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Stem
A candidate is asked to manage a classic presentation of Lymphoma (Hodgkin & Non-Hodgkin) in an exam setting. Use precise definitions, scores, doses, and decision thresholds.
Core knowledge (model answer backbone)
Lymphoma is a clonal malignancy of lymphocytes arising in lymphoid tissue, divided by the Reed-Sternberg cell into Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). HL spreads contiguously, is driven by the CD15+/CD30+ Reed-Sternberg cell, presents with cervical/supraclavicular nodes and a mediastinal mass, and is treated with ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine). NHL is heterogeneous — follicular (indolent, t(14;18) BCL2), DLBCL (commonest aggressive, R-CHOP), mantle cell (t(11;14) cyclin D1, CD5+), Burkitt (t(8;14) MYC, fastest human tumour, Ki67 ~100 percent), MALT (H. pylori, gastric). Diagnosis = EXCISIONAL biopsy (not FNA — need architecture). Ann Arbor staging (Cotswolds) with B symptoms (fever over 38C, drenching night sweats, weight loss over 10 percent in 6 months). PET-CT for staging and Deauville 5-point scale for response. IPS (HL) and IPI (NHL) for prognosis. Emergencies: SVC syndrome, mediastinal-mass airway, tumour lysis, cord compression.
Red flags
- Painless rubbery cervical/supraclavicular lymphadenopathy persisting beyond 4 to 6 weeks — urgent excisional biopsy
- Progressive dyspnoea/facial swelling/venous distension over a mediastinal mass — superior vena cava syndrome; elevate head, steroids, urgent haematology
- High-burden aggressive NHL or Burkitt starting therapy — tumour lysis syndrome; hydrate, rasburicase/allopurinol, monitor K+/phosphate/Ca2+/urate
- Back pain with new neurological deficit and known/ suspected lymphoma — epidural cord compression; IV dexamethasone, urgent MRI
High-yield structure examiners expect
Cover: Overview & Definition, Classification, Epidemiology & Risk Factors, Pathophysiology, Clinical Presentation, Differential Diagnosis.
Key doses / thresholds (from topic teaching)
- below 40 g/L
- below 105 g/L
- IV dexamethasone 10 mg then 16 mg/day, urgent MRI whole spine,
- aiming for urine output at least 100 mL/m2/h; alkalinisation is no longer routi
- Allopurinol 300 mg orally daily** (lower dose in renal imp
- piperacillin-tazobactam 4.5 g IV every 6 to 8 hours** or **ceftazidim
Questions
a) Define the condition and give the most important classification or severity framework used in exams. (3 marks)
- Clear one-line definition matching standard teaching.
- Named classification / stages / types with discriminating features.
- One sentence on why classification changes management.
b) Outline pathophysiology in a mechanism chain that explains the main clinical features. (3 marks)
- Initiating insult → intermediate pathway → end-organ effect.
- Link at least two symptoms/signs to mechanism.
- Mention one complication pathway (e.g. shock, perforation, herniation, arrhythmia).
c) List discriminating clinical features and bedside assessment. (3 marks)
- Classic presentation plus one atypical group (elderly, pregnancy, child, immunocompromised).
- Named signs/manoeuvres if relevant.
- What must never be missed on exam/bedside (pregnancy test, airway, glucose, etc.).
d) Investigations with thresholds and one named score if applicable. (3 marks)
- First-line tests and what positive findings mean.
- Gold-standard or definitive investigation when needed.
- Score components reproduced exactly if a named score is standard for this topic.
e) Immediate resuscitation and definitive management with doses where standard. (3 marks)
- ABC / time-critical steps first.
- First-line drug(s) with agent + dose + route (or procedure steps).
- Escalation triggers (theatre, ICU, thrombolysis window, antidote, etc.).
- Disposition and safety-netting.
Marking tips
Full marks require specificity (numbers, names, doses) not generic "give antibiotics/fluids." Regional practice (ICMR / NICE / AHA) may be cited as alternative where relevant.