Haematology for AMC MCQ

A 24 year old man has a painless, rubbery, enlarging lump in his neck for two months, with drenching night sweats and 7 kg of weight loss. He mentions the lump aches after he drinks alcohol. He is otherwise well with no sore throat. An excision node biopsy shows Reed-Sternberg cells. What is the most likely diagnosis?

1. Human immunodeficiency virus (HIV) Widespread swollen nodes with risk factors for HIV. It does not fit the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol.
2. Lymphoma correct Correct. Painless, growing lymph nodes with fever, night sweats, weight loss and Reed-Sternberg cells is Hodgkin lymphoma.
3. Leukaemia Bone marrow failure with swollen nodes and abnormal blood counts. Here, the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol points elsewhere.
4. Tuberculosis Swollen nodes with weight loss and night sweats, an important lookalike. That does not match the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol.
5. Metastatic carcinoma A hard, fixed node from a cancer that has spread from elsewhere. But the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol does not point to it.

The point: Lymphoma (a cancer of the lymph glands) causes painless swollen lymph nodes, often with what are called B symptoms: fever, soaking night sweats and weight loss with no clear cause. Hodgkin lymphoma tends to affect younger adults. It spreads from one group of nodes to the next group nearby, and the biopsy shows Reed-Sternberg cells (a specific abnormal cell). Pain in the swollen node after drinking alcohol is a classic clue, though it does not happen often. Non-Hodgkin lymphoma is more varied and can grow fast or slowly. The diagnosis needs a biopsy that removes the whole lymph node, rather than a needle sample, because the way the cells are arranged inside the node is needed to make the diagnosis. Staging (working out how far it has spread) uses a CT or PET scan, and a blood test called lactate dehydrogenase (LDH) is used as a marker. Treatment is chemotherapy, sometimes with radiotherapy or newer targeted drugs, and Hodgkin lymphoma has a good chance of cure. Watch for two dangerous complications: superior vena cava obstruction, where a mass in the chest blocks the big vein returning blood to the heart, and tumour lysis syndrome, a dangerous shift in blood chemistry that can happen when treatment kills a large, fast-growing lymphoma quickly. Other causes of swollen lymph nodes to consider are simple reactive nodes, infections such as tuberculosis, glandular fever (Epstein-Barr virus) or HIV, leukaemia, and cancer that has spread from elsewhere.

Source: Cancer Council Australia — lymphoma diagnosis and management Cancer Council Australia · tier 2, specialty society or college

A 24 year old man has a painless, rubbery, enlarging lump in his neck for two months, with drenching night sweats and 7 kg of weight loss. He mentions the lump aches after he drinks alcohol. He is otherwise well with no sore throat. An excision node biopsy shows Reed-Sternberg cells. What is the most appropriate next step in management?

1. Treat an infective mimic where found Treat tuberculosis or another infection if that turns out to be the cause. It does not fit the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol.
2. Excision biopsy to diagnose and classify The first step, giving the tissue sample needed for diagnosis. But the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol does not point to it.
3. Chemotherapy correct Correct. Chemotherapy is the main treatment, and Hodgkin lymphoma has an excellent chance of cure.
4. Tumour lysis prophylaxis before treating bulky disease Fluids plus a drug (rasburicase or allopurinol) before treating a large, fast-growing lymphoma. That does not match the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol.
5. Radiotherapy or targeted therapy in selected cases Added in some cases depending on the type and stage. Here, the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol points elsewhere.

The point: Lymphoma (a cancer of the lymph glands) causes painless swollen lymph nodes, often with what are called B symptoms: fever, soaking night sweats and weight loss with no clear cause. Hodgkin lymphoma tends to affect younger adults. It spreads from one group of nodes to the next group nearby, and the biopsy shows Reed-Sternberg cells (a specific abnormal cell). Pain in the swollen node after drinking alcohol is a classic clue, though it does not happen often. Non-Hodgkin lymphoma is more varied and can grow fast or slowly. The diagnosis needs a biopsy that removes the whole lymph node, rather than a needle sample, because the way the cells are arranged inside the node is needed to make the diagnosis. Staging (working out how far it has spread) uses a CT or PET scan, and a blood test called lactate dehydrogenase (LDH) is used as a marker. Treatment is chemotherapy, sometimes with radiotherapy or newer targeted drugs, and Hodgkin lymphoma has a good chance of cure. Watch for two dangerous complications: superior vena cava obstruction, where a mass in the chest blocks the big vein returning blood to the heart, and tumour lysis syndrome, a dangerous shift in blood chemistry that can happen when treatment kills a large, fast-growing lymphoma quickly. Other causes of swollen lymph nodes to consider are simple reactive nodes, infections such as tuberculosis, glandular fever (Epstein-Barr virus) or HIV, leukaemia, and cancer that has spread from elsewhere.

Source: Cancer Council Australia — lymphoma diagnosis and management Cancer Council Australia · tier 2, specialty society or college

A 24 year old man has a painless, rubbery, enlarging lump in his neck for two months, with drenching night sweats and 7 kg of weight loss. He mentions the lump aches after he drinks alcohol. He is otherwise well with no sore throat. An excision node biopsy shows Reed-Sternberg cells. What is the most appropriate definitive management?

1. Radiotherapy or targeted therapy in selected cases Added in some cases depending on the type and stage. But the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol does not point to it.
2. Treat an infective mimic where found Treat tuberculosis or another infection if that turns out to be the cause. It does not fit the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol.
3. Fertility and long-term follow-up correct Correct. Given his age and good outlook, protecting his fertility and long-term follow-up are part of his care.
4. Emergency treatment of superior vena cava obstruction Given when a chest mass is blocking the big vein. That does not match the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol.
5. Tumour lysis prophylaxis before treating bulky disease Fluids plus a drug (rasburicase or allopurinol) before treating a large, fast-growing lymphoma. Here, the picture of painless swollen nodes with fever, night sweats, weight loss and node pain after alcohol points elsewhere.

The point: Lymphoma (a cancer of the lymph glands) causes painless swollen lymph nodes, often with what are called B symptoms: fever, soaking night sweats and weight loss with no clear cause. Hodgkin lymphoma tends to affect younger adults. It spreads from one group of nodes to the next group nearby, and the biopsy shows Reed-Sternberg cells (a specific abnormal cell). Pain in the swollen node after drinking alcohol is a classic clue, though it does not happen often. Non-Hodgkin lymphoma is more varied and can grow fast or slowly. The diagnosis needs a biopsy that removes the whole lymph node, rather than a needle sample, because the way the cells are arranged inside the node is needed to make the diagnosis. Staging (working out how far it has spread) uses a CT or PET scan, and a blood test called lactate dehydrogenase (LDH) is used as a marker. Treatment is chemotherapy, sometimes with radiotherapy or newer targeted drugs, and Hodgkin lymphoma has a good chance of cure. Watch for two dangerous complications: superior vena cava obstruction, where a mass in the chest blocks the big vein returning blood to the heart, and tumour lysis syndrome, a dangerous shift in blood chemistry that can happen when treatment kills a large, fast-growing lymphoma quickly. Other causes of swollen lymph nodes to consider are simple reactive nodes, infections such as tuberculosis, glandular fever (Epstein-Barr virus) or HIV, leukaemia, and cancer that has spread from elsewhere.

Source: Cancer Council Australia — lymphoma diagnosis and management Cancer Council Australia · tier 2, specialty society or college