ITE Hematology and Oncology 2 — Questions and Answers
Question 1: A 67-year-old man presents with bone pain, fatigue, and recurrent pneumonias. Labs show calcium 12.2 mg/dL, creatinine 2.3 mg/dL, Hgb 9.1 g/dL, and total protein 10.2 g/dL. Serum protein electrophoresis reveals an M-spike. What is the most likely diagnosis?
- Multiple myeloma (Correct answer)
- Waldenstrom macroglobulinemia
- Chronic lymphocytic leukemia
- Monoclonal gammopathy of undetermined significance (MGUS)
Correct answer: Multiple myeloma
Multiple myeloma classically presents with the CRAB criteria (hyperCalcemia, Renal insufficiency, Anemia, Bone pain) along with a monoclonal spike on SPEP.
Question 2: A 24-year-old man presents with painless cervical lymphadenopathy, fever, drenching night sweats, and 12-lb weight loss over 2 months. Lymph node biopsy reveals large binucleated cells with prominent 'owl-eye' nucleoli. What is the most likely diagnosis?
- Hodgkin lymphoma (Correct answer)
- Non-Hodgkin lymphoma
- EBV infectious mononucleosis
- Sarcoidosis
Correct answer: Hodgkin lymphoma
Reed-Sternberg cells (large binucleated cells with prominent 'owl-eye' nucleoli) on biopsy are pathognomonic for Hodgkin lymphoma.
Question 3: A 62-year-old woman has bilateral painless cervical and axillary lymphadenopathy. Flow cytometry of a lymph node biopsy shows CD5+, CD19+, CD20+ (dim), CD23+ cells with kappa light chain restriction. What is the most likely diagnosis?
- Chronic lymphocytic leukemia / Small lymphocytic lymphoma (CLL/SLL) (Correct answer)
- Mantle cell lymphoma
- Follicular lymphoma
- Diffuse large B-cell lymphoma
Correct answer: Chronic lymphocytic leukemia / Small lymphocytic lymphoma (CLL/SLL)
The CD5+, CD19+, CD20 (dim), CD23+ immunophenotype is characteristic of CLL/SLL, distinguishing it from other B-cell lymphomas.
Question 4: A 38-year-old man presents with fatigue, easy bruising, and gingival bleeding for 3 weeks. CBC shows WBC 68,000/μL with 85% blasts, Hgb 7.8 g/dL, and platelets 18,000/μL. Bone marrow confirms AML. Which induction chemotherapy regimen is standard?
- Cytarabine for 7 days plus daunorubicin for 3 days ('7+3') (Correct answer)
- CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)
- Rituximab monotherapy
- Imatinib plus hydroxyurea
Correct answer: Cytarabine for 7 days plus daunorubicin for 3 days ('7+3')
The '7+3' regimen — 7 days of continuous infusion cytarabine plus 3 days of an anthracycline — is the standard induction for AML.
Question 5: A 54-year-old male smoker presents with facial plethora and headaches. Labs show Hgb 19.6 g/dL, Hct 62%, normal O2 saturation, and JAK2 V617F mutation. Splenomegaly is present. What is the most appropriate initial treatment?
- Phlebotomy to reduce hematocrit plus low-dose aspirin (Correct answer)
- Hydroxyurea cytoreduction alone
- Erythropoietin supplementation
- Allogeneic stem cell transplant
Correct answer: Phlebotomy to reduce hematocrit plus low-dose aspirin
Polycythemia vera is initially managed with phlebotomy to reduce hematocrit below 45% and low-dose aspirin to prevent thrombosis.
Question 6: A patient develops sudden confusion, fever of 39.1°C, microangiopathic hemolytic anemia, platelet count of 14,000/μL, and creatinine of 2.8 mg/dL. Peripheral smear shows many schistocytes. ADAMTS13 activity is <10%. What is the treatment of choice?
- Therapeutic plasma exchange (Correct answer)
- Platelet transfusion
- Hemodialysis
- Rituximab monotherapy without plasma exchange
Correct answer: Therapeutic plasma exchange
Acquired TTP with severely reduced ADAMTS13 activity requires urgent plasma exchange to remove the anti-ADAMTS13 antibody and replenish the enzyme.
Question 7: A 28-year-old man with severe hemophilia A (factor VIII activity <1%) presents with rapidly expanding knee hemarthrosis after a fall. What is the first-line treatment?
- Factor VIII concentrate replacement therapy (Correct answer)
- Desmopressin (DDAVP)
- Cryoprecipitate infusion
- Fresh frozen plasma infusion
Correct answer: Factor VIII concentrate replacement therapy
Hemophilia A is treated with specific factor VIII concentrate replacement, which is preferred over non-specific blood products for efficacy and safety.
ITE Hematology and Oncology 2
A 67-year-old man presents with bone pain, fatigue, and recurrent pneumonias.
Labs show calcium 12.2 mg/dL, creatinine 2.3 mg/dL, Hgb 9.1 g/dL, and total protein 10.2 g/dL.
Serum protein electrophoresis reveals an M-spike.
What is the most likely diagnosis?