Leukaemias, lymphomas and myeloma

33 NEET-PG practice questions on Leukaemias, lymphomas and myeloma, part of Pathology. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium

   A 68-year-old retired teacher is found to have a total leucocyte count of 48,000/µL on a routine check-up, with 85% small mature-looking lymphocytes and many smudge cells. He has small, painless cervical nodes. Flow cytometry shows CD19+, CD5+, CD23+, CD200+ cells with weak surface kappa light chain. What is the most likely diagnosis?

   1. AMantle cell lymphoma
   2. BFollicular lymphoma
   3. CHairy cell leukaemia
   4. DChronic lymphocytic leukaemia

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   Answer: D · Chronic lymphocytic leukaemia

   Small mature B cells that co-express CD5 and CD23, with weak (dim) monoclonal surface light chain and smudge cells, are typical of chronic lymphocytic leukaemia/small lymphocytic lymphoma. CD5 is normally a T-cell marker, so its presence on clonal B cells narrows the choice to CLL or mantle cell lymphoma, and CD23 separates them. Many patients are diagnosed incidentally and need only observation until they have symptoms or cytopenias. Testing for del(17p) or TP53 mutation before treatment guides the choice of drug.

   • A: Mantle cell lymphoma is CD5+ but CD23-negative and cyclin D1-positive from t(11;14).
   • B: Follicular lymphoma is CD10-positive and CD5-negative.
   • C: Hairy cell leukaemia is CD5-negative and expresses CD103, CD11c and CD25.

2. Question 2 · Medium

   A 26-year-old man in Chandigarh has neck lymph nodes, and a node biopsy shows classic Reed-Sternberg cells. Consider these statements about the immunophenotype of these cells: 1. CD15 positive. 2. CD30 positive. 3. CD45 negative. 4. CD20 strongly positive in all cells. Which statements are correct?

   1. A1 and 2 only
   2. B3 and 4 only
   3. C1, 2 and 3 only
   4. D1, 2 and 4 only

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   Answer: C · 1, 2 and 3 only

   Classic Reed-Sternberg cells are typically CD15 and CD30 positive and CD45 negative, with weak PAX5. Although they come from germinal centre B cells, they have lost most of the B-cell programme, so CD20 is usually negative or only weak and patchy in a minority of cells. Strong uniform CD20 expression would point to nodular lymphocyte predominant Hodgkin lymphoma or a large B-cell lymphoma instead. Statements 1, 2 and 3 are therefore correct.

   • A: Leaves out the CD45 negativity of Reed-Sternberg cells.
   • B: Includes strong CD20 and leaves out CD15 and CD30.
   • D: Includes strong CD20, which is not a feature of classic Reed-Sternberg cells.

3. Question 3 · Hard

   A 70-year-old man in Gwalior has headache, blurred vision and nosebleeds. Fundi show dilated, sausage-shaped retinal veins with haemorrhages. Total protein is 10.8 g/dL with an IgM-kappa M protein of 4.2 g/dL; marrow shows lymphoplasmacytic cells with the MYD88 L265P mutation. There are no lytic lesions. What is the most urgent step?

   1. AStart lenalidomide
   2. BRed cell transfusion
   3. CBisphosphonate infusion
   4. DPlasmapheresis

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   Answer: D · Plasmapheresis

   IgM monoclonal protein, lymphoplasmacytic infiltration and MYD88 L265P indicate Waldenström macroglobulinaemia. Large pentameric IgM molecules raise blood viscosity, causing headache, visual blurring with retinal vein engorgement, and mucosal bleeding. Because IgM stays mostly within the vascular space, plasmapheresis lowers viscosity rapidly and is the urgent treatment, followed by therapy against the clone such as rituximab-based regimens or a BTK inhibitor. Red cell transfusion should be avoided until viscosity is reduced, as it can worsen hyperviscosity.

   • A: Lenalidomide is a myeloma drug and does not lower viscosity quickly.
   • B: Transfusion before plasmapheresis can worsen hyperviscosity.
   • C: Bisphosphonates treat myeloma bone disease; there are no lytic lesions here.

4. Question 4 · Easy

   A 30-year-old man in Vellore has bleeding gums and bruises. His smear shows abnormal promyelocytes with heavy granules and bundles of Auer rods, and the coagulation screen shows DIC. Which genetic abnormality defines his leukaemia?

   1. ARUNX1::RUNX1T1 from t(8;21)
   2. BPML::RARA from t(15;17)
   3. CKMT2A::MLLT3 from t(9;11)
   4. DCBFB::MYH11 from inv(16)

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   Answer: B · PML::RARA from t(15;17)

   Hypergranular promyelocytes with bundles of Auer rods (faggot cells) and DIC are the hallmarks of acute promyelocytic leukaemia. The t(15;17) translocation creates the PML::RARA fusion, which blocks myeloid differentiation at the promyelocyte stage. All-trans retinoic acid and arsenic trioxide overcome this block and have made APL one of the most curable leukaemias. Treatment is started on suspicion because early death from bleeding is common.

   • A: RUNX1::RUNX1T1 is seen in AML with maturation, without this DIC picture.
   • C: KMT2A::MLLT3 is seen in AML with monocytic features, not hypergranular promyelocytes.
   • D: CBFB::MYH11 is seen in AML with abnormal eosinophils.

5. Question 5 · Medium

   A 70-year-old man with known chronic lymphocytic leukaemia on observation in Mysuru now has jaundice and Hb 7.4 g/dL, down from 12 g/dL two months ago. Reticulocytes 9%, many spherocytes, DAT positive for IgG. What is the most likely cause of his anaemia?

   1. AHypersplenism
   2. BMarrow replacement by leukaemic lymphocytes
   3. CWarm autoimmune haemolytic anaemia
   4. DPure red cell aplasia

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   Answer: C · Warm autoimmune haemolytic anaemia

   CLL is often complicated by autoimmune disorders, most commonly warm autoimmune haemolytic anaemia, because the disease disturbs immune regulation. Spherocytes, reticulocytosis and a DAT positive for IgG confirm immune haemolysis. Marrow infiltration would give a low reticulocyte count. It is treated first with corticosteroids, and recurrent or resistant cases need CLL-directed therapy.

   • A: Hypersplenism does not produce a positive DAT and spherocytes with this degree of haemolysis.
   • B: Marrow infiltration would cause anaemia with a low reticulocyte count.
   • D: Pure red cell aplasia would give near-absent reticulocytes.

6. Question 6 · Medium

   A 27-year-old woman is brought to casualty in Lucknow with gum bleeding and a large bruise. Hb 7.6 g/dL, WBC 2,100/µL, platelets 18,000/µL; the smear shows hypergranular promyelocytes with Auer rods. PT is prolonged and fibrinogen is 80 mg/dL. Cytogenetics will take several days. What is the next best step?

   1. AStart heparin infusion for DIC
   2. BStart all-trans retinoic acid immediately
   3. CWait for PML::RARA confirmation
   4. DDo a bone marrow biopsy before treatment

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7. Question 7 · Medium

   A 47-year-old woman in Bhubaneswar with chronic myeloid leukaemia has been on imatinib for 6 months, and her blood count is now normal. Which test is used to monitor her response to treatment at this stage?

   1. ALeucocyte alkaline phosphatase score
   2. BPeripheral smear examination every month
   3. CRepeat bone marrow biopsy every 3 months
   4. DQuantitative RT-PCR for BCR::ABL1 transcripts

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8. Question 8 · Hard

   A 45-year-old man in Indore with chronic-phase CML lost his molecular response after 2 years on imatinib despite good adherence. He then failed dasatinib. Mutation analysis of the BCR::ABL1 kinase domain shows T315I. Which drug from this list is active against this mutation?

   1. ADasatinib at a higher dose
   2. BNilotinib
   3. CPonatinib
   4. DBosutinib

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9. Question 9 · Hard

   A 31-year-old woman in Kochi has gum bleeding. Hb 9.2 g/dL, WBC 3,000/µL, platelets 34,000/µL, fibrinogen 110 mg/dL. Her marrow shows 12% blasts and 40% abnormal hypergranular promyelocytes, and RT-PCR detects PML::RARA. How is this classified under the WHO 5th edition?

   1. AAcute promyelocytic leukaemia, as the fusion defines AML
   2. BNot leukaemia until blasts reach 20%
   3. CChronic myelomonocytic leukaemia
   4. DMyelodysplastic neoplasm with increased blasts

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10. Question 10 · Easy

    A 50-year-old man in Ludhiana has fatigue and a massive spleen. He has pancytopenia with monocytopenia, and the bone marrow aspirate is a dry tap. Circulating lymphoid cells have fine hair-like cytoplasmic projections and are CD103, CD11c and CD25 positive. Which mutation is characteristic?

    1. ANPM1 exon 12
    2. BBRAF V600E
    3. CJAK2 V617F
    4. DMYD88 L265P

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11. Question 11 · Medium

    A 56-year-old farmer in Punjab has fever and fatigue for 3 weeks. Hb 7.8 g/dL, WBC 46,000/µL, platelets 30,000/µL. The marrow has 60% large blasts with fine chromatin, a few containing slender red rods; cytochemistry shows the blasts are strongly myeloperoxidase positive. What is the diagnosis?

    1. AAcute lymphoblastic leukaemia
    2. BChronic myeloid leukaemia in chronic phase
    3. CMyelodysplastic syndrome
    4. DAcute myeloid leukaemia

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12. Question 12 · Easy

    A 66-year-old man with multiple myeloma has a protein in his urine that is not detected by the dipstick but is shown by urine immunofixation. What is this Bence Jones protein made of?

    1. AAlbumin and beta-2 microglobulin
    2. BFree monoclonal light chains
    3. CFree monoclonal heavy chains
    4. DIntact monoclonal IgG

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13. Question 13 · Medium

    A 59-year-old woman in Kollam has newly diagnosed IgG-kappa myeloma with a serum free kappa level of 2,400 mg/L and acute kidney injury (creatinine 4.8 mg/dL). Urine dipstick shows only trace protein. What is the most likely mechanism of her kidney injury?

    1. ALight chain casts with Tamm-Horsfall protein in tubules
    2. BRenal vein thrombosis
    3. CImmune complex deposits along the glomerular basement membrane
    4. DAA amyloid deposition in glomeruli

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14. Question 14 · Medium

    A 34-year-old man on induction with all-trans retinoic acid and arsenic trioxide for acute promyelocytic leukaemia develops fever, breathlessness, weight gain of 5 kg, pleural effusions and pulmonary infiltrates on day 8. Blood cultures are negative. What is the most likely cause?

    1. AInvasive pulmonary aspergillosis
    2. BDifferentiation syndrome
    3. CArsenic-induced heart block
    4. DTransfusion-related acute lung injury

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15. Question 15 · Easy

    An 8-year-old boy in a medical college hospital in Kerala has a rapidly growing abdominal mass from the ileocaecal region. Biopsy shows sheets of medium-sized cells with a starry-sky pattern, and Ki-67 is almost 100%. Which translocation is most typical?

    1. At(14;18)
    2. Bt(11;14)
    3. Ct(9;22)
    4. Dt(8;14)

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16. Question 16 · Medium

    A 63-year-old man in Pune has generalised lymphadenopathy and multiple polyps in the colon on colonoscopy. Polyp biopsy shows small lymphoid cells with irregular nuclei that are CD20+, CD5+, CD23- and cyclin D1+. What is the diagnosis?

    1. AExtranodal marginal zone lymphoma
    2. BChronic lymphocytic leukaemia
    3. CMantle cell lymphoma
    4. DFollicular lymphoma

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17. Question 17 · Medium

    A 15-year-old boy in Ranchi has breathlessness when lying flat and facial swelling. Chest X-ray shows a large anterior mediastinal mass. WBC 85,000/µL with blasts that are TdT+, cytoplasmic CD3+, CD7+ and CD19-. What is the most likely diagnosis?

    1. APrimary mediastinal B-cell lymphoma
    2. BB-lymphoblastic leukaemia
    3. CNodular sclerosis Hodgkin lymphoma
    4. DT-lymphoblastic leukaemia/lymphoma

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18. Question 18 · Medium

    A 58-year-old man in Shillong has dyspepsia, and endoscopy shows thickened gastric folds. Biopsy shows small B cells infiltrating and destroying gastric glands (lymphoepithelial lesions); Helicobacter pylori is seen, and staging shows disease confined to the stomach. What is the first-line treatment?

    1. AHelicobacter pylori eradication therapy
    2. BTotal gastrectomy
    3. CWhole-abdomen radiotherapy as first treatment
    4. DR-CHOP chemotherapy

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19. Question 19 · Easy

    A 24-year-old woman in Thrissur has painless cervical lymph nodes. Biopsy shows large binucleate cells with prominent owl-eye nucleoli in a mixed background of lymphocytes, eosinophils and plasma cells. Which markers are these large cells expected to express?

    1. ACD20 and CD45
    2. BCD15 and CD30
    3. CCD10 and BCL6
    4. DCD3 and CD4

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20. Question 20 · Hard

    A 62-year-old retired bank officer in Pune has an IgG-lambda M protein of 1.8 g/dL found on tests for a raised ESR. Bone marrow shows 6% clonal plasma cells. Hb 13.4 g/dL, calcium 9.2 mg/dL, creatinine 0.9 mg/dL, and whole-body low-dose CT shows no lytic lesions. What is the diagnosis?

    1. ASolitary plasmacytoma of bone
    2. BMultiple myeloma needing treatment
    3. CMonoclonal gammopathy of undetermined significance
    4. DSmouldering (asymptomatic) multiple myeloma

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21. Question 21 · Easy

    A 42-year-old man in Indore with a WBC of 1,60,000/µL, basophilia and splenomegaly is confirmed to have chronic myeloid leukaemia and is started on imatinib. What does imatinib inhibit?

    1. AThe Bruton tyrosine kinase
    2. BThe BCR::ABL1 tyrosine kinase
    3. CThe FLT3 receptor kinase
    4. DThe JAK2 tyrosine kinase

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22. Question 22 · Medium

    A 35-year-old man in Agra has a single enlarged neck node for a year. Biopsy shows a vaguely nodular pattern with scattered large cells with multilobed nuclei resembling popcorn, in a background of small B cells. Which immunophenotype do the large cells most likely have?

    1. ACD10+, BCL2+, CD15-, CD30-
    2. BCD20+, CD45+, CD15-, CD30-
    3. CCD3+, CD4+, CD15-, CD30-
    4. DCD20-, CD45-, CD15+, CD30+

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23. Question 23 · Medium

    A 5-year-old boy in AIIMS, New Delhi is newly diagnosed with B-lymphoblastic leukaemia. Consider these features: 1. Age between 1 and 10 years. 2. Hyperdiploidy with more than 50 chromosomes. 3. ETV6::RUNX1 fusion from t(12;21). 4. Presenting WBC of 1,20,000/µL. Which are favourable prognostic factors?

    1. A1, 2 and 3 only
    2. B2, 3 and 4 only
    3. C1, 3 and 4 only
    4. D2 and 3 only

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24. Question 24 · Hard

    A 52-year-old man who lived for 20 years in southern Japan presents in Chennai with skin rash, lymphadenopathy and confusion. Calcium 14.2 mg/dL; WBC 38,000/µL with lymphocytes whose nuclei are deeply lobulated like flowers. The cells are CD4+ and CD25+. Which virus is most likely responsible?

    1. AHIV-1
    2. BHTLV-1
    3. CHHV-8
    4. DEpstein-Barr virus

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25. Question 25 · Medium

    A 68-year-old man in Jabalpur with multiple myeloma has many lytic lesions on low-dose whole-body CT, but his technetium bone scan was reported as almost normal, and serum alkaline phosphatase is normal. What explains this?

    1. ATechnetium binds monoclonal protein in blood
    2. BOsteoblast activity is suppressed in myeloma
    3. CMyeloma lesions are mainly sclerotic
    4. DThe lesions are too small to be seen on scans

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