Practice questions II lymphoid neoplasm

Practice questions

Lymphoid neoplasms II

© Jun Wang, MD, PhD

07/26/2018

1. Use this case for the next two questions. A 31-year-old man presents with slowly enlarged right cervical mass for 4 months. He has night sweating for 2 months. He has a history of infectious mononucleosis 5 years ago. Physical examination reveal a 4 cm tender mass at his lower right anterolateral neck. No other lymphadenopathy is seen. His laboratory tests are unremarkable. Biopsy of the mass reveal a lesion with nodular appearance, separated by fibrous bands. These nodules are composed of a mixed inflammatory cell infiltrate of neutrophils, eosinophils, lymphocytes and plasma cells. Scattered larger binucleated cells with prominent nucleoli are seen. Per immunohistochemistry studies, these large cells are positive for CD15 and CD30, but negative for ALK, CD20 and CD45. What is the most likely diagnosis?

A. Anaplastic large cell lymphoma

B. Diffuse large B cell lymphoma

C. Follicular lymphoma

D. Hodgkin lymphoma

E. Reactive lymphadenopathy

2. A 31-year-old man presents with slowly enlarged right cervical mass for 4 months. He has night sweating for 2 months. He has a history of infectious mononucleosis 5 years ago. Physical examination reveal a 4 cm tender mass at his lower right anterolateral neck. No other lymphadenopathy is seen. His laboratory tests are unremarkable. Biopsy of the mass reveal a lesion with nodular appearance, separated by fibrous bands. These nodules are composed of a mixed inflammatory cell infiltrate of neutrophils, eosinophils, lymphocytes and plasma cells. Scattered larger binucleated cells with prominent nucleoli are seen. Per immunohistochemistry studies, these large cells are positive for CD15 and CD30, but negative for ALK, CD20 and CD45. What microorganism is most likely associated with his condition?

A. EB virus

B. Human herpes virus 8

C. Human immunodeficiency virus

D. Human papillomavirus

E. Human T cell leukemia virus type I

3. Use this case for the next two questions. A 79-year-old Japanese immigrant presents with fatigue, low-grade fever and bone pain for 3 months. His past medical history is unremarkable. Physical examination reveal a few enlarged lymph nodes at both sides of his neck. Liver and spleen extend below costal edge for 4 and 3 cm, respectively. No skin lesion is seen. CBC is within normal range. His liver function tests are unremarkable. His serum calcium is elevated. Peripheral blood smears reveal atypical lymphoid cells with multilobated nuclei. Flow cytometry studies reveal these cells are positive for CD3 and CD4, but negative for CD20, CD30, CD138 or ALK. What is the most likely diagnosis?

A. Adult T cell leukemia/lymphoma

B. Anaplastic large cell lymphoma, leukemic phase

C. Chronic lymphocytic leukemia

D. Multiple myeloma, leukemic phase

E. Sezary syndrome

4. A 79-year-old Japanese immigrant presents with fatigue, low-grade fever and bone pain for 3 months. His past medical history is unremarkable. Physical examination reveal a few enlarged lymph nodes at both sides of his neck. Liver and spleen extend below costal edge for 4 and 3 cm, respectively. No skin lesion is seen. CBC is within normal range. His liver function tests are unremarkable. His serum calcium is elevated. Peripheral blood smears reveal atypical lymphoid cells with multilobated nuclei. Flow cytometry studies reveal these cells are positive for CD3 and CD4, but negative for CD20, CD30, CD138 or ALK. What microorganism is the most likely associated with his condition?

A. EB virus

B. Human herpes virus 8

C. Human immunodeficiency virus

D. Human T cell leukemia virus type I

5. Use this case for the next two questions. A 31-year-old man presents with a painless mass at his left lower neck for 4 months. He developed night sweating and low-grade fever during the last 2 months. He has a history of infectious mononucleosis at the age of 18. He smokes cigarette 1 pack a day for 20 years. His history is otherwise unremarkable. Physical examinations confirms the presence of a 5 cm tender mass at his left lower neck. No other abnormality is seen. Laboratory tests reveal a hemoglobin at 7.6 g/dL (normal 13-18 g/L), platelet count at 35 x 10⁹/L (normal 150-450 x 10⁹/L). His white count and differential are within normal range. Peripheral blood smears reveal normal morphology of white cells. Biopsy of the neck mass reveal a lymph node with sheets of large atypical cell with bizarre nuclei, including donut-shaped and horse-shoe shaped large nuclei and abundant cytoplasm. Multinucleated atypical cells are also seen. Immunohistochemistry studies reveal these atypical cells are positive for ALK, CD5, CD30, CD45, but negative for CD20, CD79a and cytokeratin. What is the most likely diagnosis?

A. Adult T cell lymphoma

B. Anaplastic large cell lymphoma

C. Diffuse large B cell lymphoma

D. Hodgkin lymphoma

E. Metastatic squamous cell carcinoma

6. A 31-year-old man presents with a painless mass at his left lower neck for 4 months. He developed night sweating and low-grade fever during the last 2 months. He has a history of infectious mononucleosis at the age of 18. He smokes cigarette 1 pack a day for 20 years. His history is otherwise unremarkable. Physical examinations confirms the presence of a 5 cm tender mass at his left lower neck. No other abnormality is seen. Laboratory tests reveal a hemoglobin at 7.6 g/dL (normal 13-18 g/L), platelet count at 35 x 10⁹/L (normal 150-450 x 10⁹/L). His white count and differential are within normal range. Peripheral blood smears reveal normal morphology of white cells. Biopsy of the neck mass reveal a lymph node with sheets of large atypical cell with bizarre nuclei, including donut-shaped and horse-shoe shaped large nuclei and abundant cytoplasm. Multinucleated atypical cells are also seen. Immunohistochemistry studies reveal these atypical cells are positive for ALK, CD5, CD30, CD45, but negative for CD20, CD79a and cytokeratin. Abnormality of what gene is most likely associated with these changes?

A. ALK

B. BRAF

C. Cyclin D 1

D. MYD 88

E. p16

7. A 71-year-old man presents with fatigue and low-grade fever for 5 months. He has had skin pruritic rashes on his face and back for 4 years. He received herbal treatments for the rashes but was not effective. Physical examination reveal widespread reddening of skin and multiple rashes on his face and back, many enlarged tender nodules along his neck, axilla and inguinal area. The skin rashes are plaques with fine scales. Ulcerations are focally seen. Laboratory tests reveal hemoglobin of 9 g/dL (normal 13-18 g/L), white count at 50 x 10⁹/L (Normal 5-10 x 10⁹/L). His platelet count is within normal range. Peripheral blood smears reveal 60% of the white cells are lymphoid with folded nuclei, some in the appearance of a brain. Flow cytometry studies reveal these cells are positive for CD3, CD4, but negative for ALK, CD8, CD20 and CD30. Biopsy of the skin rashes and the nodules reveal infiltration of skin and lymph nodes by atypical lymphoid cells with identical immunoprofile. What is most likely the diagnosis?

A. Adult T cell leukemia

B. Anaplastic large cell lymphoma, leukemic phase

C. Chronic lymphocytic leukemia

D. Psoriasis with reactive lymphadenopathy

E. Sezary syndrome

8. A 40-year-old woman presents with pruritic skin rashes on her chest for 6 months. She has a history of type II diabetes for 3 years. Her history is otherwise unremarkable except being over-weight since age 18. Physical examination reveals a 2.5 cm light brown plaque with irregular border. The plaque is covered by fine white scales. No lymphadenopathy nor organomegaly is found. Her laboratory tests are within normal range. Biopsy of the plaque reveal skin with diffuse intermediate-sized lymphocytic infiltration extending into epidermis. These lymphocytes have folded nuclei. Focally there are intraepidermal lymphocytic microabscesses. No fungal elements are seen per special stains. Immunohistochemistry studies reveal these lymphocytes are positive for CD3, CD4 but negative for CD8 and CD20. T-cell receptor gene rearrangement studies reveal monoclonal population. What is most likely the diagnosis?

A. Cutaneous anaplastic large cell lymphoma

B. Dermatophytosis

C. Marginal zone lymphoma

D. Mycosis fungoides

E. Sezary syndrome

9. Use this case for the next three questions. A 56-year-old man presents with worsening fatigue and back pain for 4 months. He has a history of prostate adenocarcinoma and colon adenocarcinoma 6  and 10 years ago, respectively. Both were treated with surgery. His history is otherwise unremarkable. Physical examination reveal pale appearance. No lymphadenopathy nor bruise is seen. Laboratory tests reveal a serum calcium at 3.1 mmol/L (normal 2.1-2.6 mmol/L), BUN at 42 mmol/L (normal 2.5-6.4 mmol/L), and creatinine at 380 mmol/L (normal 62-115 mmol/L). CBC is within normal range. Peripheral blood smear reveal clustering of red cells in a chain. Radiological examination reveal multiple lytic lesions at T1, T4, and T5 vertebra. Biopsy of the lytic bone lesion reveal sheets of cells with eccentrically located round to oval nuclei with condensed chromatin forming a “clock-face” pattern, accounting for approximately 20% of marrow cellularity. Some of them have clustered grapelike intracytoplasmic inclusions. Immunohistochemistry studies reveal these cells are positive for CD38, CD138, but negative for CD3, CD20 and cytokeratin. What is the most likely diagnosis?

A. Adult T cell leukemia/lymphoma

B. Diffuse large B cell lymphoma

C. Metastatic prostate adenocarcinoma

D. Multiple myeloma

E. Small lymphocytic lymphoma

10. A 56-year-old man presents with worsening fatigue and back pain for 4 months. He has a history of prostate adenocarcinoma and colon adenocarcinoma 6  and 10 years ago, respectively. Both were treated with surgery. His history is otherwise unremarkable. Physical examination reveal pale appearance. No lymphadenopathy nor bruise is seen. Laboratory tests reveal a serum calcium at 3.1 mmol/L (normal 2.1-2.6 mmol/L), BUN at 42 mmol/L (normal 2.5-6.4 mmol/L), and creatinine at 380 mmol/L (normal 62-115 mmol/L). CBC is within normal range. Peripheral blood smear reveal clustering of red cells in a chain. Radiological examination reveal multiple lytic lesions at T1, T4, and T5 vertebra. Biopsy of the lytic bone lesion reveal sheets of cells with eccentrically located round to oval nuclei with condensed chromatin forming a “clock-face” pattern, accounting for approximately 20% of marrow cellularity. Some of them have clustered grapelike intracytoplasmic inclusions. Immunohistochemistry studies reveal these cells are positive for CD38, CD138, but negative for CD3, CD20 and cytokeratin. What additional serum component is most likely elevated in this patient?

A. CEA

B. IgG

C. Parathyroid hormone

D. Prostatic specific antigen

11. A 56-year-old man presents with worsening fatigue and back pain for 4 months. He has a history of prostate adenocarcinoma and colon adenocarcinoma 6  and 10 years ago, respectively. Both were treated with surgery. His history is otherwise unremarkable. Physical examination reveal pale appearance. No lymphadenopathy nor bruise is seen. Laboratory tests reveal a serum calcium at 3.1 mmol/L (normal 2.1-2.6 mmol/L), BUN at 42 mmol/L (normal 2.5-6.4 mmol/L), and creatinine at 380 mmol/L (normal 62-115 mmol/L). CBC is within normal range. Peripheral blood smear reveal clustering of red cells in a chain. Radiological examination reveal multiple lytic lesions at T1, T4, and T5 vertebra. Biopsy of the lytic bone lesion reveal sheets of cells with eccentrically located round to oval nuclei with condensed chromatin forming a “clock-face” pattern, accounting for approximately 20% of marrow cellularity. Some of them have clustered grapelike intracytoplasmic inclusions. Immunohistochemistry studies reveal these cells are positive for CD38, CD138, but negative for CD3, CD20 and cytokeratin. What is most likely associated with his elevated BUN and creatinine?

A. Bence Jones protein

B. Hyperviscosity

C. Kidney involvement of lymphoma

D. Metastatic tumor to kidney

E. Nephrolithiasis associated with hypercalcemia

12. Use this case for the next two questions. A 45-year-old woman presents with fatigue, anorexia and feet swelling for 3 months. She has a history of hypertension for 20 years. Her past medical history is otherwise unremarkable. Physical examination reveals grade 2 edema on both lower legs, as well as a blood pressure at 150/100 mmHg. Laboratory tests reveal a hemoglobin at 8 g/dL (normal 12-16 g/L), glucose at 125 mg/dL (normal 70-110 mg/dL), BUN at 31 mg/dL (normal 8-25 mg/dL), creatinine at 3.3 mg/dL (normal 0.6-1.1 mg/dL). Her white count and platelets are within normal range. Kidney biopsy reveals amorphous deposits at the walls of small artery and tubular basement membrane. These deposits are positive for Congo Red. Immunofluoresence studies reveal these deposits are kappa light chain. The glomeruli are relatively unremarkable. What is the most likely associated with his abnormal renal function?

A. Chronic inflammation associated amyloid deposit (AA amyloidosis)

B. Diabetes associated glomerular injury

C. Hypertension caused kidney injury

D. Light chain toxicity to kidney

13. A 45-year-old woman presents with fatigue, anorexia and feet swelling for 3 months. She has a history of hypertension for 20 years. Her past medical history is otherwise unremarkable. Physical examination reveals grade 2 edema on both lower legs, as well as a blood pressure at 150/100 mmHg. Laboratory tests reveal a hemoglobin at 8 g/dL (normal 12-16 g/L), glucose at 125 mg/dL (normal 70-110 mg/dL), BUN at 31 mg/dL (normal 8-25 mg/dL), creatinine at 3.3 mg/dL (normal 0.6-1.1 mg/dL). Her white count and platelets are within normal range. Kidney biopsy reveals amorphous deposits at the walls of small artery and tubular basement membrane. These deposits are positive for Congo Red. Immunofluoresence studies reveal these deposits are kappa light chain. The glomeruli are relatively unremarkable. What is a proper laboratory test to identify the underlying etiology of her kidney abnormality?

A. Electron microscopy study for immune complex deposit

B. Glucose tolerance test for diabetes

C. Immunofixation for monoclonal gammopathy

D. Urolysis for microalbumin levels

14. Use this case for the next three questions. A 55-year-old man presents with blurred vision, gum bleeding, fatigue, night sweating and loss of 15 pound in 10 months. Physical examination reveals several tender nodules at his right lower neck measuring up to 4 cm in greatest dimension. Laboratory studies reveal a hemoglobin at 7.9 g/dL (Normal 13-18 g/dL), white cell count at 3.4 x 10⁹/L (normal 5-10 x 10⁹/L), platelet at 185 x 10⁹/L (normal 150-450 x 10⁹/L). Serum total protein is 8.5 g/dL (normal 6-8 g /dL, gamma globulin is 3.5 g/dL (normal 0.5-1.6 g/dL). Immunofixation reveal a discrete band of IgM kappa. Quantification of serum immunoglobulin studies reveal an IgM level of 685 mg/dL (normal 40-230 mg/dL). Levels of IgA and IgG are within normal range. No bone lesion is seen per radiologic examinations. Biopsy of the cervical nodule reveal a lymph nodes containing sheets of small to intermediate sized lymphocytes, some of them have eccentrically located nuclei and vague perinuclear pallor area. Immunohistochemistry studies reveal these cells are positive for CD19, CD20, CD138, with kappa light chain restriction, but negative for ALK, CD3, CD5, CD10, CD15 and CD30. What is most likely the diagnosis?

A. Anaplastic large cell lymphoma

B. Diffuse large B cell lymphoma

C. Hodgkin lymphoma

D. Lymphoplasmacytic lymphoma

E. Multiple myeloma

15. A 55-year-old man presents with blurred vision, gum bleeding, fatigue, night sweating and loss of 15 pound in 10 months. Physical examination reveals several tender nodules at his right lower neck measuring up to 4 cm in greatest dimension. Laboratory studies reveal a hemoglobin at 7.9 g/dL (Normal 13-18 g/dL), white cell count at 3.4 x 10⁹/L (normal 5-10 x 10⁹/L), platelet at 185 x 10⁹/L(normal 150-450 x 10⁹/L). Serum total protein is 8.5 g/dL (normal 6-8 g /dL, gamma globulin is 3.5 g/dL (normal 0.5-1.6 g/dL). Immunofixation reveal a discrete band of IgM kappa. Quantification of serum immunoglobulin studies reveal an IgM level of 685 mg/dL (normal 40-230 mg/dL). Levels of IgA and IgG are within normal range. Biopsy of the cervical nodule reveal a lymph nodes containing sheets of small to intermediate sized lymphocytes, some of them have eccentrically located nuclei and vague perinuclear halo. Immunohistochemistry studies reveal these cells are positive for CD19, CD20, CD138, with kappa light chain restriction, but negative for ALK, CD3, CD5, CD10, CD15 and CD30. What is most likely causing his blurred vision?

A. Autoimmune process associated with abnormal IgM

B. Bone destruction as part of the neoplastic process

C. Distended retinal vessels

D. Neoplasm infiltrating his optic nerve

16. A 55-year-old man presents with blurred vision, gum bleeding, fatigue, night sweating and loss of 15 pound in 10 months. Physical examination reveals several tender nodules at his right lower neck measuring up to 4 cm in greatest dimension. Laboratory studies reveal a hemoglobin at 7.9 g/dL (Normal 13-18 g/dL), white cell count at 3.4 x 10⁹/L (normal 5-10 x 10⁹/L), platelet at 185 x 10⁹/L(normal 150-450 x 10⁹/L). Serum total protein is 8.5 g/dL (normal 6-8 g /dL, gamma globulin is 3.5 g/dL (normal 0.5-1.6 g/dL). Immunofixation reveal a discrete band of IgM kappa. Quantification of serum immunoglobulin studies reveal an IgM level of 685 mg/dL (normal 40-230 mg/dL). Levels of IgA and IgG are within normal range. Biopsy of the cervical nodule reveal lymph nodes containing sheets of small to intermediate sized lymphocytes, some of them have eccentrically located nuclei and vague perinuclear halo. Immunohistochemistry studies reveal these cells are positive for CD19, CD20, CD138, with kappa light chain restriction, but negative for ALK, CD3, CD5, CD10, CD15 and CD30. Mutation of what gene is most likely associated with these findings?

A. ALK

B. Bcl-2

C. Cyclin D 1

D. MYD 88

E. STAT 3

17. A 62-year-old woman presents with numbness of both hands for 6 months. She has a history of type II diabetes for 20 years. She smokes cigarette, 1 pack a day for 45 years. Physical examination reveals mild reduction of a scale 4/5 muscle strength for both wrists and all fingers of both hands. Laboratory tests are within normal range except a glucose of 130 mg/dL (normal 70-110 mg/dL). Urinalysis results are unremarkable. Serum protein electrophoresis reveal a monoclonal spike. Immunifixation reveals a mu paraprotein. No monoclonal light chain is detected. Total serum IgM is 1.1 g/dL. Complete radiologic work up reveal no evidence of bone lesion. Bone marrow biopsy reveal plasma cell population of approximately 5%. What is most likely the diagnosis?

A. Diabetic neuropathy

B. Lymphoplasmacytic lymphoma

C. Monoclonal gammopathy of undermined significance

D. Multiple myeloma

E. Plasmacytoma with Waldenstrom macroglobulinemia

Answers

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