Full-spectrum board review — risk factors, infection associations, presentation, staging, treatment, complications, and post-treatment surveillance — with difficult-level clinical vignettes at the end.
| Mechanism | Infection | Lymphoma Type |
|---|---|---|
| Direct lymphocyte transformation | Epstein-Barr virus (EBV) | Burkitt, non-Hodgkin, Hodgkin |
| Human T-lymphotropic virus type 1 (HTLV-1) | T-cell leukemia | |
| Immunosuppression | HIV | Hodgkin, non-Hodgkin |
| Chronic antigenic stimulation | Helicobacter pylori | Non-Hodgkin (mucosa-associated lymphoid tissue / MALT) |
| Chlamydia psittaci | ||
| Campylobacter jejuni / coli | ||
| Borrelia burgdorferi | ||
| Hepatitis C | Splenic marginal zone lymphoma |
Requires open lymph node biopsy — diagnosis is based on morphology. Hodgkin lymphoma is confirmed by the presence of Reed-Sternberg cells (large, binucleated "owl-eye" cells, CD15+/CD30+).
| Stage | Description |
|---|---|
| I | Single nodal group or single extralymphatic lesion |
| II | Multiple nodal groups on same side of diaphragm or limited contiguous extralymphatic involvement |
| III | Multiple nodal groups on both sides of diaphragm; may involve the spleen |
| IV | Noncontiguous extralymphatic involvement |
After 5 years of being cancer-free, the patient can be transitioned from oncology back to a primary care physician for ongoing surveillance.
| Domain | Recommendation |
|---|---|
| Cancer screening |
Breast: average-risk mammography starting age 40; if history of chest or axilla radiation → start 8 years after treatment or age 40, whichever comes first; consider annual breast MRI if chest RT given between ages 10–30; consider referral to discuss chemoprevention. Routine cervical, colorectal, lung, and prostate cancer screening per USPSTF guidelines. |
| Laboratory screening | Annual CBC, fasting glucose, comprehensive metabolic panel; lipid profile per USPSTF; TSH annually if history of neck irradiation. |
| Cardiac screening | Annual blood pressure screening + lifestyle modification/treatment of obesity, HTN, tobacco use. Consider stress test and/or echocardiogram every 10 years (frequency per risk factors). Carotid ultrasound every 10 years if history of neck irradiation. |
| Counseling | Annual depression screening. Neurocognitive impairment screening if high risk (history of brain radiation or intrathecal chemotherapy). Infertility: consider reproductive endocrinology referral. |
| Immunizations |
Age-appropriate immunizations per CDC schedule, including annual influenza vaccine; resume live vaccines ≥3 months after chemotherapy completion. PCV13 → followed by PPSV23 at least 8 weeks later → repeat PPSV23 every 5 years. Haemophilus influenzae type b: 3 doses following hematopoietic stem cell transplantation. |
A 24-year-old woman was treated for stage II nodular sclerosing Hodgkin lymphoma with mantle-field radiation at age 16. She is now asymptomatic and asks when she should start breast cancer screening. She has no family history of breast cancer.
Correct answer: B
Chest radiation mandates annual mammogram + breast MRI beginning 8 years after radiation or age 40, whichever comes first. Irradiated at 16 → the 8-year mark (age 24) precedes age 40, so screening starts now, at 24.
A — right timing coincidentally, but omits the required MRI. C — waiting until 40 ignores 16 years of elevated risk. D — this is treatment-related risk, not hereditary; BRCA testing isn't the driver. E — MRI is added given younger age, denser breast tissue, and elevated risk in this population.
A 45-year-old man completed treatment for Hodgkin lymphoma with mediastinal radiation 12 years ago. At today's survivorship visit he feels well. Which combination of surveillance is most appropriate to order today?
Correct answer: B
Survivors treated with chest RT (± anthracyclines) require lifelong annual surveillance: CBC, fasting glucose/CMP, lipid profile, blood pressure, and depression screening — this continues well beyond the 5-year cancer-free mark (though oncology hands off to primary care at that point).
A — TSH is annual only if there's a history of neck irradiation, and it's not the only needed test. C — stress test/echo is every 10 years, not the sole screen; cardiac risk is mainly tracked via BP and metabolic panels. D — surveillance is lifelong, not time-limited at 12 years. E — routine surveillance imaging isn't standard in an asymptomatic long-term survivor.
A lymph node biopsy from a 28-year-old with cervical lymphadenopathy shows large, binucleated cells with prominent "owl-eye" nucleoli in a background of eosinophils, plasma cells, and small lymphocytes. IHC: atypical cells are CD15+ and CD30+. Which diagnosis is most consistent?
Correct answer: B
Reed-Sternberg cells (binucleated, "owl-eye" nucleoli) with CD15+/CD30+ in a reactive mixed background = classic Hodgkin lymphoma.
A — DLBCL is CD20+, sheets of large atypical B-cells, no RS cells. C — Burkitt shows a "starry sky" pattern, MYC translocation, monomorphic cells. D — CLL shows small mature lymphocytes/smudge cells, not RS cells. E — mono can show reactive atypical lymphocytes but lacks true RS cells with this immunophenotype.
A 32-year-old man with newly diagnosed bulky mediastinal Hodgkin lymphoma has facial swelling and dilated veins over the upper chest/neck that worsen lying flat, plus mild dyspnea, no stridor or altered mental status. Contrast CT confirms SVC compression by the mass. Most appropriate next step?
Correct answer: C
Stable patient, no airway compromise or cerebral edema → confirm tissue diagnosis first (steroids/empiric therapy can lyse lymphoid tissue and obscure histology). Supportive care (head-of-bed elevation) while workup proceeds; definitive treatment is chemo ± RT once confirmed — never radiotherapy alone.
A — steroids pre-biopsy can compromise diagnostic yield; reserved for true emergencies. B — stenting is for severe/refractory symptoms, not first-line in a stable patient. D — bulky lymphoma with SVC syndrome needs prompt evaluation. E — no indication of thrombus; pathology here is external compression by tumor.
A 55-year-old man presents with epigastric discomfort. Endoscopic biopsy reveals gastric MALT lymphoma. Testing confirms Helicobacter pylori infection, and imaging shows localized, early-stage disease. What is the most appropriate initial treatment?
Correct answer: B
Gastric MALT lymphoma is strongly associated with chronic H. pylori infection. In early, localized disease, antibiotic eradication therapy alone can induce regression of the lymphoma — a unique feature among lymphomas.
A — chemo is reserved for eradication failure or advanced/refractory disease. C — radiotherapy alone is not first-line here and is never used alone in lymphoma treatment generally. D — splenectomy pertains to splenic marginal zone lymphoma (linked to hepatitis C), not gastric MALT. E — active eradication therapy, not observation, is indicated once H. pylori is confirmed.
A 30-year-old woman with Hodgkin lymphoma is being staged with PET/CT. She has documented fevers of 39°C, drenching night sweats, and has lost 12% of her body weight over the past 4 months. Imaging shows disease in cervical and mediastinal nodes only, all above the diaphragm. How should her stage be classified?
Correct answer: B
Multiple nodal groups on the same side of the diaphragm (cervical + mediastinal) = Stage II. Fevers >38.5°C, drenching night sweats, and unintentional weight loss ≥10% over the preceding 6 months meet criteria for B symptoms.
A/E — Stage I would mean a single nodal group; this patient has two groups involved (still same side of diaphragm, so not III/IV either). C — Stage III requires nodal involvement on both sides of the diaphragm or splenic involvement. D — Stage IV requires noncontiguous extralymphatic involvement, not present here.