Practice questions Lymphoid neoplasms III
Practice
questions
Lymphoid
neoplasms III
© Jun Wang, MD, PhD
1. Use this case and image for the next three questions. A 12-year-old boy presents to the clinic with persistent fatigue, easy bruising, and occasional nosebleeds for the past 2 weeks. He has progressive fatigue for a month. His past medical history is unremarkable. His vital signs are within normal range. Physical examination reveals pale skin and conjunctiva without jaundice. Numerous petechiae are seen on his extremities. A few cervical lymph nodes are palpated. His CBC reveals a hemoglobin of 8.5 g/dL (11.5-12.8 g/dL), WBC count of 54 x 109/L (4.5-10 x 109/L), platelet count of 75 x 109/L (160-320 x 109/L). An image of his peripheral blood smear is shown. What test should be performed next for diagnosis?
(Image credit: James Grellier - derivative of original work by VashiDonsk at en.wikipedia, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
B. Bone marrow biopsy
C. Flow cytometry study
D. Hemoglobin electrophoresis
E. Lymph node biopsy
2. A 12-year-old boy presents to the clinic with persistent fatigue, easy bruising, and occasional nosebleeds for the past 2 weeks. He has progressive fatigue for a month. His past medical history is unremarkable. His vital signs are within normal range. Physical examination reveals pale skin and conjunctiva without jaundice. Numerous petechiae are seen on his extremities. A few cervical lymph nodes are palpated. His CBC reveals a hemoglobin of 8.5 g/dL (11.5-12.8 g/dL), WBC count of 54 x 109/L (4.5-10 x 109/L), platelet count of 75 x 109/L (160-320 x 109/L). An image of his peripheral blood smear is shown.
(Image credit: James Grellier - derivative of original work by VashiDonsk at en.wikipedia, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Flow cytometry studies reveals these cells occupies approximately 50% of nucleated blood cells, and expressing CD3, CD33, CD34 and TdT, but not CD19, CD20 or myeloperoxidase. What is most likely the diagnosis?
B. B-cell acute lymphoblastic leukemia
C. Chronic myeloid leukemia
D. Chronic lymphocytic leukemia
E. Hairy cell leukemia
F. T-cell acute lymphoblastic leukemia
3. A 12-year-old boy presents to the clinic with persistent fatigue, easy bruising, and occasional nosebleeds for the past 2 weeks. He has progressive fatigue for a month. His past medical history is unremarkable. His vital signs are within normal range. Physical examination reveals pale skin and conjunctiva without jaundice. Numerous petechiae are seen on his extremities. A few cervical lymph nodes are palpated. His CBC reveals a hemoglobin of 8.5 g/dL (11.5-12.8 g/dL), WBC count of 54 x 109/L (4.5-10 x 109/L), platelet count of 75 x 109/L (160-320 x 109/L). An image of his peripheral blood smear is shown.
(Image credit: James Grellier - derivative of original work by VashiDonsk at en.wikipedia, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Flow cytometry studies reveals these cells occupies approximately 50% of nucleated blood cells, and expressing CD3, CD33, CD34 and TdT, but not CD19, CD20 or myeloperoxidase. What gene is most likely altered in these tumor cells?
B. C-myc
C. ETV6
D. MLL2
E. NOTCH1
4. Use this case and image for the next three questions. An 8-year-old girl presents to the clinic with recurrent fever, bone pain, and nosebleed for 1 month. Her bone pain has been gradually worsened. Physical exam reveals pale skin and conjunctiva without jaundice. Numerous petechiae and bruises are noted on her chest and extremities. Her CBC reveals a hemoglobin of 7.5 g/dL (11-13.5 g/dL), WBC count of 21 x 109/L (4.5-10 x 109/L), platelet count of 75 x 109/L (180-360 x 109/L). An image of her peripheral blood smear is shown.
What test should be performed next for diagnosis?
B. Flow cytometry study
C. Hemoglobin electrophoresis
D. Iron and lead studies
E. Radiologic evaluation of affected bones
5. An 8-year-old girl presents to the clinic with recurrent fever, bone pain, and nosebleed for 1 month. Her bone pain has been gradually worsened. Physical exam reveals pale skin and conjunctiva without jaundice. Numerous petechiae and bruises are noted on her chest and extremities. Her CBC reveals a hemoglobin of 7.5 g/dL (11-13.5 g/dL), WBC count of 21 x 109/L (4.5-10 x 109/L), platelet count of 75 x 109/L (180-360 x 109/L). An image of her peripheral blood smear is shown.
(Image credit: Christaras A, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons)
Flow cytometry studies reveal approximately 80% of nucleated blood cells expressing CD19, CD33, CD34 and TdT, but not CD3 and myeloperoxidase. What is most likely the diagnosis?
B. B-cell acute lymphoblastic leukemia
C. Chronic myeloid leukemia
D. Chronic lymphocytic leukemia
E. Hairy cell leukemia
F. T-cell acute lymphoblastic leukemia
6. An 8-year-old girl presents to the clinic with recurrent fever, bone pain, and nosebleed for 1 month. Her bone pain has been gradually worsened. Physical exam reveals pale skin and conjunctiva without jaundice. Numerous petechiae and bruises are noted on her chest and extremities. Her CBC reveals a hemoglobin of 7.5 g/dL (11-13.5 g/dL), WBC count of 21 x 109/L (4.5-10 x 109/L), platelet count of 75 x 109/L (180-360 x 109/L). An image of her peripheral blood smear is shown.
(Image credit: Christaras A, CC BY-SA 3.0 <http://creativecommons.org/licenses/by-sa/3.0/>, via Wikimedia Commons)
Flow cytometry studies reveal approximately 80% of nucleated blood cells expressing CD19, CD33, CD34 and TdT, but not CD3 and myeloperoxidase. Additional cytogenetic studies reveal t(9;22)(q34;q11.2). What gene is most likely altered in these tumor cells?
A. ABLB. BRAF
C. ETV6
D. MLL2
E. NOTCH1
7. Use this case and image for the next question. A 71-year-old man presents to the clinic for annual check-up. He does not have any symptoms. Physical examination is unremarkable. Her CBC reveals a WBC count of 24 x 109/L (4.5-10 x 109/L). His hemoglobin and platelet count are within normal ranges. An image of his peripheral blood smear is shown. Flow cytometry studies reveals 80% of lymphocytes are clonal and express CD5, CD19, CD20, CD23 and kappa light chain, but not CD3, CD10 or cyclin D1. What is the most likely diagnosis?
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B. B-cell acute lymphoblastic leukemia
C. Chronic myeloid leukemia
D. Chronic lymphocytic leukemia
E. Hairy cell leukemia
F. T-cell acute lymphoblastic leukemia
8. Use this case and image for the next three questions. A 62-year-old woman presents to the clinic with a painless swelling in her neck for the last 5 months. She denies fever, night sweats, or weight loss. Physical examination reveals multiple non-tender lymph nodes in the left lower neck. Laboratory test results including CBC are within normal ranges. An image of her lymph node biopsy is shown.
(Image credit: User:Patho, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Immunohistochemistry shows the cells are positive for CD10, CD20, and negative for CD3, CD5, CD15, and CD30. BCL-2 is positive in the center portion of these nodular structures. What genetic abnormality is most likely seen in this lesion?
B. t(11;14)(q13;q32)
C. t(11;18)(q21;q21)
D. t(14;18)(q32;q21)
E. t(15;17)(q22;q12)
F. Trisomy 12
9. A 62-year-old woman presents to the clinic with a painless swelling in her neck for the last 5 months. She denies fever, night sweats, or weight loss. Physical examination reveals multiple non-tender lymph nodes in the left lower neck. Laboratory test results including CBC are within normal ranges. An image of her lymph node biopsy is shown.
(Image credit: User:Patho, CC BY-SA 3.0
<https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Immunohistochemistry shows the cells are positive for CD10, CD20, and negative for CD3, CD5, CD15, and CD30. BCL-2 is positive in the center portion of these nodular structures. What gene is most likely abnormal in this lesion?
B. Bcl-2
C. CCND1
D. MALT1
E. MYD88
10. A 62-year-old woman presents to the clinic with a painless swelling in her neck for the last 5 months. She denies fever, night sweats, or weight loss. Physical examination reveals multiple non-tender lymph nodes in the left lower neck. Laboratory test results including CBC are within normal ranges. An image of her lymph node biopsy is shown.
(Image credit: User:Patho, CC BY-SA 3.0
<https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Immunohistochemistry shows the cells are positive for CD10, CD20, and negative for CD3, CD5, CD15, and CD30. BCL-2 is positive in the center portion of these nodular structures. What is most likely the diagnosis?
A. Adult
T-cell lymphoma
B. Burkitt
lymphoma
C. Diffuse large B cell lymphoma
D. Follicular lymphoma
E. Mantle cell lymphoma
F. Marginal zone lymphoma
11. Use this case and image for the next three questions. A 59-year man presents to the clinical with progressive fatigue, and night sweats for a few months. He has had occasional abdominal discomfort and a 15lb weight loss. His past medical history is unremarkable. Physical examination reveal generalized lymphadenopathy. His spleen is approximately 5 cm below the left costal margin. His CBC reveals a hemoglobin of 7.5 g/dL (14-18 g/dL), WBC count of 16 x 109/L (4.5-11 x 109/L), platelet count of 175 x 109/L (150-450 x 109/L). Peripheral blood smear reveals small atypical lymphocytes with irregular nuclei. An image of his cervical lymph node biopsy is shown.
(Image credit: 藤澤孝志, CC BY-SA 4.0
<https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)
Per immumohistochemistry studies, these cells are positive for CD5, CD20 and cyclin D1, and negative for CD3, CD10, CD15, CD23 and CD30. What genetic abnormality is most likely seen in this lesion?
B. t(9;22) (q34;q11)
C. t(11;14)(q13;q32)
D. t(11;18)(q21;q21)
E. t(14;18)(q32;q21)
F. t(15;17)(q22;q12)
12. A 59-year man presents to the clinical with progressive fatigue, and night sweats for a few months. He has had occasional abdominal discomfort and a 15lb weight loss. His past medical history is unremarkable. Physical examination reveal generalized lymphadenopathy. His spleen is approximately 5 cm below the left costal margin. His CBC reveals a hemoglobin of 7.5 g/dL (14-18 g/dL), WBC count of 16 x 109/L (4.5-11 x 109/L), platelet count of 175 x 109/L (150-450 x 109/L). Peripheral blood smear reveals small atypical lymphocytes with irregular nuclei. An image of his cervical lymph node biopsy is shown.
(Image credit: 藤澤孝志, CC BY-SA 4.0
<https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)
Per immumohistochemistry studies, these cells are positive for CD5, CD20 and cyclin D1, and negative for CD3, CD10, CD15, CD23 and CD30. What gene is most likely abnormal in this lesion?
B. Bcl-2
C. CCND1
D. MALT1
E. MYD88
13. A 59-year man presents to the clinical with progressive fatigue, and night sweats for a few months. He has had occasional abdominal discomfort and a 15lb weight loss. His past medical history is unremarkable. Physical examination reveal generalized lymphadenopathy. His spleen is approximately 5 cm below the left costal margin. His CBC reveals a hemoglobin of 7.5 g/dL (14-18 g/dL), WBC count of 16 x 109/L (4.5-11 x 109/L), platelet count of 175 x 109/L (150-450 x 109/L). Peripheral blood smear reveals small atypical lymphocytes with irregular nuclei. An image of his cervical lymph node biopsy is shown.
(Image credit: 藤澤孝志, CC BY-SA 4.0
<https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)
Per immumohistochemistry studies, these cells are positive for CD5, CD20 and cyclin D1, and negative for CD3, CD10, CD15, CD23 and CD30. What is most likely the diagnosis?
A. Adult T-cell lymphoma
B. Diffuse large B cell lymphoma
C. Follicular lymphoma
D. Mantle cell lymphoma
E. Marginal zone lymphoma
F. Small lymphocytic lymphoma
14. Use this case and image for the next four questions. A 58-year-old woman presents to the clinic with vague epigastric discomfort and intermittent nausea for 6 months. She was diagnosed with Helicobacter pylori infection several years ago. Other significant past medical history including infectious mononucleosis when she was in high school. She has a 15 pack-year history of cigarette smoking. She drinks 1 glass of wine each day for the last 5 years. Physical examination reveals no significant abnormalities. An upper endoscopy reveals a thickened, nodular gastric mucosa with multiple small ulcerations. An image of her stomach biopsy is shown.
Immunohistochemistry demonstrates that the lymphoid cells are positive for CD20 and negative for ALK, CD3, CD5, CD10, CD15, CD30 and cyclin D1. What genetic abnormality is most likely seen in this lesion?
B. t(9;22) (q34;q11),
C. t(11;14)(q13;q32)
D. t(11;18)(q21;q21)
E. t(14;18)(q32;q21)
F. t(15;17)(q22;q12)
15. A 58-year-old woman presents to the clinic with vague epigastric discomfort and intermittent nausea for 6 months. She was diagnosed with Helicobacter pylori infection several years ago. Other significant past medical history including infectious mononucleosis when she was in high school. She has a 15 pack-year history of cigarette smoking. She drinks 1 glass of wine each day for the last 5 years. Physical examination reveals no significant abnormalities. An upper endoscopy reveals a thickened, nodular gastric mucosa with multiple small ulcerations. An image of her stomach biopsy is shown.
(Image credit: Nephron, CC BY-SA 3.0
<https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Immunohistochemistry demonstrates that the lymphoid cells are positive for CD20 and negative for ALK, CD3, CD5, CD10, CD15, CD30 and cyclin D1. What gene is most likely abnormal in this lesion?
B. Bcl-2
C. CCND1
D. MALT1
E. MYD88
16. A 58-year-old woman presents to the clinic with vague epigastric discomfort and intermittent nausea for 6 months. She was diagnosed with Helicobacter pylori infection several years ago. Other significant past medical history including infectious mononucleosis when she was in high school. She has a 15 pack-year history of cigarette smoking. She drinks 1 glass of wine each day for the last 5 years. Physical examination reveals no significant abnormalities. An upper endoscopy reveals a thickened, nodular gastric mucosa with multiple small ulcerations. An image of her stomach biopsy is shown.
(Image credit: Nephron, CC BY-SA 3.0
<https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Immunohistochemistry demonstrates that the lymphoid cells are positive for CD20 and negative for ALK, CD3, CD5, CD10, CD15, CD30 and cyclin D1. What is most likely associated with her stomach findings?
B. Cigarette smoking
C. EB virus
D. Helicobacter Pylori
E. HHV8
17. A 58-year-old woman presents to the clinic with vague epigastric discomfort and intermittent nausea for 6 months. She was diagnosed with Helicobacter pylori infection several years ago. Other significant past medical history including infectious mononucleosis when she was in high school, and Hashimoto thyroiditis when she was 35 years old. She has a 15 pack-year history of cigarette smoking. She drinks 1 glass of wine each day for the last 5 years. Physical examination reveals no significant abnormalities. An upper endoscopy reveals a thickened, nodular gastric mucosa with multiple small ulcerations. An image of her stomach biopsy is shown.
(Image credit: Nephron, CC BY-SA 3.0
<https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
Immunohistochemistry demonstrates that the lymphoid cells are positive for CD20 and negative for ALK, CD3, CD5, CD10, CD15, CD30 and cyclin D1. What is most likely the diagnosis?
A. Diffuse large B cell lymphoma
B. Extranodal NK cell lymphoma
C. Follicular lymphoma
D. Mantle cell lymphoma
E. Marginal zone lymphoma
F. Small lymphocytic lymphoma
18. Use this case and image for the next two questions. A 51-year-old man presents to the clinic with progressive fatigue, recurrent infections and easy bruising for 6 months. He also reports vague left side abdominal pain in the last 3 weeks. His past medical history is unremarkable. Physical examination reveals pale skin and conjunctiva without jaundice. A few petechiae are noted at his extremities. No lymphadenopathy is noted. His spleen is non-tender, and can be palpated approximately 10 cm below the left costal margin. His CBC reveals a hemoglobin of 9.5 g/dL (14-18 g/dL), WBC count of 2.5 x 109/L (4.5-11 x 109/L), platelet count of 75 x 109/L (150-450 x 109/L). An image of his peripheral blood smear is shown.
(Image credit: Paulo Henrique Orlandi Mourao, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
These cells are positive for CD19, CD20 and CD11c, but negative for CD5, CD10, CD23, CD34 and TdT.. Bone marrow aspirate was not successful. What gene is most likely abnormal in this lesion?
B. BRAF
C. CCND1
D. MALT1
E. MYD88
19. A 51-year-old man presents to the clinic with progressive fatigue, recurrent infections and easy bruising for 6 months. He also reports vague left side abdominal pain in the last 3 weeks. His past medical history is unremarkable. Physical examination reveals pale skin and conjunctiva without jaundice. A few petechiae are noted at his extremities. No lymphadenopathy is noted. His spleen is non-tender, and can be palpated approximately 10 cm below the left costal margin. His CBC reveals a hemoglobin of 9.5 g/dL (14-18 g/dL), WBC count of 2.5 x 109/L (4.5-11 x 109/L), platelet count of 75 x 109/L (150-450 x 109/L). An image of his peripheral blood smear is shown.
(Image credit: Paulo Henrique Orlandi Mourao, CC BY-SA 3.0
<https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons)
These cells are positive for CD19, CD20 and CD11c, but negative for CD5, CD10, CD23, CD34 and TdT. Bone marrow aspirate was not successful. What is the most likely diagnosis?
B. Chronic myeloid leukemia
C. Chronic lymphocytic leukemia
D. Faconi anemia
E. Hairy cell leukemia
F. Leukemic phase of mantle cell lymphoma
20. Use this case for the next question. A 57-year-old woman presents to the clinic with a painless left neck mass that has been growing for the last 3 months. She had left breast well differentiated invasive ductal carcinoma 5 years ago that was treated with lumpectomy and localized radiation therapy. Physical examination reveals a 5 cm mobile firm mass in the left supraclavicular region. No other abnormalities are noted. Her laboratory test results including CBC are within normal ranges. An image of the biopsy is shown.
(Cropped from original image by CoRus13, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)
These cells are positive for CD19, CD20, bcl2, and bcl6, but negative for ALK, CD3, CD5, CD10, CD30, CD56 and cytokeratin. Proliferative index by Ki67 is approximately 75%. What is the diagnosis?
A. Anaplastic large cell lymphoma
B. Diffuse large B cell lymphoma
C. Hodgkin lymphoma
D. Mantle cell lymphoma
E. Marginal zone lymphoma
F. Metastatic ductal carcinoma
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