Practice questions I lymphoid neoplasms
Practice questions
Lymphoid neoplasms I
©
Jun Wang, MD, PhD
07/26/2018
1. Use this case for the
next three questions. A 5-year-old boy from southeastern Asia presents with
rapidly enlarging mass on his left lower face. Radiological examination reveals
a tumor invading into left mandible with bone destruction. Biopsy reveals
sheets of monotonous intermediated sized tumor cells with round nuclei and
scant cytoplasm. Among these tumor cells are many larger cells with abundant cytoplasm
containing darkly stained cell debris. Immunohistochemistry studies reveal
these tumor cells are positive for CD10, CD20, but negative for CD3, CD5, CD99
and pan cytokeratin. Proliferative index by Ki67 is approximately 100%. What
gene is most likely altered in these tumor cells?
A.
Bcl2
B.
BRAF
C.
C-myc
D.
Cyclin D1
E.
EWS
2. A 5-year-old boy from southeastern Asia presents with rapidly
enlarging mass on his left lower face. Radiological examination reveals a tumor
invading into left mandible with bone destruction. Biopsy reveals sheets of
monotonous intermediated sized tumor cells with round nuclei and scant
cytoplasm. Among these tumor cells are many larger cells with abundant cytoplasm
containing darkly stained cell debris. Immunohistochemistry studies reveal
these tumor cells are positive for CD10, CD20, but negative for CD3, CD5, CD99
and pan cytokeratin. Proliferative index by Ki67 is approximately 100%. What
viral infection is most likely associated with this abnormality?
A.
Epstein Barr virus
B.
Human herpes virus 8
C.
Human immunodeficiency
virus
D.
Human papilloma virus
3. A 5-year-old boy from southeastern Asia presents with rapidly
enlarging mass on his left lower face. Radiological examination reveals a tumor
invading into left mandible with bone destruction. Biopsy reveals sheets of
monotonous intermediated sized tumor cells with round nuclei and scant
cytoplasm. Among these tumor cells are many larger cells with abundant cytoplasm
containing darkly stained cell debris. Immunohistochemistry studies reveal
these tumor cells are positive for CD10, CD20, but negative for CD3, CD5, CD99
and pan cytokeratin. Proliferative index by Ki67 is approximately 100%. What is
the most likely diagnosis?
A.
Burkitt lymphoma
B.
Diffuse large B cell
lymphoma
C.
Ewing sarcoma
D.
Follicular lymphoma
E.
Poorly differentiated
adenocarcinoma
4. A 70-year-old man presents with swelling of his right testicle
for 3 months. He has fatigue, night sweat for one month, and lost 20 pound
unintentionally. His past medical history include melanoma of right forearm 5
year ago, that was resected. Laboratory tests are within normal range. A biopsy
was performed and reveals testicular parenchyma diffusely infiltrated by
atypical cells with large irregular nuclei. Nucleoli can be seen in some cells.
Immunohistochemistry studies reveal these cells are positive for bcl2, CD20 and
CD45, negative for cytokeratin, S100, alpha fetoprotein, hCG and placental
alkaline phosphatase. Proliferative index per ki67 is approximately 90%. What
is most likely the diagnosis?
A. Burkitt lymphoma
B. Diffuse large B cell
lymphoma
C. Follicular lymphoma
D. Metastatic melanoma
E. Seminoma
5. Use this case for the
next two questions. A 55-year-old man presents with worsening central
epigastric discomfort for a month. He has a history of antrum peptic ulcer for
3 years. Physical examination and laboratory tests are unremarkable.
Gastroscopic examination reveals a 5 cm ulcer at the lesser curvature side of
antrum. Microscopic examination of the ulcer reveal diffuse lymphocytic and
plasmacytic infiltration. Scattered neutrophils are seen. The lymphocytes form
vague nodular appearance and have intermediate sized round nuclei. No nucleoli
are seen. Some lymphocytes are seen infiltrating pyloric glands.
Immunohistochemistry studies reveal that these lymphocytes express CD20, and
predominantly kappa light chain. They are negative for CD3, CD5 and CD10. What
is the most likely diagnosis?
A.
Burkitt lymphoma
B.
Diffuse large B cell
lymphoma
C.
Follicular lymphoma
D.
Marginal zone lymphoma
E.
Small lymphocytic lymphoma
6.
A 55-year-old man presents with worsening
central epigastric discomfort for a month. He has a history of antrum peptic
ulcer for 3 years. Physical examination and laboratory tests are unremarkable.
Gastroscopic examination reveals a 5 cm ulcer at the lesser curvature side of
antrum. Microscopic examination of the ulcer reveal diffuse lymphocytic and
plasmacytic infiltration. Scattered neutrophils are seen. The lymphocytes form
vague nodular appearance and have intermediate sized round nuclei. No nucleoli are
seen. Some lymphocytes are seen infiltrating pyloric glands.
Immunohistochemistry studies reveal that these lymphocytes express CD20, and
predominantly kappa light chain. They are negative for CD3, CD5 and CD10.
A. Epstein Barr virus
B. Helicobacter pylori
C. Human herpes virus 8
D. Human immunodificeincy virus
E. Human papilloma virus
7. Use this case for the
next three questions. A 65-year-old woman presents with fatigue for three
months. Her past history includes hypertension, type 2 diabetes, and coronary
artery disease. Her physical examination are unremarkable except a blood
pressure of 180/100 mmHg. Her CBC reveals a hemoglobin of 7.5 g/dl, white count
21 × 109/L, an absolute lymphocyte
count of 20 × 109/L. Peripheral blood smear reveal majority of the
lymphocytes are small lymphocytes with scant cytoplasm, round nuclei and
clumped chromatin. Many of these nuclei have a soccer ball appearance. Flow
cytometry studies reveal these lymphocytes are positive for CD5, CD20, CD23
with lambda chain restriction, and negative for TdT, CD10, CD11c and cyclin D1.
Myeloid series and platelets are unremarkable. A complete work up reveals a 2
cm mass at her stomach. A biopsy reveals gastric mucosa infiltrated with
atypical lymphocytes with similar morphology and immunohistochemistry profiles
of those found in her peripheral blood. What is the most likely diagnosis?
A. Acute B cell lymphoblastic leukemia
B. Acute T cell lymphoblastic leukemia
C. Chronic lymphocytic leukemia
D. Hairy cell leukemia
E. Mantle cell lymphoma, leukemic phase
8. A 65-year-old woman presents with fatigue for three months. Her
past history also include hypertension, type 2 diabetes, and coronary artery
disease. Her physical examination are unremarkable except a blood pressure of
180/100 mmHg. Her CBC reveals a hemoglobin of 7.5 g/dl, white count 21 × 109/L, an absolute lymphocyte count of 20 × 109/L.
Peripheral blood smear reveal majority of the lymphocytes are small lymphocytes
with scant cytoplasm, round nuclei and clumped chromatin. Many of these nuclei
have a soccer ball appearance. Flow cytometry studies reveal these lymphocytes
are positive for TdT, CD5, CD20, CD23 with lambda chain restriction, and
negative for CD10, CD11c and cyclin D1. Myeloid series and platelets are
unremarkable. A complete work up reveals a 2 cm mass at her stomach. A biopsy
reveals gastric mucosa infiltrated with atypical lymphocytes with similar
morphology and immunohistochemistry profiles of those found in her peripheral
blood. What is a useful marker to assess her prognosis?
A. Bcl2
B. BRAF
C. C-myc
D. Notch1
E. Zap 70
9. A 65-year-old woman presents with fatigue for three months. She
has a history of right breast invasive ductal carcinoma that was treated with
lumpectomy and chemotherapy 5 years ago. Her past history also include hypertension,
type 2 diabetes, and coronary artery disease. Her physical examination are
unremarkable except a blood pressure of 180/100 mmHg. Her CBC reveals a
hemoglobin of 7.5 g/dl, white count 21 × 109/L,
an absolute lymphocyte count of 20 × 109/L. Peripheral blood smear
reveal majority of the lymphocytes are small lymphocytes with scant cytoplasm,
round nuclei and clumped chromatin. Many of these nuclei have a soccer ball
appearance. Flow cytometry studies reveal these lymphocytes are positive for
CD5, CD20, CD23 with lambda chain restriction, and negative for TdT, CD10,
CD11c and cyclin D1. Myeloid series and platelets are unremarkable. A complete
work up reveals a 2 cm mass at her stomach. A biopsy reveals gastric mucosa
infiltrated with atypical lymphocytes with similar morphology and
immunohistochemistry profiles of those found in her peripheral blood. During a
follow up workup 6 months later, the gastric mass enlarged to 4 cm. Biopsy reveal
diffuse infiltrate of atypical cells with large irregular nuclei, some of them
have prominent nucleoli. Immunohistochemistry studies reveal these large cells
are positive for CD20, but negative for CD3, CD11c and cyclin D1. What is the
most likely diagnosis now?
A. Blastoid change of mantle cell lymphoma
B. Local infiltration of hairy cell leukemia
C. Local involvement of acute B cell lymphoblastic leukemia
D. Local involvement of acute T cell lymphoblastic leukemia
E. Richter syndrome
10. Use this case for the
next two questions. A 57-year-old woman presents with a slowly growing
right axillary mass for 10 months. She denies any other symptoms. She has
history of invasive lobular carcinoma of her right breast 2 years ago and
received lumpectomy and chemotherapy. Her past medical history is otherwise
unremarkable. Physical examination reveals a 3 cm firm mass that is movable in
her right axilla. Her laboratory tests including CBC are within normal range.
The mass was resected and microscopically it is a lymph node with nodular growth
of small to intermediate sized cells with scant cytoplasm and single slightly
irregular nuclei. The center of these nodules are lighter that periphery. Between
these nodules are small lymphocytes. No neutrophils or eosinophils are seen. Immunohistochemistry
studies reveal the cells in these nodules are positive for CD10, CD20, bcl2,
but negative for cytokeratin, CD5, CD23, CD30 and cyclin D1. What is the most
likely diagnosis?
A. Follicular lymphoma
B. Hodgkin lymphoma, nodular sclerosis type
C. Mantle cell lymphoma
D. Metastatic lobular carcinoma
E. Small lymphocytic lymphoma
11. A 57-year-old woman presents with a slowly growing right
axillary mass for 10 months. She denies any other symptoms. She has history of
invasive lobular carcinoma of her right breast 2 years ago and received
lumpectomy and chemotherapy. Her past medical history is otherwise
unremarkable. Physical examination reveals a 3 cm firm mass that is movable in
her right axilla. Her laboratory tests including CBC are within normal range. The
mass was resected and microscopically it is a lymph node with nodular growth of
small to intermediate sized cells with scant cytoplasm and single slightly
irregular nuclei. The center of these nodules are lighter that periphery.
Between these nodules are small lymphocytes. No neutrophils or eosinophils are
seen. Immunohistochemistry studies reveal the cells in these nodules are
positive for CD10, CD20, bcl2, but negative for CD5, CD23, CD30 and cyclin D1.
Abnormality of what gene is most likely found in these cells?
A. ALK
B. BRAF
C. C-myc
D. CDH1
E. MLL2
12. Use this case for the
next two questions. A 65-year-old man presents with fatigue, coughing with
white sputum, progressive dyspnea and vague dull chest pain for a few weeks. He
states that he has lost 10 pound recently. He does not have fever nor night
sweating. He has been HIV positive for 30 years. His past medical history is
otherwise unremarkable. Physical examination reveals inaudible breath sounds
with a dull percussion of his left chest. Laboratory tests are unremarkable
except a reduced CD4+ lymphocyte count. Radiological examination reveals left
pleural effuse but no mass is found. Diagnostic thoracentesis was performed.
Microbiological studies of his pleural effusion are negative. Microscopic
examination of the pleural effusion reveals abundant markedly atypical cells
with large irregular nuclei, and cytoplasmic vacuoles. A few neutrophils are
seen. Immunohistochemistry studies reveal these atypical cells are positive for
CD20 but negative for CD30 and cytokeratin. In situ hybridization for EB virus
is positive. What is the most likely diagnosis?
A. Empyema
B. Hodgkin lymphoma
C. Primary effusion lymphoma
D. Reactive pleural effusion due to EB virus associated pneumonia
E. Reactive pleural effusion due to pneumocystis jiroveci
pneumonia
13. A 65-year-old man presents with fatigue, coughing with white
sputum, progressive dyspnea and vague dull chest pain for a few weeks. He
states that he has lost 10 pound recently. He does not have fever nor night
sweating. He has been HIV positive for 30 years. His past medical history is
otherwise unremarkable. Physical examination reveals inaudible breath sounds
with a dull percussion of his left chest. Laboratory tests are unremarkable
except a reduced CD4+ lymphocyte count. Radiological examination reveals left
pleural effuse but no mass is found. Diagnostic thoracentesis was performed.
Microbiological studies of his pleural effusion are negative. Microscopic
examination of the pleural effusion reveals abundant markedly atypical cells
with large irregular nuclei, and cytoplasmic vacuoles. A few neutrophils are
seen. Immunohistochemistry studies reveal these atypical cells are positive for
CD20 but negative for CD30 and cytokeratin. In situ hybridization for EB virus
is positive. Besides HIV and EB virus, what microorganism is associated with
his condition?
A. Human herpes virus 8
B. Human papillomavirus
C. Human T cell leukemia virus type I
D. Staphylococcus aureus
E. Streptococcus pneumoniae
14. Use this case for the
next two questions. A 53-year-old man presents with epigastric discomfort
for a year. He has a history of Helicobacter associated gastric peptic ulcer 5
years ago, and was treated with antibiotics. His history is otherwise
unremarkable. Physical examination reveals a tender mass at his left
supraclavicular region measuring 1.5 cm in greatest dimension. His laboratory
tests are all within normal range. Gastroscopic examination reveals a 2.5 cm
ulcer at his antrum. Biopsy of the mass reveal gastric mucosa with diffuse
infiltrate of small to intermediate sized cells with scant cytoplasm and
irregular dark nuclei. Immunohistochemistry studies reveal these cells are
positive for CD5, CD20, cyclin D1 and kappa light chain, but negative for
cytokeratin, CD3, CD10 and bcl 2. Biopsy of the supraclavicular mass reveal a
lymph node with various sizes of follicles without epithelioid cells. Flow
cytometry studies of tissue from the supraclavicular lymph node reveal
polyclonal lymphoid population. What is the most likely diagnosis of the
gastric lesion?
A. Follicular lymphoma
B. Mantle cell lymphoma
C. Marginal zone lymphoma, MALT type
D. Poorly differentiated adenocarcinoma with supraclavicular lymph
node metastasis
E. Recurrent peptic ulcer
15. A 53-year-old man presents with epigastric discomfort for a
year. He has a history of Helicobacter associated gastric peptic ulcer 5 years
ago, and was treated with antibiotics. His history is otherwise unremarkable.
Physical examination reveals a tender mass at his left supraclavicular region
measuring 1.5 cm in greatest dimension. His laboratory tests are all within
normal range. Gastroscopic examination reveals a 2.5 cm ulcer at his antrum.
Biopsy of the mass reveal gastric mucosa with diffuse infiltrate of small to
intermediate sized cells with scant cytoplasm and irregular dark nuclei.
Immunohistochemistry studies reveal these cells are positive for CD5, CD20,
cyclin D1 and kappa light chain, but negative for cytokeratin, CD3, CD10 and
bcl 2. Biopsy of the supraclavicular mass reveal a lymph node with various
sizes of follicles without epithelioid cells. Flow cytometry studies of tissue
from the supraclavicular lymph node reveal polyclonal lymphoid population.
Abnormality of what gene is associated with his gastric lesion?
A. Bcl 2
B. C-myc
C. Cyclin D1
D. MALT1
E. MIR15A/MIR16A
16. Use this case for the
next two questions. A 48-year-old man presents with fatigue, easy bruise
and left upper abdomen discomfort for 3 months. His past history is unremarkable.
Physical examination reveals enlarged spleen extended 6 cm below the costal
margin. His CBC reveals a hemoglobin of 7.5 g/dl, platelet count of 70 x 109/L.
His white cell count is within normal range, with an absolute neutrophil count
at 0.7 x 109/L (normal 2-8 x 109/L). Microscopic
examination of peripheral blood smears reveals slightly enlarged lymphoid cells
with round to oval nuclei and thread like cytoplasmic extensions. The red cells
and platelets are morphologically unremarkable. Bone marrow aspiration was not
successful. Bone marrow core biopsy reveals hypercellular marrow with sheets of
intermediate sized cells with centrally located round nuclei and pale
cytoplasm. Immunohistochemistry studies reveal these cells are positive for
CD20, CD11c, but negative for TdT, CD3, CD5, CD10, CD23 and cyclin D1. Focally
there are evidence of marrow fibrosis. What is the most likely diagnosis?
A. Acute B cell lymphoblastic lymphoma
B. Adult T cell leukemia
C. Chronic lymphocytic leukemia
D. Hairy cell leukemia
E. Primary myelofibrosis
17. A 48-year-old man presents with fatigue, easy bruise and left
upper abdomen discomfort for 3 months. His past history is unremarkable.
Physical examination reveals enlarged spleen extended 6 cm below the costal
margin. His CBC reveals a hemoglobin of 7.5 g/dl, platelet count of 70 x 109/L.
His white cell count is within normal range, with an absolute neutrophil count
at 0.7 x 109/L (normal 2-8 x 109/L). Microscopic
examination of peripheral blood smears reveals slightly enlarged lymphoid cells
with round to oval nuclei and thread like cytoplasmic extensions. Bone marrow
aspiration was not successful. Bone marrow core biopsy reveals hypercellular
marrow with sheets of intermediate sized cells with centrally located round
nuclei and pale cytoplasm. The red cells and platelets are morphologically
unremarkable. Immunohistochemistry studies reveal these cells are positive for
CD20, CD11c, but negative for CD3, CD5, CD10, CD23 and cyclin D1. Focally there
are evidence of marrow fibrosis. Abnormality of what gene is most likely
associated with his condition?
A. ALK
B. BRAF
C. Cyclin D 1
D. JAK2
E. MPL
18. Use this case for the
next two questions. A 21-year-old man presents with productive cough, nose
bleeding and low-grade fever for a month. He has night sweating and has lost 10
lb. He was originally diagnosed as bronchitis and received antibiotics therapy
without improvement. His history is otherwise unremarkable. Physical
examination reveals tachypnea (25/min) and tachycardia (140/min). There is no
palpable lymphadenopathy or organomegaly. Laboratory tests reveal hemoglobin of
8.4 g/dL (normal 13-18 g/dL), platelet of 35 x 109/L (normal 140-450
x 109/L), white count 11 x 109/L. Smear of peripheral
blood reveal many large cells with scant agranular cytoplasm. Per flow
cytometry studies, these large cells are positive for CD3, TdT, but negative
for CD79a. Radiological studies reveal a 5 cm mass in his posterior
mediastinum. Bone marrow aspiration reveals more than 30% are similar large
cells that have the same flow cytometry findings. Biopsy of the mediastinum
mass reveals a tumor with sheets of tumor cell with similar morphology and
immunohistochemistry profiles as those seen in peripheral blood and marrow. What
is most likely the diagnosis?
A. Acute B cell lymphoblastic leukemia
B. Acute T cell lymphoblastic leukemia
C. Chronic lymphocytic leukemia
D. Hairy cell leukemia
E. Hodgkin lymphoma
19. A 21-year-old man presents with productive cough, nose
bleeding and low-grade fever for a month. He has night sweating and has lost 10
lb. He was originally diagnosed as bronchitis and received antibiotics therapy
without improvement. His history is otherwise unremarkable. Physical
examination reveals tachypnea (25/min) and tachycardia (140/min). There is no
palpable lymphadenopathy or organomegaly. Laboratory tests reveal hemoglobin of
8.4 g/dL (normal 13-18 g/dL), platelet of 35 x 109/L (normal 140-450
x 109/L), white count 11 x 109/L. Smear of peripheral
blood reveal many large cells with scant agranular cytoplasm. Per flow
cytometry studies, these large cells are positive for CD3, TdT, but negative
for CD79a. Radiological studies reveal a 5 cm mass in his posterior
mediastinum. Bone marrow aspiration reveals more than 30% are similar large
cells that have the same flow cytometry findings. Biopsy of the mediastinum
mass reveals a tumor with sheets of tumor cell with similar morphology and
immunohistochemistry profiles as those seen in peripheral blood and marrow. Abnormality
of what gene is most likely associated with his condition?
A. BRAF
B. C-myc
C. MYD88
D. Notch 1
E. RUNX1
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neoplasms
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