You are working on a hematology rotation and get to spend the day with Dr. Lynn Foma, an exceptional hematologist notable for her sense of humour, passion for medical education, and arm wrestling skills. After briefly introducing yourself you are quick to ask for an arm wrestle. Sadly, you hear the thud before you even notice you have lost the challenge. Dr. Foma smiles and asks you to go see a patient with an anterior mediastinal mass. Before you leave she makes sure you know what the 4 T’s are. You answer:

Today is a new week, and you are back with Dr. Foma today. You spent your weekend pumping iron and watching The Terminator to get ready for this upcoming arm wrestle. Whoops you just lost again. As you wallow in misery, Dr. Foma would like to know which of the following is NOT an established risk factor for non-Hodgkins lymphoma. You answer:

Everywhere you go, everyone you see, you have challenged to arm wrestles. You will get this. You will beat Dr. Foma. To increase your strength you are currently challenging Mrs. Node, a 36 year old black female. Midway through your arm wrestle you notice something in Mrs. Node’s neck. You do a quick palpation and feel a soft, mobile lymph node. On further questioning Mrs. Node indicates she has several of these nodes throughout her body. When working up lymphadenopathy which of the following is most concerning for malignancy?

You are spending the weekend relaxing in the spa to recover your sore arms. Of course, who do you see but Dr. Foma. Luckily she establishes a brief truce. Instead she would like to know which of the following is the most aggressive form of B Cell non Hodgkin’s lymphoma. You have been hitting the books so are quick to answer:

Dr. Foma is impressed, and you are scared. While answering Dr. Foma’s previous question you noticed something simple. She’s shredded. So absolutely above your level you’re not sure about this whole arm wrestling thing anymore. Maybe the truce was a blessing in disguise you think. While you’re silently muttering to yourself in a pool of cold sweat she starts asking another question. There are a shocking number of Lymphoma subtypes and mastering them all requires some serious dedication, kind of like becoming an arm wrestling champ. Despite this, some Lymphoma subtypes have features that make them fairly memorable. Can you tell me what Burkitt Lymphoma and Anaplastic Large Cell Lymphoma have in common?

You’ve started into a downward spiral. Now whenever you meet someone new all you do is dread that they are going to challenge you to an arm wrestle. You’ve taken to hiding in the basement of your hospital with the pathologists to avoid Dr. Foma. At least down there all you have to do is field the occasional staging / grading question. Like this one. If you had a patient newly diagnosed with NHL with the following characteristics: Involvement of 3 lymph node regions on the same side of the diaphragm, no involvement of extralymphatic organs. What Lugano stage would it be considered?

It couldn’t last forever… Now settled into your basement refuge one day when you were running upstairs to grab lunch you turned the corner and found yourself face to face with Dr. Foma. Startled at first by your gaunt appearance, she overwhelms you with kindness asking how you have been. Come with me, she states warmly, I was just about to discuss treatment options with a new patient of mine who has been diagnosed with an aggressive form of NHL. Which of the following is NOT one of the options that she may discuss with the patient?

As you walk down the hall, Dr. Foma states casually “We need to make sure we have that final arm wrestle soon, I know your rotation finishes soon, how’s tomorrow?” All you can do is nod... You feel like a ghost as you follow Dr. Foma into the examination room. You meet Mr. Randy Chop, a 63 year old male. Mr. Chop has Stage II DLBCL, It is in the cervical and axillary node regions on his left side and nowhere else. He is totally independent with no limitations physically, socially, or mentally. In fact the diagnosis was made incidentally. His most recent lab work demonstrated a Serum LDH of 150 U/L (Normal range: 140 - 240 U/L). You treat him with R-CHOP. What is his 4 Year survival?

Today is the day. Your body feels weak, but your mind is ready. Worse case scenario: your arm breaks in half, and lucky for you all this doctoring has allowed you to make some orthopod friends. Everybody is here, watching. You grip Dr. Foma’s hand. You brace yourself. Ready, set, go! You can’t believe it. You are holding her back. You are winning. But then you get distracted by an indurated plaque on her arm. Which of the following T Cell lymphomas commonly presents cutaneously in adults?

You feel the back of your hand slam to the table. Your moment of distraction was all Dr. Loma needed. Everyone who was watching cheers then disperses. You feel defeated and embarrassed. Dr. Loma looks you in the eyes and asks: “Why did you let up you were winning.” You point to the plaque on her arm. She is impressed as she infers your concern. She lets you know that this plaque is just psoriasis. However, she entertains your differential. If it was Mycosis fungoides and I had it treated 5 years ago, how often would I be having lab work and seeing a physician for a history and physical?

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