Question 66#

A 64-year-old man is reviewed in the haematology clinic. Which one of the following features would suggest that a diagnosis monoclonal gammopathy of undetermined significance is more likely than myeloma?

A. Bone pain

Correct Answer B: Paraproteinaemia is seen in both myeloma and monoclonal gammopathy of undetermined significance (MGUS) - at this level a diagnosis of MGUS is more likely. The other features indicate myeloma.

MGUS:
Monoclonal gammopathy of undetermined significance (MGUS, also known as benign paraproteinaemia and monoclonal gammopathy) is a common condition that causes a paraproteinaemia and is often mistaken for myeloma. Differentiating features are listed below.

Around 10% of patients eventually develop myeloma at 5 years, with 50% at 15 years.

Features: 

• Usually asymptomatic
• No bone pain or increased risk of infections
• Around 10-30% of patients have a demyelinating neuropathy

Differentiating features from myeloma:

• Normal immune function
• Normal beta-2 microglobulin levels
• Lower level of paraproteinaemia than myeloma (e.g. < 30g/l IgG, or < 20g/l IgA)
• Stable level of paraproteinaemia
• No clinical features of myeloma (e.g. lytic lesions on x-rays or renal disease) 

Question 67#

What is the most useful marker of prognosis in myeloma?

A. Calcium level

Correct Answer E: 

Myeloma: prognosis:
B2-microglobulin is a useful marker of prognosis - raised levels imply poor prognosis. Low levels of albumin are also associated with a poor prognosis.

International prognostic index:

Stage Criteria Median survival (months):

• Stage I B2 microglobulin < 3.5 mg/l Albumin > 35 g/l  (62)
• Stage II Not I or III (45)
• Stage III B2 microglobulin > 5.5 mg/l  (29)

Question 68#

Regarding the Ann-Arbor classification of Hodgkin's lymphoma, which one of the following would be staged as IIIB?

A. Nodes on both sides of diaphragm with pruritus

Correct Answer C: 

Hodgkin's lymphoma: staging:
Hodgkin's lymphoma is a malignant proliferation of lymphocytes characterized by the presence of the Reed Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades.

Ann-Arbor staging of Hodgkin's lymphoma:

• I: single lymph node
• II: 2 or more lymph nodes/regions on same side of diaphragm
• III: nodes on both sides of diaphragm
• IV: spread beyond lymph nodes

Each stage may be subdivided into A or B:

• A = no systemic symptoms other than pruritus
• B = weight loss > 10% in last 6 months, fever > 38c, night sweats (poor prognosis) 

Question 69#

Which one of the following is the most common type of Hodgkin's lymphoma?

A. Lymphocyte predominant

Correct Answer B: Hodgkin's lymphoma - most common type = nodular sclerosing.

Hodgkin's lymphoma: histological classification and prognosis:
Hodgkin's lymphoma is a malignant proliferation of lymphocytes characterized by the presence of the Reed-Sternberg cell. It has a bimodal age distributions being most common in the third and seventh decades.

Histological classification: 

• Nodular sclerosing: most common, good prognosis
• Mixed cellularity: good prognosis
• Lymphocyte predominant: best prognosis
• Lymphocyte depleted: least common, worst prognosis

'B' symptoms also imply a poor prognosis: 

• Weight loss > 10% in last 6 months
• Fever > 38ºC
• Night sweats

Other factors associated with a poor prognosis identified in a 1998 NEJM paper included:

• Age > 45 years
• Stage IV disease
• Haemoglobin < 10.5 g/dl
• Lymphocyte count < 600/μl or < 8%
• Male
• Albumin < 40 g/l
• White blood count > 15,000/μl

Question 70#

A 62-year-old man is called for review after a positive faecal occult blood test done as part of the national screening programme. During counselling for colonoscopy he asks what percentage of patients with a positive faecal occult blood test have colorectal cancer.

What is the most accurate answer? 

A. 0.5 - 2%

Correct Answer B: Colorectal cancer screening - PPV of FOB = 5 - 15%.

There is also a 30-45% chance of having an adenoma with a positive faecal occult blood test.

Colorectal cancer: screening:

Overview:

• Most cancers develop from adenomatous polyps. Screening for colorectal cancer has been shown to reduce mortality by 16%
• The NHS now has a national screening programme offering screening every 2 years to all men and women aged 60 to 69 years. Patients aged over 70 years may request screening
• Eligible patients are sent faecal occult blood (FOB) tests through the post
• Patients with abnormal results are offered a colonoscopy

At colonoscopy, approximately:

• 5 out of 10 patients will have a normal exam
• 4 out of 10 patients will be found to have polyps which may be removed due to their premalignant potential
• 1 out of 10 patients will be found to have cancer