymphoma in India is:
Which protein is a key marker of Reed-Sternberg cells in Hodgkin's lymphoma?
In which type of Hodgkin's lymphoma are classical Reed-Sternberg cells most characteristically observed?
Which among the following is the commonest malignancy of childhood?
A 32-year-old female presents with a 2-month history of progressive, painless swelling in the left side of her neck. She also reports low-grade fever, night sweats, and unintentional weight loss. Physical examination reveals a firm, non-tender, immobile mass in the left cervical region, and multiple smaller lymph nodes in the supraclavicular area. Chest X-ray shows mediastinal widening, and a lymph node biopsy confirms the presence of Reed-Sternberg cells. What is the most appropriate management for this patient?
Which of the following is the most common hematologic malignancy associated with Neurofibromatosis-1 (NF-1) in a child?
In a patient with general fatigue, normal TLC/ DLC, and superficial discrete lymphadenopathy, with lymph node biopsy showing effaced architecture, atypical cells with indented nuclei and prominent nucleoli, positive for CD10 and BCL-2, which of the following is the most likely diagnosis?
Which of the following statements on lymphoma is not true?
A 12-year-old boy comes to the physician because of headache, fever, nausea and vomiting. His mother reports that he has been unwell for a couple of days but seems to have become worse. In addition to his headache, he has a very stiff neck. He has no other past medical history except for well-controlled asthma. His pulse is 114/min and he has a fever of 38.5°C (101.3°F). His examination is notable for meningismus, as evidenced by discomfort elicited by movement of his neck. He also becomes visibly uncomfortable when you check his pupillary responses with a flashlight. Which of the following patterns of cerebrospinal fluid would you expect to see if this boy turns out to have viral meningitis?
A child presents with fever and vesicular lesions on the upper limb and the lower limb. Neck stiffness was present. Similar lesions were present on the palms, soles, and oral cavity. CSF analysis revealed normal glucose levels and elevated lymphocytes and protein. What is the most likely diagnosis?
Lymphomas Indian Medical PG Practice Questions and MCQs
Question 1: The most common subtype of Non-Hodgkin's lymphoma in India is:
- A. Diffuse small cell lymphocytic lymphoma
- B. Diffuse large B cell lymphoma (Correct Answer)
- C. Follicular lymphoma
- D. Burkitt's lymphoma
Explanation: ***Diffuse large B cell lymphoma*** - It is the most common subtype of **Non-Hodgkin's lymphoma** observed in India, reflecting a higher prevalence in the population. - Characterized by **aggressive clinical behavior** [1] and typically presents as a rapidly enlarging mass, often involving lymph nodes or extranodal sites. *Burkitt's lymphoma* - This subtype is known for its **high proliferation rate** and is more common in specific demographics, such as children and immunocompromised individuals. - It typically presents with **jaw lesions** or abdominal masses, which is not typical in the broader Indian population. *Diffuse small cell lymphocytic lymphoma* - More accurately classified as **chronic lymphocytic leukemia** (CLL), it is not the most common subtype of Non-Hodgkin's lymphoma. - Characterized by a **milder clinical course** and presents with lymphocytosis in peripheral blood, lacking aggressive features. *Follicular lymphoma* - This is usually a **low-grade lymphoma** associated with **indolent behavior** and may not be the most commonly diagnosed subtype in India. - It typically involves multiple lymph nodes and is characterized by **nodular patterns on histology**, making it less prevalent than diffuse large B cell lymphoma. Follicular lymphoma is rare in Asian populations [2]. **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. 563-564. [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. 602-604.
Question 2: Which protein is a key marker of Reed-Sternberg cells in Hodgkin's lymphoma?
- A. CD19
- B. CD20
- C. CD15 (Correct Answer)
- D. CD45
Explanation: ***CD15*** - **CD15** (along with **CD30**) is a characteristic **immunophenotypic marker** of **Reed-Sternberg cells** in **classical Hodgkin's lymphoma** [1]. - The classic immunophenotype is **CD30+/CD15+/CD45-/CD20-** (CD20 may be weakly positive in some cases). - **CD30 is the most sensitive marker** (positive in >95% of cases), while **CD15 is positive in 75-85%** of classical Hodgkin's lymphoma cases. - Both markers together aid in the definitive diagnosis and differentiation of Hodgkin's lymphoma from other lymphomas. *CD19* - **CD19** is an important **B-cell marker** expressed on normal B lymphocytes and in most B-cell non-Hodgkin lymphomas, but it is typically **negative** in Reed-Sternberg cells [1]. - Its presence usually points away from Hodgkin's lymphoma and towards a B-cell lineage malignancy. *CD20* - **CD20** is another key **B-cell marker** found on the surface of normal B lymphocytes and **most B-cell non-Hodgkin lymphomas**. - Reed-Sternberg cells usually **lack CD20 expression** (or show only weak positivity in 20-40% of cases), helping to distinguish Hodgkin's lymphoma from B-cell non-Hodgkin lymphomas [1]. *CD45* - **CD45** (also known as leukocyte common antigen, LCA) is expressed on nearly all **hematopoietic cells**, including most lymphomas. - However, **Reed-Sternberg cells are typically negative or only weakly positive for CD45**, which is a significant diagnostic feature that helps differentiate Hodgkin's lymphoma from many non-Hodgkin lymphomas [1]. **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. 614-618.
Question 3: In which type of Hodgkin's lymphoma are classical Reed-Sternberg cells most characteristically observed?
- A. Lymphocyte depleted
- B. Nodular sclerosis
- C. Lymphocyte predominance
- D. Mixed cellularity Hodgkin (Correct Answer)
Explanation: ***Lymphocyte predominance*** - The **Hodgkin's lymphoma (HL) lymphocyte predominance** variant characteristically displays a predominance of lymphocytes in the cellular makeup [1]. - This subtype is often associated with a better prognosis and fewer symptoms than other types of HL [1]. *Lymphocyte depleted* - This subtype features a significant decrease in lymphocytes, leading to a **higher proportion of Reed-Sternberg cells** [3]. - It typically presents with a more aggressive clinical course, which contrasts with lymphocyte predominance [3]. *Mixed cellularity hodgkin* - Mixed cellularity shows a variety of cell types, including a significant number of **Reed-Sternberg cells**, but does not demonstrate **lymphocyte predominance** [2]. - This subtype is generally found in older patients and associated with advanced disease, unlike lymphocyte predominance [2]. *Nodular sclerosis* - Nodular sclerosis subtype is characterized by **collagen bands** and a particular architecture that is distinct from lymphocyte predominance [2]. - It primarily affects younger patients and can often involve mediastinal lymph nodes; however, it does not have the features of lymphocyte predominance [2]. **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, p. 618. [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] 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.
Question 4: Which among the following is the commonest malignancy of childhood?
- A. Brain tumor
- B. Neuroblastoma
- C. Lymphoma
- D. Acute Lymphoblastic Leukemia (ALL) (Correct Answer)
Explanation: ***Acute Lymphoblastic Leukemia (ALL)*** - **ALL** accounts for approximately 25% of all childhood cancers and is the **most common leukemia** in children. - It is characterized by the rapid production of immature white blood cells (lymphoblasts) in the bone marrow, leading to symptoms like **fatigue, fever, and easy bruising**. *Brain tumor* - **Brain tumors** are the **second most common malignancy** in childhood, after leukemia. - While significant, they are not as frequent as ALL in the overall pediatric cancer population. *Neuroblastoma* - **Neuroblastoma** is a cancer of the nerve cells and is one of the most common cancers in **infants** and **young children (under age 5)**. - It arises from **neuroblasts** (immature nerve cells) and often presents as an abdominal mass, but its overall incidence is lower than ALL. *Lymphoma* - **Lymphomas**, including Hodgkin and non-Hodgkin types, are cancers of the lymphatic system and are significant but **less common than ALL** in childhood. - Non-Hodgkin lymphoma is more common in childhood than Hodgkin lymphoma, but both together are still outranked by leukemia.
Question 5: A 32-year-old female presents with a 2-month history of progressive, painless swelling in the left side of her neck. She also reports low-grade fever, night sweats, and unintentional weight loss. Physical examination reveals a firm, non-tender, immobile mass in the left cervical region, and multiple smaller lymph nodes in the supraclavicular area. Chest X-ray shows mediastinal widening, and a lymph node biopsy confirms the presence of Reed-Sternberg cells. What is the most appropriate management for this patient?
- A. NHL with a highly aggressive chemotherapy regimen
- B. Hodgkin Lymphoma with the ABVD regimen (Correct Answer)
- C. NHL with Rituximab
- D. Hodgkin Lymphoma with surgical excision only
- E. Hodgkin Lymphoma with radiation therapy only
Explanation: ***Hodgkin Lymphoma with the ABVD regimen*** - The presence of **Reed-Sternberg cells** in a lymph node biopsy, along with **painless lymphadenopathy**, **mediastinal widening**, and **B symptoms** (fever, night sweats, weight loss), is characteristic of **Hodgkin Lymphoma**. - **ABVD chemotherapy** (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) is the standard frontline treatment regimen for Hodgkin Lymphoma, especially in advanced stages or with B symptoms. *NHL with a highly aggressive chemotherapy regimen* - This patient's symptoms and especially the presence of **Reed-Sternberg cells** are pathognomonic for **Hodgkin Lymphoma**, not Non-Hodgkin Lymphoma (NHL). - While some NHLs require aggressive chemotherapy, the specific findings in this case point away from an NHL diagnosis. *NHL with Rituximab* - **Rituximab** is a monoclonal antibody targeting the **CD20 antigen** found on B-cells and is primarily used in the treatment of **B-cell Non-Hodgkin Lymphomas**. - Since the diagnosis here is Hodgkin Lymphoma, characterized by Reed-Sternberg cells (which are atypical B cells that typically lack CD20), rituximab is not an appropriate primary treatment. *Hodgkin Lymphoma with surgical excision only* - **Hodgkin Lymphoma** is a systemic disease, as evidenced by mediastinal widening and B symptoms, indicating spread beyond a localized area. - **Surgical excision alone** is not curative for Hodgkin Lymphoma; systemic chemotherapy, often combined with radiation therapy, is essential for effective treatment. *Hodgkin Lymphoma with radiation therapy only* - While **radiation therapy** plays a role in Hodgkin Lymphoma treatment, it is typically used in **combination with chemotherapy** (combined modality therapy) or reserved for **early-stage, favorable-risk disease without B symptoms**. - This patient presents with **advanced disease** (mediastinal involvement, B symptoms, multiple lymph node regions), which requires **systemic chemotherapy** as the primary treatment modality. - Radiation alone would be inadequate for achieving optimal disease control and cure in this clinical scenario.
Question 6: Which of the following is the most common hematologic malignancy associated with Neurofibromatosis-1 (NF-1) in a child?
- A. Chronic Myeloid Leukemia (CML)
- B. Acute Lymphoblastic Leukemia (ALL)
- C. Acute Myeloid Leukemia (AML)
- D. Juvenile Myelomonocytic Leukemia (JMML) (Correct Answer)
Explanation: ***Juvenile Myelomonocytic Leukemia (JMML)*** - **JMML** is a myelodysplastic/myeloproliferative neoplasm that is strongly associated with **NF-1** in children, particularly due to mutations in the *NF1* gene. - Children with **NF-1** have a significantly increased risk of developing **JMML** compared to the general pediatric population. *Chronic Myeloid Leukemia (CML)* - While CML can occur in children, it is typically associated with the **Philadelphia chromosome (BCR-ABL1 fusion gene)** and not a common tumor directly linked to NF-1. - **CML** is relatively rare in childhood compared to other leukemias and is not a characteristic complication of NF-1. *Acute Lymphoblastic Leukemia (ALL)* - **ALL** is the most common childhood cancer overall, but its association with **NF-1** is not as specific or strong as that of **JMML**. - While children with NF-1 may have a slightly increased risk of certain cancers, **ALL** is not the *most common* tumor directly linked to NF-1. *Acute Myeloid Leukemia (AML)* - **AML** has a weak association with **NF-1**, particularly specific subtypes, but it is less frequent and less specifically linked than **JMML**. - The direct genetic pathway involving the **NF1 gene** mutation in the development of **AML** is not as clearly defined as it is for **JMML**.
Question 7: In a patient with general fatigue, normal TLC/ DLC, and superficial discrete lymphadenopathy, with lymph node biopsy showing effaced architecture, atypical cells with indented nuclei and prominent nucleoli, positive for CD10 and BCL-2, which of the following is the most likely diagnosis?
- A. Mycosis Fungoides
- B. Burkitt's Lymphoma
- C. Follicular Lymphoma (Correct Answer)
- D. Hodgkin Lymphoma
Explanation: ***Follicular Lymphoma*** - The description of **atypical cells with indented nuclei** (cleaved cells) and **prominent nucleoli**, along with **CD10** and **BCL-2 positivity**, are classic features of follicular lymphoma [1], [2]. - **Effaced architecture** of the lymph node, and **superficial discrete lymphadenopathy** in an adult, further support this diagnosis [1]. *Mycosis Fungoides* - This is a **cutaneous T-cell lymphoma** characterized by skin lesions (patches, plaques, tumors) and rarely involves lymph nodes in the early stages. - It would show **CD3+ T-cells** on immunophenotyping, not CD10+ B-cells. *Burkitt's Lymphoma* - Characterized by rapidly growing tumors and a **"starry sky"** histological pattern with numerous macrophages [3]. - While it is CD10 positive, it would typically be **BCL-2 negative** due to the specific translocation involved (t(8;14) c-MYC/IgH). *Hodgkin Lymphoma* - Defined by the presence of **Reed-Sternberg cells** (large, multinucleated cells with prominent nucleoli, often described as "owl's eye" appearance). - These cells are typically **CD15+ and CD30+**, and BCL-2 expression is less specific and CD10 is not characteristic. **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. 561-562. [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. 602-604. [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. 606.
Question 8: Which of the following statements on lymphoma is not true?
- A. In general, follicular (nodular) NHL has worse prognosis compared to diffuse NHL. (Correct Answer)
- B. HD more often tends to remain localized to a single group of lymph nodes and spreads by contiguity.
- C. Several types of non-Hodgkin's lymphoma (NHL) may have a leukemic phase.
- D. A single classification system for Hodgkin's disease (HD) is almost universally accepted.
Explanation: ***In general follicular NHL has worse prognosis compared to diffuse NHL*** - Follicular Non-Hodgkin's lymphoma (NHL) typically has a **more indolent** course than diffuse lymphoma, leading to **better long-term survival** [1]. - Diffuse Large B-cell Lymphoma (DLBCL) is usually more aggressive and tends to have a **poorer prognosis** despite being treatable. *HD tends to remain localized to a single group of lymph nodes and spreads by contiguity* - Hodgkin's Disease (HD) is known for progressing in a **contiguous manner** [2], but it can **spread beyond localized regions** as well. - While it often starts in a single area, advanced stages may show **systemic spread**, contradicting the strict localization concept. *Several types of Non-Hodgkin's lymphoma may have a leukemic phase* - Certain Non-Hodgkin's lymphomas, such as **chronic lymphocytic leukemia (CLL)**, indeed can present with a significant **leukemic phase** [3]. - This characteristic differentiates them from other lymphomas that typically do not exhibit this phase. *A single classification system of Hodgkin's disease is almost universally accepted* - There are **multiple classification systems** for Hodgkin's Disease [4], including the Ann Arbor system and others, indicating no **universal acceptance**. - Ongoing research may lead to updates and varied classification approaches, showing the **evolution of diagnostic criteria**. **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. 561-562. [2] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 557-558. [3] Cross SS. Underwood's Pathology: A Clinical Approach. 6th ed. Common Clinical Problems From Diseases Of The Urinary And Male Genital Tracts, pp. 560-561. [4] 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.
Question 9: A 12-year-old boy comes to the physician because of headache, fever, nausea and vomiting. His mother reports that he has been unwell for a couple of days but seems to have become worse. In addition to his headache, he has a very stiff neck. He has no other past medical history except for well-controlled asthma. His pulse is 114/min and he has a fever of 38.5°C (101.3°F). His examination is notable for meningismus, as evidenced by discomfort elicited by movement of his neck. He also becomes visibly uncomfortable when you check his pupillary responses with a flashlight. Which of the following patterns of cerebrospinal fluid would you expect to see if this boy turns out to have viral meningitis?
- A. Normal opening pressure; Elevated cell count; Elevated protein; Normal glucose (Correct Answer)
- B. Normal opening pressure; Elevated cell count; Elevated protein; Low glucose
- C. Elevated opening pressure; Normal cell count; Normal protein; Normal glucose
- D. Elevated opening pressure; Elevated cell count; Elevated protein; Low glucose
Explanation: ***Normal opening pressure; Elevated cell count; Elevated protein; Normal glucose*** - In **viral meningitis**, the **opening pressure** is typically normal, though it can be mildly elevated. - The CSF profile for viral meningitis characteristically shows an **elevated cell count (lymphocytic predominance)**, mildly **elevated protein**, and **normal glucose** levels. *Normal opening pressure; Elevated cell count; Elevated protein; Low glucose* - While **elevated cell count** and **protein** can be seen, **low glucose** is a hallmark of **bacterial meningitis**, not viral. - Bacterial meningitis also typically presents with a significantly **elevated opening pressure**. *Elevated opening pressure; Normal cell count; Normal protein; Normal glucose* - This profile is not consistent with meningitis of any type, as **meningitis** by definition involves inflammation leading to an elevated cell count. - **Normal cell count** and **protein** would rule out an active meningeal infection. *Elevated opening pressure; Elevated cell count; Elevated protein; Low glucose* - This CSF profile is highly suggestive of **bacterial meningitis**, characterized by **elevated opening pressure**, **markedly elevated cell count (neutrophilic predominance)**, **elevated protein**, and **low glucose**. - The clinical presentation with acute worsening and meningeal signs could fit bacterial meningitis, but the specific CSF findings differentiate it from viral.
Question 10: A child presents with fever and vesicular lesions on the upper limb and the lower limb. Neck stiffness was present. Similar lesions were present on the palms, soles, and oral cavity. CSF analysis revealed normal glucose levels and elevated lymphocytes and protein. What is the most likely diagnosis?
- A. Bacterial meningitis with sepsis
- B. Coxsackie viral meningitis and Hand Foot Mouth disease (Correct Answer)
- C. Tuberculous meningitis
- D. Herpes simplex gingivostomatitis and meningoencephalitis
Explanation: Coxsackie viral meningitis and Hand Foot Mouth disease - The presence of **vesicular lesions** on the palms, soles, and oral cavity, along with fever, is highly characteristic of **Hand Foot Mouth Disease (HFMD)** caused by Coxsackievirus. - The CSF findings of **normal glucose**, **elevated lymphocytes** (pleocytosis), and **elevated protein** are typical for **aseptic meningitis**, which is often caused by enteroviruses like Coxsackievirus [2]. *Bacterial meningitis with sepsis* - **Bacterial meningitis** would typically present with **low CSF glucose**, **high protein**, and a predominance of **neutrophils**, not lymphocytes [2]. - The characteristic vesicular rash of HFMD is not seen in bacterial meningitis. *Tuberculous meningitis* - **Tuberculous meningitis** typically has **very low CSF glucose**, **markedly elevated protein**, and a pleocytosis with a high percentage of lymphocytes. - The vesicular lesions on the palms, soles, and oral cavity are not a feature of tuberculous meningitis. *Herpes simplex gingivostomatitis and meningoencephalitis* - While **Herpes simplex** can cause **vesicular lesions** (gingivostomatitis) and **meningoencephalitis** with similar CSF findings (lymphocytic pleocytosis, elevated protein), the widespread nature of the lesions on the palms and soles is **not characteristic of HSV** [1]. - HSV lesions are typically clustered and localized to specific dermatomes or mucosal surfaces.
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