MCQ: Hematopathology | MCQ Quiz | OmpathStudy Kenya

Question 1

What is the incidence of Non-Hodgkin Lymphoma per 100,000 population?

Question 2

Which of the following best describes the spread pattern of Non-Hodgkin Lymphoma compared to Hodgkin Lymphoma?

Accepted Answer

Irregular, non-contiguous spread — NHL spreads irregularly and unpredictably, with significant extranodal involvement. In contrast, HL spreads in an orderly, contiguous fashion from one nodal group to adjacent ones.

Question 3

Which classification system is the current gold standard for lymphoma classification?

Accepted Answer

WHO/REAL classification — The REAL/WHO classification (1994/2001/2008) is the current gold standard. It combines morphology, immunophenotype, genetics, and clinical features. Earlier systems used morphology only or grade only.

Question 4

In lymphoid neoplasms, what molecular event precedes malignant transformation?

Accepted Answer

Antigen receptor gene rearrangement — In all lymphoid neoplasms, antigen receptor gene rearrangement precedes transformation. This means all daughter cells synthesize identical antigen receptor proteins — this is the molecular basis of clonality in lymphoma.

Question 5

A MALT lymphoma does NOT respond to antibiotic therapy for H. pylori. Which translocation explains this?

Accepted Answer

t(11;18) or t(1;14) — MALT lymphomas with t(11;18) or t(1;14) activate the NFκB pathway independently of H. pylori stimulation. These tumours do not regress with antibiotics and require chemotherapy.

Question 6

Which lymphoma is associated with MALT of the skin specifically?

Accepted Answer

Borrelia species — Different sites of MALT lymphoma have different infectious triggers: skin → Borrelia spp; eyes → Chlamydia psittaci; intestines → Campylobacter jejuni; stomach → H. pylori.

Question 7

A 14-year-old male presents with a large mediastinal mass, night sweats and mild bone marrow involvement. Immunophenotyping shows CD1+, CD2+, CD5+, CD7+, TdT+. What is the diagnosis?

Accepted Answer

Precursor T-cell lymphoblastic lymphoma — Adolescent male + thymic/mediastinal mass + TdT+ + T-cell markers = Precursor T-cell ALL/LBL. This is aggressive but 90% achieve complete remission with aggressive chemo + CNS prophylaxis.

Question 8

Which translocation carries the worst prognosis in Precursor B-cell ALL?

Accepted Answer

t(9;22) — Philadelphia chromosome — The Philadelphia chromosome t(9;22) is the worst prognostic cytogenetic finding in ALL. t(12;21) carries the best prognosis. t(4;11) is associated with poor prognosis in infants.

Question 9

What are "proliferation centres" in CLL/SLL histology?

Accepted Answer

Loose aggregates of mitotically active prolymphocytes — Proliferation centres (pseudofollicles) are pathognomonic of CLL/SLL. They are loose aggregates of larger prolymphocytes that are mitotically active, scattered within the diffusely effaced lymph node architecture.

Question 10

A patient with CLL has Hb 9g/dL and platelets 80×10⁹/L. What Binet and Rai stage is this?

Accepted Answer

Binet C, Rai IV — Binet C = Hb <10g/dL OR platelets <100×10⁹. Rai IV = lymphocytosis + thrombocytopenia. Both indicate advanced disease requiring treatment. Rai III = anaemia; Rai IV = thrombocytopenia.

Question 11

What combination achieves complete remission in 69% of CLL patients?

Accepted Answer

Rituximab + Fludarabine + Cyclophosphamide — RFC achieves complete remission in 69% of CLL cases. Fludarabine-containing regimens are preferred over CVP or CHOP. Alemtuzumab (anti-CD25) is more immunocompromising.

Question 12

A 62-year-old woman has widespread painless lymphadenopathy for 3 years. Biopsy shows centrocytes and centroblasts in a nodular pattern. BCL-2+, CD10+. She is asymptomatic. What is the management?

Accepted Answer

Watch and wait — Stage II–IV asymptomatic follicular lymphoma = watch and wait. Treatment begins only when symptoms or complications develop. Up to 25% of cases also undergo spontaneous regression.

Question 13

Histologic transformation in follicular lymphoma occurs at what rate per year and to what subtype?

Accepted Answer

3% per year to DLBCL — Follicular lymphoma transforms to aggressive diffuse large B-cell lymphoma at approximately 3% per year. Overall transformation rate over the disease course is 30–50%. Grade IIIb is already treated as DLBCL.

Question 14

Which prognostic scoring system is used specifically for follicular lymphoma?

Accepted Answer

FLIPI — FLIPI uses: age 60, Stage III–IV, Hb <12g/dL, 4 nodal areas, and high LDH. IPI and NCCN-IPI are used for high-grade lymphomas like DLBCL.

Question 15

What unique gastrointestinal manifestation can occur in Mantle Cell Lymphoma?

Accepted Answer

Lymphomatoid polyposis of small bowel and colon — MCL can involve the GI tract producing lymphomatoid polyposis — multiple polyp-like lesions throughout the bowel. This is a characteristic but underappreciated feature of MCL. ~70% present at Stage IV.

Question 16

What is seen on trephine biopsy in Mantle Cell Lymphoma?

Accepted Answer

Small-medium cells with variable nuclear shapes and increased reticulin; intrasinusoidal infiltration prominent — MCL trephine biopsy characteristically shows intrasinusoidal infiltration — a pattern also seen in splenic marginal zone lymphoma. Assessment of CD20 is important as Rituximab is used.

Question 17

Which DLBCL subtype presents with superior vena cava syndrome?

Accepted Answer

Primary mediastinal (Mediastinal) DLBCL — Mediastinal DLBCL presents with a large anterior mediastinal mass causing SVC syndrome (facial oedema, arm swelling, JVP elevation). It predominantly affects young women and has distinct biology.

Question 18

Which DLBCL subtype is specifically associated with HIV and body cavity effusions?

Accepted Answer

Primary effusion DLBCL — Primary effusion lymphoma is HIV-related, associated with HHV-8, and presents as malignant effusions in body cavities (pleural, peritoneal, pericardial) without a solid tumour mass.

Question 19

A patient with Burkitt lymphoma has peripheral blood film showing large lymphoblasts with basophilic cytoplasm containing vacuoles. Which immunophenotype is expected?

Accepted Answer

CD19+, CD10+, BCL2−, BCL6+, SIgM+ — Burkitt lymphoma is BCL2− — this is crucial to distinguish it from follicular lymphoma (BCL2+). Both are CD10+. The BCL2 negativity is due to MYC translocation driving rapid proliferation without BCL2 anti-apoptotic support.

Question 20

What is the hallmark histological finding in Burkitt lymphoma and what does it represent?

Accepted Answer

Starry sky pattern — tingible-body macrophages engulfing apoptotic tumour cells — The starry sky appearance results from numerous pale macrophages (stars) scattered against a dark background of densely packed tumour cells (sky). The macrophages are engulfing apoptotic cells from the extremely high turnover rate ( 95% mitotic index).

Question 21

Thomas Hodgkin first described Hodgkin Lymphoma in which year?

Accepted Answer

1832 — Thomas Hodgkin first described Hodgkin Lymphoma in 1832. It remains distinct from NHL in biology, morphology, immunophenotype, clinical features, and treatment.

Question 22

What is the age distribution pattern of Hodgkin Lymphoma?

Accepted Answer

Bimodal: 15–34 years and >55 years — HL has a characteristic bimodal age distribution. The first peak (15–34 years) is mainly Nodular Sclerosis type. The second peak ( 55 years) is mainly Mixed Cellularity and Lymphocyte Depleted types.

Question 23

How does EBV contribute to the pathogenesis of Hodgkin Lymphoma?

Accepted Answer

LMP-1 upregulates NFκB → lymphocyte activation and RS cell survival — EBV's latent membrane protein-1 (LMP-1) transmits signals that upregulate NFκB, a transcription factor involved in lymphocyte activation and cell survival. RS cells also secrete cytokines (IL-5, IL-6, IL-13, TNF, GM-CSF) that recruit reactive cells supporting tumour growth.

Question 24

What is the diagnostic Reed-Sternberg cell?

Accepted Answer

Large cell (15–45μm) with multiple nuclei or multilobed single nucleus, each with large inclusion-like nucleolus — The RS cell must be present in an appropriate background of non-neoplastic inflammatory cells (lymphocytes, plasma cells, eosinophils). RS cells alone are insufficient for diagnosis — context is essential.

Question 25

Which RS cell variant is pathognomonic of Nodular Sclerosis Hodgkin Lymphoma?

Accepted Answer

Lacunar cell — Lacunar cells have delicate, folded/multilobate nuclei surrounded by abundant pale cytoplasm. During histological sectioning, the cytoplasm retracts, leaving the nucleus sitting in an artificial empty space (lacuna). Pathognomonic of Nodular Sclerosis HL.

Question 26

Which Hodgkin Lymphoma subtype has the strongest association with EBV (70%) and HIV?

Accepted Answer

Mixed cellularity — Mixed Cellularity HL is EBV+ in 70% of cases and is common in HIV-infected individuals and males. It has a biphasic age distribution and 50% present at Stage III or IV with poor prognosis.

Question 27

Which Hodgkin Lymphoma subtype has the worst prognosis and is most associated with advanced disease?

Accepted Answer

Lymphocyte depleted — Lymphocyte depleted HL is the rarest (<1%), most aggressive, and has the worst prognosis. It is common in older males and HIV+ patients, almost always presents with advanced disease, and has two variants: reticular and diffuse fibrosis.

Question 28

What is the immunophenotype of NLPHL (L&H/Popcorn cells) that distinguishes it from Classical HL?

Accepted Answer

CD19+, CD20+, BCL6+, CD15−, CD30−, EBV− — NLPHL is a B-cell neoplasm where L&H cells express B-cell antigens and are CD15−/CD30−/EBV−. Classical HL RS cells are CD15+/CD30+ — this is the key distinguishing immunophenotype.

Question 29

A patient has lymphadenopathy and reports pain at the lymph node site after drinking alcohol. What condition is this classic for?

Accepted Answer

Hodgkin Lymphoma — Alcohol-induced pain at sites of lymph node involvement is a classic and specific symptom of Hodgkin Lymphoma. Its mechanism is not fully understood but is a high-yield examination finding.

Question 30

In Ann Arbor staging, what does Stage IIISE mean?

Accepted Answer

Lymph nodes both sides of diaphragm + spleen + localized extralymphatic site — Ann Arbor Stage III = both sides of diaphragm. S = spleen involvement. E = limited contiguous extralymphatic involvement. Understanding the suffix system is essential for staging questions.

Question 31

Bilateral iliac crest biopsies are important in lymphoma staging because they diagnose which stage?

Accepted Answer

Stage IV — Stage IV is diagnosed when the bone marrow is involved. Bilateral iliac crest (trephine) biopsies are therefore essential in lymphoma staging to detect marrow involvement and correctly assign Stage IV disease.

Question 32

A 40-year-old woman presents with pruritus and psoriasis-like plaques on her trunk for 2 years. Biopsy shows T-cells with cerebriform nuclei infiltrating the epidermis with Pautrier microabscesses. Diagnosis?

Accepted Answer

Mycosis fungoides — Mycosis fungoides is a chronic cutaneous T-cell lymphoma progressing through inflammatory → plaque → tumour phases. Pautrier microabscesses (clusters of neoplastic T-cells in the epidermis) and cerebriform nuclei are pathognomonic. Treatment is phototherapy.

Question 33

What distinguishes Sézary syndrome from Mycosis fungoides?

Accepted Answer

Sézary syndrome has generalised erythroderma + leukaemia of Sézary cells in peripheral blood — Sézary syndrome is considered a leukaemic variant of mycosis fungoides. The Sézary cells are CD4+ T-cells with cerebriform nuclei circulating in blood. Treatment is PUVA (psoralen + UV light).

Question 34

Adult T-cell Leukaemia/Lymphoma presents with a unique biochemical abnormality. What is it?

Accepted Answer

Hypercalcaemia — Adult T-cell leukaemia/lymphoma (HTLV-1 associated) classically presents with cutaneous lesions + bone marrow involvement + hypercalcaemia. The tumour cells have characteristic "flower cell" or "clover leaf" multilobated nuclei and express CD25 (IL-2 receptor).

Question 35

What is the morphological hallmark of Anaplastic Large Cell Lymphoma?

Accepted Answer

Large anaplastic cells with horseshoe/embryo-shaped nuclei — "hallmark cells" — ALCL hallmark cells have characteristic horseshoe or embryo-like nuclei with voluminous cytoplasm. They cluster around venules and infiltrate sinuses, potentially mimicking metastatic carcinoma. CD30+, t(2;5), ALK overexpression.

Question 36

Extranodal NK/T-cell lymphoma, nasal type, was previously known as what?

Accepted Answer

Lethal midline granuloma — Extranodal NK/T-cell lymphoma nasal type was previously called lethal midline granuloma and midline malignant reticulosis. It causes destructive sinonasal masses due to tumour cells invading small vessels causing ischaemic necrosis. Associated with EBV; expresses CD16+, CD56+.

Question 37

Which lymphoma is specifically associated with Sjögren's syndrome and Hashimoto's thyroiditis?

Accepted Answer

MALT lymphoma — MALT lymphomas arise at sites of chronic immune/inflammatory reactions: salivary glands in Sjögren's syndrome, thyroid in Hashimoto's thyroiditis, and stomach in H. pylori infection. The concept is: chronic antigen stimulation → lymphoid hyperplasia → secondary genetic hits → lymphoma.

Question 38

Which of the following is the only currently curative treatment option for follicular lymphoma?

Accepted Answer

Allogeneic SCT — Chemotherapy achieves remission but is not curative in follicular lymphoma. Autologous SCT can help with relapse control but is not curative. Only allogeneic SCT offers the prospect of cure, likely via a graft-vs-lymphoma immunological effect.

Question 39

Beta-2 microglobulin is used as a prognostic marker in which condition?

Accepted Answer

NHL — Beta-2 microglobulin (B2M) is a prognostic serum marker used in NHL alongside LDH. Elevated levels indicate high tumour burden and poor prognosis. It is part of the standard laboratory workup for NHL alongside FBC, ESR, LDH, uric acid, renal function, ALP, calcium, albumin.

Question 40

A patient with NHL relapses after R-CHOP. They receive R-ICE salvage therapy and respond well. What is the next most appropriate step?

Accepted Answer

Autologous stem cell transplantation — In relapsed DLBCL that responds to salvage chemotherapy (R-ICE), autologous SCT consolidates the response and offers the best chance of long-term remission. Allogeneic SCT with reduced-intensity conditioning is considered for chemoresistant disease or subsequent relapses.

MCQ: Hematopathology | MCQ Quiz | OmpathStudy Kenya

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