PA19.{1-3,5-6} | Lymphadenopathy & Lymphomas — Graded Quiz

A 24-year-old woman notices a painless 2 cm right posterior cervical lymph node while combing her hair. It has been present for 3 weeks. She has low-grade fever and mild fatigue. There are no other enlarged nodes. CBC shows mild lymphocytosis (lymphocytes 5,200/µL) with 15% atypical lymphocytes. Monospot test is positive. The node is soft and mildly tender. Which is the most appropriate management strategy?

A 30-year-old man presents with 8 weeks of cervical lymphadenopathy. Excision biopsy histology: lymph node architecture is partially effaced by non-caseating epithelioid cell granulomas without central necrosis; giant cells of the Langhans type are present; no Reed-Sternberg cells; no malignant cells; ZN stain negative for AFB; no organisms on fungal staining. Serum ACE is elevated. Chest X-ray shows bilateral hilar lymphadenopathy. Which diagnosis is most consistent with this pathological picture?

A 28-year-old male presents with 8 weeks of cervical lymphadenopathy, low-grade fever, and night sweats. Excision biopsy: the node is partially effaced; large binucleate cells with prominent eosinophilic 'owl-eye' nucleoli are identified against a background of lymphocytes, eosinophils, plasma cells, and histiocytes without collagen bands. Immunostaining: CD15+, CD30+, CD45−, CD20−. EBV-encoded RNA (EBER) in-situ hybridisation is positive. Which subtype of classical Hodgkin lymphoma is this, and what is its key epidemiological/EBV association?

A 20-year-old woman presents with a large anterior mediastinal mass on chest X-ray, discovered incidentally during an MBBS entrance medical examination. She is asymptomatic. CT chest: 12 cm anterior mediastinal mass with areas of necrosis and fibrous septa. PET-CT: SUVmax 18, no subdiaphragmatic involvement. CBC and LDH are normal. Excision biopsy shows: broad collagen bands dividing the node into nodules; lacunar cells (mononuclear, with retracted cytoplasm); eosinophils in background; CD30+, CD15+, CD45−. According to Ann Arbor staging, this is Stage IIA. Which statement about her prognosis and treatment approach is most accurate?

A 42-year-old man undergoes excision biopsy of a 3 cm axillary lymph node. The pathological report describes: 'Nodal architecture is partially effaced; multiple well-defined follicle-like structures are present throughout the cortex, medulla, and perisinusoidal areas; these follicles lack polarisation into dark and light zones and contain monomorphic small centrocytes; tingible-body macrophages are absent from the follicles; no Reed-Sternberg cells.' IHC: CD20+, CD10+, BCL-2+, BCL-6+. FISH: t(14;18)(q32;q21) detected. What is the diagnosis, and how does it differ from reactive follicular hyperplasia histologically?

A 16-year-old boy in sub-Saharan Africa presents with a rapidly enlarging jaw swelling over 3 weeks. Biopsy of the mass shows: intermediate-sized lymphoid cells (slightly larger than a small lymphocyte) with round nuclei, fine chromatin, multiple small nucleoli, and minimal cytoplasm; a 'starry sky' pattern is created by tingible-body macrophages scattered among the tumour cells. Ki-67 is nearly 100%. IHC: CD20+, CD10+, BCL-6+, BCL-2−, MYC+. FISH: c-MYC rearrangement with IgH at t(8;14). Which statement best explains the pathogenesis of this tumour and its geographical distribution?

A 68-year-old man presents with painless generalised lymphadenopathy, splenomegaly, and fatigue for 6 months. He has no B symptoms. Lymph node biopsy: partial effacement of nodal architecture; multiple distinct follicles composed of uniform small centrocytes (CD10+, BCL-2+, BCL-6+) and a minority of centroblasts; proliferating cells are confined to follicles. Bone marrow trephine: paratrabecular lymphoid aggregates with small cleaved cells. LDH is normal. A bone marrow karyotype shows t(14;18). What is the most accurate statement about this patient's disease trajectory?

A pathologist preparing a practical tutorial for Year-2 students describes the microscopic appearance of a lymph node from a 55-year-old man with cervical lymphadenopathy of 4 months duration. The description reads: 'Low power shows complete architectural effacement; high power shows large cells with vesicular nuclei, prominent multiple nucleoli, and abundant pale cytoplasm, growing in sheets (diffuse pattern); background inflammatory cells are sparse; no RS cells. IHC: CD20+, CD10−, BCL-2+, MUM1+, Ki-67 70%. EBV negative.' Which lymphoma subtype and its cell-of-origin does this most accurately represent?

An aspiring surgeon removes a posterior cervical lymph node from a 42-year-old man and sends the fresh specimen for frozen section. The pathologist calls back: 'The frozen section shows lymphoid tissue with architectural effacement; I cannot exclude lymphoma. I need the entire excision biopsy in formalin for paraffin sections and IHC. Please do not send the node for FNAC or culture.' The surgeon asks why the pathologist insists on the intact node and paraffin sections instead of FNAC, which is faster. Which explanation is most accurate?

A 35-year-old HIV-positive male with a CD4 count of 45 cells/µL presents with a rapidly enlarging right submandibular swelling, fever, and weight loss of 8 kg over 6 weeks. Biopsy of the mass shows: intermediate-sized lymphoid cells with round nuclei, finely dispersed chromatin, 2–3 small nucleoli, and a narrow rim of basophilic cytoplasm; the cells grow diffusely; tingible-body macrophages are abundant creating a 'starry sky' appearance; Ki-67 is 99.8%. IHC: CD20+, CD10+, BCL-6+, BCL-2−, MYC rearranged (FISH). EBV: EBER positive. This is best classified as:

A 40-year-old man presents with a large (10 cm) matted mass of cervical and supraclavicular lymph nodes, fever, drenching night sweats, and 12 kg weight loss over 3 months. PET-CT shows involvement of cervical, mediastinal, and abdominal para-aortic nodes, plus the spleen. No liver or bone marrow involvement. Excision biopsy: Hodgkin lymphoma, mixed cellularity type. What is the Ann Arbor stage, and which factor places this in the unfavourable prognostic category?

A 55-year-old woman is found to have bilateral posterior cervical and inguinal lymphadenopathy on a routine examination. She has no symptoms. A lymph node biopsy from the inguinal region shows: 'Effaced nodal architecture; sinuses filled and expanded by large cells with abundant pale cytoplasm, small round nuclei, and inconspicuous nucleoli; the cells show prominent erythrophagocytosis; IHC: CD68+, S100+, CD1a−, CD21+.' Which diagnosis does this histological pattern indicate?