Overview of Leukemias and Lymphomas for USMLE

Okay, welcome. My name is Devine. I'm a resident. This is episode 203 of the Devine Intervention Podcast. And in this podcast, I'm going to be talking about a topic that I don't know, for whatever bizarre reason, people tend to get this wrong like a lot on MDMA exams, especially for Step 2CK. So it's going to be like a somewhat limited coverage of leukemias and lymphomas, specifically for the USMLE Step 2CK and Step 3 exams. So I'll just talk about some things that are high yield that people tend to, you know, kind of screw up on these tests. And to be perfectly honest with you, I think I'm going to set this up in a fairly unique way. And it will be how to specifically on MBME exams, get questions correct that test leukemias and lymphomas, right? So the first big question, and so this should hopefully be kind of like a short podcast. So the first big question you want to ask yourself when in being exams is okay divine How do leukemias classically present and how do lymphomas classically present? Here's the deal. The way a leukemia will likely present on your test is you will see a person that has a disproportionately elevated white blood cell count. It's not always true, but that is usually the case, right? But I will say even more cogent is like this thing where every other blood element will be low. So they will have like low hemoglobin indicating that they have an anemia and they will have low like a low platelet count indicating that they have a thrombocytopenia. So if you see either a high white a disproportionately high white blood cell count or you see a normal white blood cell count but you notice that every other thing is low the platelets are low the hemoglobin is low if you see that you absolutely want to think about a lymph sorry leukemia on an mbm exam. Okay, now on the flip side, lymphomas, people that have lymphomas, the primary physical exam finding is almost always those people having some sort of lymphadenopathy. In fact, they are for sure going to have lymphadenopathy on the exam. And usually people that have lymphomas tend to not have CBC abnormalities, right? So their white count may be normal, their hemoglobin may be normal, their platelet count may be normal. That's something you absolutely need to keep at the back of your mind for tests, okay? Usually, they do not have CBC abnormalities, and the primary presentation tends to be lymphadenopathy. And it's almost always in young people. Yes, can old people get lymphomas? That's absolutely true, they can, right? But it's almost always in a young person, right? And then, in addition to being in a young person, they also tend to have chronic B symptoms. So, they'll say over the last X number of weeks. or x number of months this person has been having like fevers some out weight loss although they usually don't have weight loss but you know fevers night sweats and the like so that's the way you tell a leukemia apart from a lymphoma in a q-step right because the mbme they're usually pretty good at writing these questions well enough to where it's kind of hard to differentiate them so pay attention to these heart signs that i'm describing to you right now and then in the leukemia world There's this algorithm I use. So once you've determined that, okay, I'm likely dealing with leukemia, right? There's an algorithm I typically use to say, okay, this is how I know the specific kind of leukemia they are asking about, right? So I look at the two extremes of life. I look at old people and young people. You know, let's start with like young people first, you know, the young come first, right? So like young people, right? And then we then have old people, right? So young people. Remember, A comes before C in the alphabet. So the young people will have A-L-L, okay? And then the old people have C-L-L, right? Those people are usually at the extremes of age. So super young people like kids, five years old, six year olds, they get A-L-L. And then, you know, old people like in their late 60s, 70s, 80s, they tend to have C-L-L, right? And then in the middle of life, right, we have the M-Ls, M-L for midlife, right? So we have A-M-L and C-M-L, right? That's the first thing, right? So now what are some unique things you want to know about each of those things that you know they usually give it as a memory hook in the question that will tell you okay you are dealing with this versus the other. Again like I said ALL is going to be in a kid right so if you see an adult an adult is not going to get ALL on an MBM exam that's pretty much a given right and then remember that ALL has an association with Down syndrome okay ALL has an association with Down syndrome right you've probably heard of this mnemonic that they all fall down. to help you remember that ALL is found in people with Down syndrome. And then if you look at the other extreme of age, CLL, right? And ALL is rapidly fatal if it's not... it um usually those kids can be dead in like weeks or something like that if you don't treat them quickly um and then cll the classic presentation will be an old person with recurrent infections right and they will have a super high white count so you may say oh divine this person has a super high white count how are they getting recurrent infections the thing is cll in and of itself is an immunodeficiency disease because the thing is yes you may have all those ferocious b cells running all over the place but the thing is those b cells essentially do not work so they may not make like a decent number of antibodies or if they make antibodies those antibodies will effectively not work okay so that's how you know that okay you're likely that's why those people tend to get recurrent infections right so again cll the really high white count right tons of infections and it's It's usually like... pneumonia and all this stuff with like strep pneumo right you'll have a crazy high white count it'll be an old person right and remember if you look at the person's um blood smear you're gonna find smudge cells okay you're gonna find smudge cells if they one thing i guess maybe i should maybe go ahead and throw out there is um it's a b cell problem right so the bug pattern since i'm almost discussing it as an immunodeficiency disorder will be practically bacterial infections okay so that's the big thing and then aml obviously right aml you need to know the genetic translocation it's 1517 right so 1517 translocation and you um you treat it with all trans-rethinoic acid right and obviously if you're looking at the cells on the histology you're going to see our rods right and our rods you need to be extremely careful when you're when you're kind of manipulating those things because those people can absolutely get um dic those our rods are very powerful triggers of secondary hemostasis so those people can run into dic with that right and then cml the big and the thing is one thing your friends at the mba can do is instead of putting all trans-rethinoic acid as an answer for the treatment of aml right one thing they can do is they can put vitamin a derivative as an answer right so that's something you need to be careful about right because the mbme one of their car like one of their most common stocks in trade is to essentially take what you know and just give it different words okay So instead of putting all trans-requinolic acid, you can put vitamin A derivative, right? So don't fall for that on a test so that you don't get gimped. And then, CML, right? I mean, I feel like anyone that has taken Step 1 or has been in med school for any length of time knows a decent amount about CML, right? So CML, classic thing would be the 922 translocation, right? That's a big one to know. And then remember, you create a fusion protein known as BCR-ABO, right? AKA the Philadelphia chromosome. So the Philadelphia chromosome gives rise. to that BCR-ABO fusion protein, and you treat this with Imatinib. Okay, you treat it with Imatinib. Imatinib is a tyrosine kinase inhibitor. I'm pretty certain I've given this rule in maybe like a video podcast I've granted where I said that if a person has a, if a drug ends in nib, that tells you right off the bat that that drug has to be a tyrosine kinase inhibitor. So that's a very high yield thing to know for purposes of exams. Okay, that's a very high yield thing to know for purposes of exam. That's the way you tell those different leukemias apart. So the lymphomas, I mean, the big thing with lymphomas is you want to think about the two big classes. So again, Hodgkin's versus non-Hodgkin's. So what are the big things to keep in mind with Hodgkin's? Obviously, if a person has Hodgkin's lymphoma, again, they will have primarily lymph nodes that will be affected. They usually will not have CBC abnormalities. It's usually going to be in a young person. Again, these things are not always true, but they are true. the vast majority of the time on NBMEs, right? And you'll have chronic B symptoms, right? And remember the highlight cell for Hodgkin's lymphoma are the Reed-Sternberg cells, right? The Reed-Sternberg cells are the classic cells for Hodgkin's lymphoma. And one thing that the NBME loves to do, especially on step three, and they also do this on step one, is to make your, well, hopefully, hope that you remember that Hodgkin's lymphoma is almost like a nice representation of the biostatistical concept of bimodality right so it tends to show up in young folk right so you know like late teenagers like late teenagers or like you know like their early 20s and then it also tends to show up in old people right so people that are you know almost 60 years old or a little over 60 years old right so it's a bimodal distribution right and then don't forget again your ristromberg cells i forgot to mention with cll cll the classic cell you think about are your smudge cells i think i may have mentioned it but I don't know why my mind is saying I didn't see it. So I'm just saying it just in case, right? And then, again, Ritz-Trenberg cells versus non-Hodgkin's. You know, non-Hodgkin's lymphoma, there's many different types. You do not see the Ritz-Trenberg cells. And pretty much most of these leukemias and lymphomas just involve... B cells for the most part, right? And remember your different kinds of Hodgkin's lymphomas. I will just tell you this because there's many, many different types. The one I will just, I just feel like there is like two key principles you want to, or let's say three key principles you want to keep in mind with Hodgkin's lymphomas. Because again, there are many types. You don't need to memorize everything about every type, but there's like one unique thing you want to make sure you know about pretty much all of them. these Hodgkin's lymphomas. The first thing is you want to know that if you have more lymphocytes in a Hodgkin's lymphoma, the prognosis is better, okay? If you have, I'll say that again, if you have more lymphocytes in a Hodgkin's lymphoma, the prognosis is better, okay? Now, the corollary to that is if you have fewer lymphocytes, then the prognosis is worse, right? So there are two, there's this kind of Hodgkin's lymphoma that's called like lymphocyte predominant sometimes people call it lymphocyte rich and then there's another one that you call lymphocyte depleted by virtue of this principle i just discussed lymphocyte rich hodgkin's lymphoma has a much better effect i i'm fairly certain it has the best prognosis of all the prognosis is the wrong word prognosis it has the best prognosis of all the hodgkin's lymphomas compared to the uh like the uh compared to all the others and certainly a lot better than the lymphocyte depleted. And then if they give you like a stock question on an MBM exam, and they're asking you about the kind of Hodgkin's lymphoma the person has, go with the nodular sclerosin variant, okay? The most common kind of Hodgkin's lymphoma, very high yield, the most common kind of Hodgkin's lymphoma is the nodular sclerosin kind of Hodgkin's lymphoma. And then if you see a person with Hodgkin's lymphoma having a lot of pruritus, and they tell you that oh this the you look at the presence cbc and you notice that oh the inocelophial count is like really high it's like six percent or ten percent or something like that then you absolutely want to think about the mixed cellularity variant okay so the the things that are released by those eosinophils can cause a pruritus although other kinds of hodgkin's lymphomas can be associated with pruritus and don't forget that your hodgkin's lymphomas right classically via cd 15 and cd 30 positive just remember cd 15 and then double that number you get cd30 and you're good to go on your test right um and then uh some of the non-hotchkins lymphomas i think i should maybe talk about right don't forget your burkitt's lymphoma starry sky pattern right 814 translocation right basically you have like a c-mic amplification and c-mic promotes like just crazy proliferation of lymphocytes right so starry sky pattern jaw mass in an african abdominal mass in uh in a person that is not african right 814 translocation semic amplification that's a very high yield thing to keep at the back of your mind for exams and then uh multiple myeloma right again it's something i've talked about at nasmi many podcasts again don't screw this up on a test these people have crap symptoms right you'll have hypercalcemia they'll have renal problems they'll have anemia and you'll have bone pain you'll have lytic lesions this is one of those things that causes lyrical lesions on imaging, lyrical lesions. It's a radiological term, okay? So Hodgkin's lymphoma, again, keep, I mean, sorry, multiple myeloma, keep that at the back of your mind. It's very easy to identify it, right? You do like your SPEP and your UPEP to make the correct diagnosis, right? And then don't forget that on a blood smear, right, you'll see like a stack of coins formation of red blood cells. That's what's classically known as the Rouleau formation. And then I know that I talked about CML. CML is actually one of those things called a myeloproliferative. uh disorder cml is a myeloproliferative disorder um please do not forget your other myeloproliferative disorders right they love to test those things on mbm exams right like uh cml is a classic one there um one other one you want to keep at the back of your mind is polycythemia vera right for the most part these myeloproliferative disorders they tend to be associated with like jack two mutations right so polycythemia vera these people have like a crazy highway blood cell count. i mean sorry not white blood cell a crazy high hematocrit right so you see these people hemoglobin is of like 20. he might have created like 65 percent right you're like that doesn't seem very normal right and usually these people have like um they'll have this thing called like um like aquagenic pruritus right so you know they take a hot shower and they eat like crazy right if you see that uh think about um think about um polycythemia vera and another thing is um another thing you may see on an mbm exam is these people may actually have um like facial plethora so their faces are like super super super red if you see that yeah definitely think about polycythemia vera The thing is, because they have so many red blood cells, there's almost like a feedback inhibition of the production of EPO. So their levels of EPO are actually pretty low, right? So because these people have such high red blood cell counts, you know, you try to bleed them out, right? So phlebotomy is like the primary treatment. You can also give these people like hydroxyurea. Remember, that's a ribonucleotide reductase inhibitor that can help there. And then another one you may see, another minor proliferative disorder you may see is like essential thrombocythemia, right? The big thing is these people have like a crazy high platelet count. crazy high mega number of like megachariocytes i've actually seen this in the real world you know it's kind of rare but it's pretty striking when you see it right so these people you may think that oh because they have a crazy high number of platelets they are just going to have thrombosis no they're also going to have a pretty large bleeding risk okay they're going to have a pretty large bleeding risk and again it's associated with jack2 mutations and again the key thing you absolutely want to keep in mind with these things is uh these people have again a super high platelet So they have a high risk of forming clot. but they also have a high risk of bleeding because again many of those platelets do not work right and then another classic myeloproliferative neoplasm you may see something called a primary myelofibrosis right um for the most part there's just something weird that happen happens with fibroblasts and they essentially just obliterate the bone marrow right so basically you have like those teardrop shaped red blood cells if you do a bone marrow uh biopsy or whatever you get like a dry tap that's like a classic thing they love to test on exams right so again Other than CML that has the 922 translocation, Philadelphia chromosome, BCR-ABO, the other myeloproliferative disorders, right, like essential thrombocythemia, primary myelofibrosis, and polycythemia vera are associated with mutations in JAK2, okay? They're associated with mutations in JAK2. Again, that's very high yield to know. And then one thing I want to talk about is like hairy cell leukemia. It's just something that tends to pop up on exams, right? Remember, the classic thing you want to keep in mind is you'll see a person's lymphocytes and those lymphocytes seem to have like these fine white projections um if you see that like 3d long projections from the lymphocytes don't confuse this with a smudge cell smudge cell is cll okay but hairy cell leukemia again lymphocytes with like you know like long like stringy projections coming from it look up a picture of this is actually a good uh histology image to be able to identify on an mbm exam and don't forget that it's positive for something on a strap okay Tertiary resistant acid phosphatase. Okay. So it's trapped. So trapped. So tertiary resistant acid phosphatase. Right. And then one other bizarre thing that I want you to keep in mind with these leukemias, lymphomas, please do not confuse myeloproliferative disorders with something called a myelodysplastic syndrome. Okay. Please do not confuse it with something called a myelodysplastic syndrome. Okay. The thing is myelodysplastic syndromes. You know, if you've had like chemo before or you've got to go to radiation therapy or you've been exposed to benzene, all these things are bad because they can become like AML. But basically, I'll tell you this. There are two critical things you want to keep. Again, you may say, Devon, you're going all basic science on me here. I promise you, I'm not willingly going all basic science on you. This stuff I'm talking about is super high yield to know for exams, like literally for step two and literally for step three. You don't need to believe me, but I know what I'm talking about. I promise you, right? So the thing is, what are the two things you need to know with myelodysplastic syndromes? Myelodysplastic syndromes, the first thing you want to keep in mind is there's something called the pseudopelgar Hewitt anomaly, right? So the Hewitt, I don't know if it's Hewitt or Hewitt or whatever, but for the most part it's H-U-E-T, okay? Basically, I think of it as a neutrophil wearing glasses, right? So, You see like a neutrophil that almost looks like a rich turnbrick cell, right? Like a neutrophil that has like a bilob nucleus. If you see that, think about the pseudopelgar hue anomaly. In fact, these myelodysplastic syndromes, they are said to be associated with hyposegmented neutrophils, not hypersegmented. Hypersegmented neutrophils, you're thinking of like a B12 or folate deficiency or megaloblastic anemia. But if you see like neutrophils and the NBME tells you that they are hyposegmented, you absolutely want to think about the myelodysplastic syndromes. And then one other thing you may see with the myelodysplastic syndromes is something called a sideroblastic anemia, right? Sorry, like a ringed sideroblast. So a ringed sideroblast does not always mean, oh, I'm just dealing with sideroblastic anemia. Does not always mean, oh, I'm just dealing with lead poisoning. No. You can also find a ringed sideroblast in a myelodysplastic syndrome. Again, I promise you, I promise you. promise you. These things I'm saying, some of you are going to get this on an exam. I'm going to remember that you heard it in this podcast. So I think those are kind of like the big... things I want to say with these leukemias and lymphomas, but you know, I kind of wanted to review them really well. Just again, quick highlight for step two CK, step three, and hopefully you'll find this to be, hopefully you'll find this to be, to be helpful. So I'm going to go ahead and, well, I guess maybe, you know, let me kind of end this with these translocations, right? Just to kind of wrap them up, right? So 814, right? Is Burkitt's lymphoma. I've talked about that. 922 is CML. I've talked about that. 1517 is AML, right? That's acute promyelocytic leukemia. 1418 is another weird one known as like follicular lymphoma. And then there's one bizarre one, 1122, but it's not a hematologic malignancy. It's more like Ewing's sarcoma, right? It's more like Ewing's sarcoma, right? So, yeah, so I think I'm going to go ahead and stop here. Like I said, this podcast will be short. As I do at the end of every podcast, I do offer one-on-one tutoring and also large group tutoring for a ton of exams, right? So. Step one, step two, CK, step two, CS, step three, preclinical med school exams, third year shelf exams. If you're a college student and you need tutoring for the MCATs, for general chemistry, organic chemistry, physics, biochemistry, histology, physiology, a tutor for all those things. And then if you're a medicine resident and you need tutoring for the ABI-M board exam or the internal medicine in training exam, I'd offer again one-on-one tutoring for that. and then um i offer these booster courses it's like 10 hours for step 2 ck step 3 it's 20 hours for step one basically i review the most notes that you need for those different tests um yeah i review those most i review those uh most notes uh for those exams and then uh um it's something that if you're like you know close to the end of your dedicated period or you just want to to kind of like put everything together relatively quickly. That's something you're always welcome to reach out to me for. And then, yeah, I feel like if you're also a med student applying to residency, so like an ERASAP or a college student applying to med school, so like an AMCAS application. Again, I do offer one-on-one coaching. So like personal statement editing, application editing, rec letters, mock interviews. Again, I've worked with a pretty large number of people applying to a pretty large number of residency programs. I kind of know what these residencies kind of look out for. So again, most of the people I've worked with, they've pretty much all matched their first choices. So again, if that's something you're interested in, do feel free to reach out to me and I'll be more than happy to point you in the right direction. And then the final thing I guess I will say is I'm offering some large group USMLE courses, but I'll need like five to seven people. So if you're a group and you need tutoring, it will probably be like over a two or three week span. Pretty much go over everything you need, either for step one or step two, CK or step three. If you find a group and you find a location, just let me know and then reach out to me through the website. So you send me an email, Divine Intervention Podcasts with an S at the end at gmail.com. And then we can kind of take things from there. You know, it's a fairly complicated process, but actually it's not complicated. It's pretty straightforward. You just let me know and then we can set things up. So have a wonderful rest of your day. I hope you find this podcast to be helpful. This is one of those podcasts that are short. but powerful. They're very high yield for your exam. So please listen to this stuff before you take any of your USMLE exams or any of your cumulus exams. Okay. So I'll see you next time in episode 204, I guess. So have a wonderful rest of your day. God bless you. Thank you for listening. Please subscribe to the YouTube channel. Just search for Divine Intervention USMLE. You'll find the YouTube channel. Please feel free to subscribe. And also, I have all this on Apple Podcasts, Google Play, Spotify. and also my wordpress website so you know please subscribe to all these things any positive reviews or negative reviews you leave helps um that's the way i improve and again like i said if there is any specific podcast you want me to make you can either you know shoot me a comment on reddit or something i think people are pretty visible on reddit or you know just send me an email and i'll be happy to again uh if it's a reasonable request and i have the time like really probably the biggest log jam on my time is just biggest in probably one of the bigger impediments to me not making podcasts is just time if i had more time i'd make a lot more podcasts but unfortunately i also have many other life commitments so wonderful rest of your day i'll see you next time time to stop blabbing good night god bless you

Okay, welcome. My name is Devine. I'm a resident.

This is episode 203 of the Devine Intervention Podcast. And in this podcast, I'm going to be talking about a topic that I don't know, for whatever bizarre reason, people tend to get this wrong like a lot on MDMA exams, especially for Step 2CK. So it's going to be like a somewhat limited coverage of leukemias and lymphomas, specifically for the USMLE Step 2CK and Step 3 exams.

So I'll just talk about some things that are high yield that people tend to, you know, kind of screw up on these tests. And to be perfectly honest with you, I think I'm going to set this up in a fairly unique way. And it will be how to specifically on MBME exams, get questions correct that test leukemias and lymphomas, right? So the first big question, and so this should hopefully be kind of like a short podcast. So the first big question you want to ask yourself when in being exams is okay divine How do leukemias classically present and how do lymphomas classically present?

Here's the deal. The way a leukemia will likely present on your test is you will see a person that has a disproportionately elevated white blood cell count. It's not always true, but that is usually the case, right? But I will say even more cogent is like this thing where every other blood element will be low. So they will have like low hemoglobin indicating that they have an anemia and they will have low like a low platelet count indicating that they have a thrombocytopenia.

So if you see either a high white a disproportionately high white blood cell count or you see a normal white blood cell count but you notice that every other thing is low the platelets are low the hemoglobin is low if you see that you absolutely want to think about a lymph sorry leukemia on an mbm exam. Okay, now on the flip side, lymphomas, people that have lymphomas, the primary physical exam finding is almost always those people having some sort of lymphadenopathy. In fact, they are for sure going to have lymphadenopathy on the exam.

And usually people that have lymphomas tend to not have CBC abnormalities, right? So their white count may be normal, their hemoglobin may be normal, their platelet count may be normal. That's something you absolutely need to keep at the back of your mind for tests, okay?

Usually, they do not have CBC abnormalities, and the primary presentation tends to be lymphadenopathy. And it's almost always in young people. Yes, can old people get lymphomas?

That's absolutely true, they can, right? But it's almost always in a young person, right? And then, in addition to being in a young person, they also tend to have chronic B symptoms. So, they'll say over the last X number of weeks. or x number of months this person has been having like fevers some out weight loss although they usually don't have weight loss but you know fevers night sweats and the like so that's the way you tell a leukemia apart from a lymphoma in a q-step right because the mbme they're usually pretty good at writing these questions well enough to where it's kind of hard to differentiate them so pay attention to these heart signs that i'm describing to you right now and then in the leukemia world There's this algorithm I use.

So once you've determined that, okay, I'm likely dealing with leukemia, right? There's an algorithm I typically use to say, okay, this is how I know the specific kind of leukemia they are asking about, right? So I look at the two extremes of life.

I look at old people and young people. You know, let's start with like young people first, you know, the young come first, right? So like young people, right?

And then we then have old people, right? So young people. Remember, A comes before C in the alphabet. So the young people will have A-L-L, okay?

And then the old people have C-L-L, right? Those people are usually at the extremes of age. So super young people like kids, five years old, six year olds, they get A-L-L.

And then, you know, old people like in their late 60s, 70s, 80s, they tend to have C-L-L, right? And then in the middle of life, right, we have the M-Ls, M-L for midlife, right? So we have A-M-L and C-M-L, right? That's the first thing, right?

So now what are some unique things you want to know about each of those things that you know they usually give it as a memory hook in the question that will tell you okay you are dealing with this versus the other. Again like I said ALL is going to be in a kid right so if you see an adult an adult is not going to get ALL on an MBM exam that's pretty much a given right and then remember that ALL has an association with Down syndrome okay ALL has an association with Down syndrome right you've probably heard of this mnemonic that they all fall down. to help you remember that ALL is found in people with Down syndrome. And then if you look at the other extreme of age, CLL, right?

And ALL is rapidly fatal if it's not... it um usually those kids can be dead in like weeks or something like that if you don't treat them quickly um and then cll the classic presentation will be an old person with recurrent infections right and they will have a super high white count so you may say oh divine this person has a super high white count how are they getting recurrent infections the thing is cll in and of itself is an immunodeficiency disease because the thing is yes you may have all those ferocious b cells running all over the place but the thing is those b cells essentially do not work so they may not make like a decent number of antibodies or if they make antibodies those antibodies will effectively not work okay so that's how you know that okay you're likely that's why those people tend to get recurrent infections right so again cll the really high white count right tons of infections and it's It's usually like... pneumonia and all this stuff with like strep pneumo right you'll have a crazy high white count it'll be an old person right and remember if you look at the person's um blood smear you're gonna find smudge cells okay you're gonna find smudge cells if they one thing i guess maybe i should maybe go ahead and throw out there is um it's a b cell problem right so the bug pattern since i'm almost discussing it as an immunodeficiency disorder will be practically bacterial infections okay so that's the big thing and then aml obviously right aml you need to know the genetic translocation it's 1517 right so 1517 translocation and you um you treat it with all trans-rethinoic acid right and obviously if you're looking at the cells on the histology you're going to see our rods right and our rods you need to be extremely careful when you're when you're kind of manipulating those things because those people can absolutely get um dic those our rods are very powerful triggers of secondary hemostasis so those people can run into dic with that right and then cml the big and the thing is one thing your friends at the mba can do is instead of putting all trans-rethinoic acid as an answer for the treatment of aml right one thing they can do is they can put vitamin a derivative as an answer right so that's something you need to be careful about right because the mbme one of their car like one of their most common stocks in trade is to essentially take what you know and just give it different words okay So instead of putting all trans-requinolic acid, you can put vitamin A derivative, right? So don't fall for that on a test so that you don't get gimped.

And then, CML, right? I mean, I feel like anyone that has taken Step 1 or has been in med school for any length of time knows a decent amount about CML, right? So CML, classic thing would be the 922 translocation, right?

That's a big one to know. And then remember, you create a fusion protein known as BCR-ABO, right? AKA the Philadelphia chromosome.

So the Philadelphia chromosome gives rise. to that BCR-ABO fusion protein, and you treat this with Imatinib. Okay, you treat it with Imatinib. Imatinib is a tyrosine kinase inhibitor.

I'm pretty certain I've given this rule in maybe like a video podcast I've granted where I said that if a person has a, if a drug ends in nib, that tells you right off the bat that that drug has to be a tyrosine kinase inhibitor. So that's a very high yield thing to know for purposes of exams. Okay, that's a very high yield thing to know for purposes of exam. That's the way you tell those different leukemias apart. So the lymphomas, I mean, the big thing with lymphomas is you want to think about the two big classes.

So again, Hodgkin's versus non-Hodgkin's. So what are the big things to keep in mind with Hodgkin's? Obviously, if a person has Hodgkin's lymphoma, again, they will have primarily lymph nodes that will be affected. They usually will not have CBC abnormalities.

It's usually going to be in a young person. Again, these things are not always true, but they are true. the vast majority of the time on NBMEs, right?

And you'll have chronic B symptoms, right? And remember the highlight cell for Hodgkin's lymphoma are the Reed-Sternberg cells, right? The Reed-Sternberg cells are the classic cells for Hodgkin's lymphoma.

And one thing that the NBME loves to do, especially on step three, and they also do this on step one, is to make your, well, hopefully, hope that you remember that Hodgkin's lymphoma is almost like a nice representation of the biostatistical concept of bimodality right so it tends to show up in young folk right so you know like late teenagers like late teenagers or like you know like their early 20s and then it also tends to show up in old people right so people that are you know almost 60 years old or a little over 60 years old right so it's a bimodal distribution right and then don't forget again your ristromberg cells i forgot to mention with cll cll the classic cell you think about are your smudge cells i think i may have mentioned it but I don't know why my mind is saying I didn't see it. So I'm just saying it just in case, right? And then, again, Ritz-Trenberg cells versus non-Hodgkin's. You know, non-Hodgkin's lymphoma, there's many different types.

You do not see the Ritz-Trenberg cells. And pretty much most of these leukemias and lymphomas just involve... B cells for the most part, right?

And remember your different kinds of Hodgkin's lymphomas. I will just tell you this because there's many, many different types. The one I will just, I just feel like there is like two key principles you want to, or let's say three key principles you want to keep in mind with Hodgkin's lymphomas.

Because again, there are many types. You don't need to memorize everything about every type, but there's like one unique thing you want to make sure you know about pretty much all of them. these Hodgkin's lymphomas.

The first thing is you want to know that if you have more lymphocytes in a Hodgkin's lymphoma, the prognosis is better, okay? If you have, I'll say that again, if you have more lymphocytes in a Hodgkin's lymphoma, the prognosis is better, okay? Now, the corollary to that is if you have fewer lymphocytes, then the prognosis is worse, right?

So there are two, there's this kind of Hodgkin's lymphoma that's called like lymphocyte predominant sometimes people call it lymphocyte rich and then there's another one that you call lymphocyte depleted by virtue of this principle i just discussed lymphocyte rich hodgkin's lymphoma has a much better effect i i'm fairly certain it has the best prognosis of all the prognosis is the wrong word prognosis it has the best prognosis of all the hodgkin's lymphomas compared to the uh like the uh compared to all the others and certainly a lot better than the lymphocyte depleted. And then if they give you like a stock question on an MBM exam, and they're asking you about the kind of Hodgkin's lymphoma the person has, go with the nodular sclerosin variant, okay? The most common kind of Hodgkin's lymphoma, very high yield, the most common kind of Hodgkin's lymphoma is the nodular sclerosin kind of Hodgkin's lymphoma.

And then if you see a person with Hodgkin's lymphoma having a lot of pruritus, and they tell you that oh this the you look at the presence cbc and you notice that oh the inocelophial count is like really high it's like six percent or ten percent or something like that then you absolutely want to think about the mixed cellularity variant okay so the the things that are released by those eosinophils can cause a pruritus although other kinds of hodgkin's lymphomas can be associated with pruritus and don't forget that your hodgkin's lymphomas right classically via cd 15 and cd 30 positive just remember cd 15 and then double that number you get cd30 and you're good to go on your test right um and then uh some of the non-hotchkins lymphomas i think i should maybe talk about right don't forget your burkitt's lymphoma starry sky pattern right 814 translocation right basically you have like a c-mic amplification and c-mic promotes like just crazy proliferation of lymphocytes right so starry sky pattern jaw mass in an african abdominal mass in uh in a person that is not african right 814 translocation semic amplification that's a very high yield thing to keep at the back of your mind for exams and then uh multiple myeloma right again it's something i've talked about at nasmi many podcasts again don't screw this up on a test these people have crap symptoms right you'll have hypercalcemia they'll have renal problems they'll have anemia and you'll have bone pain you'll have lytic lesions this is one of those things that causes lyrical lesions on imaging, lyrical lesions. It's a radiological term, okay? So Hodgkin's lymphoma, again, keep, I mean, sorry, multiple myeloma, keep that at the back of your mind.

It's very easy to identify it, right? You do like your SPEP and your UPEP to make the correct diagnosis, right? And then don't forget that on a blood smear, right, you'll see like a stack of coins formation of red blood cells. That's what's classically known as the Rouleau formation.

And then I know that I talked about CML. CML is actually one of those things called a myeloproliferative. uh disorder cml is a myeloproliferative disorder um please do not forget your other myeloproliferative disorders right they love to test those things on mbm exams right like uh cml is a classic one there um one other one you want to keep at the back of your mind is polycythemia vera right for the most part these myeloproliferative disorders they tend to be associated with like jack two mutations right so polycythemia vera these people have like a crazy highway blood cell count. i mean sorry not white blood cell a crazy high hematocrit right so you see these people hemoglobin is of like 20. he might have created like 65 percent right you're like that doesn't seem very normal right and usually these people have like um they'll have this thing called like um like aquagenic pruritus right so you know they take a hot shower and they eat like crazy right if you see that uh think about um think about um polycythemia vera and another thing is um another thing you may see on an mbm exam is these people may actually have um like facial plethora so their faces are like super super super red if you see that yeah definitely think about polycythemia vera The thing is, because they have so many red blood cells, there's almost like a feedback inhibition of the production of EPO. So their levels of EPO are actually pretty low, right?

So because these people have such high red blood cell counts, you know, you try to bleed them out, right? So phlebotomy is like the primary treatment. You can also give these people like hydroxyurea. Remember, that's a ribonucleotide reductase inhibitor that can help there. And then another one you may see, another minor proliferative disorder you may see is like essential thrombocythemia, right?

The big thing is these people have like a crazy high platelet count. crazy high mega number of like megachariocytes i've actually seen this in the real world you know it's kind of rare but it's pretty striking when you see it right so these people you may think that oh because they have a crazy high number of platelets they are just going to have thrombosis no they're also going to have a pretty large bleeding risk okay they're going to have a pretty large bleeding risk and again it's associated with jack2 mutations and again the key thing you absolutely want to keep in mind with these things is uh these people have again a super high platelet So they have a high risk of forming clot. but they also have a high risk of bleeding because again many of those platelets do not work right and then another classic myeloproliferative neoplasm you may see something called a primary myelofibrosis right um for the most part there's just something weird that happen happens with fibroblasts and they essentially just obliterate the bone marrow right so basically you have like those teardrop shaped red blood cells if you do a bone marrow uh biopsy or whatever you get like a dry tap that's like a classic thing they love to test on exams right so again Other than CML that has the 922 translocation, Philadelphia chromosome, BCR-ABO, the other myeloproliferative disorders, right, like essential thrombocythemia, primary myelofibrosis, and polycythemia vera are associated with mutations in JAK2, okay? They're associated with mutations in JAK2.

Again, that's very high yield to know. And then one thing I want to talk about is like hairy cell leukemia. It's just something that tends to pop up on exams, right?

Remember, the classic thing you want to keep in mind is you'll see a person's lymphocytes and those lymphocytes seem to have like these fine white projections um if you see that like 3d long projections from the lymphocytes don't confuse this with a smudge cell smudge cell is cll okay but hairy cell leukemia again lymphocytes with like you know like long like stringy projections coming from it look up a picture of this is actually a good uh histology image to be able to identify on an mbm exam and don't forget that it's positive for something on a strap okay Tertiary resistant acid phosphatase. Okay. So it's trapped. So trapped.

So tertiary resistant acid phosphatase. Right. And then one other bizarre thing that I want you to keep in mind with these leukemias, lymphomas, please do not confuse myeloproliferative disorders with something called a myelodysplastic syndrome.

Okay. Please do not confuse it with something called a myelodysplastic syndrome. Okay.

The thing is myelodysplastic syndromes. You know, if you've had like chemo before or you've got to go to radiation therapy or you've been exposed to benzene, all these things are bad because they can become like AML. But basically, I'll tell you this. There are two critical things you want to keep.

Again, you may say, Devon, you're going all basic science on me here. I promise you, I'm not willingly going all basic science on you. This stuff I'm talking about is super high yield to know for exams, like literally for step two and literally for step three. You don't need to believe me, but I know what I'm talking about.

I promise you, right? So the thing is, what are the two things you need to know with myelodysplastic syndromes? Myelodysplastic syndromes, the first thing you want to keep in mind is there's something called the pseudopelgar Hewitt anomaly, right?

So the Hewitt, I don't know if it's Hewitt or Hewitt or whatever, but for the most part it's H-U-E-T, okay? Basically, I think of it as a neutrophil wearing glasses, right? So, You see like a neutrophil that almost looks like a rich turnbrick cell, right? Like a neutrophil that has like a bilob nucleus. If you see that, think about the pseudopelgar hue anomaly.

In fact, these myelodysplastic syndromes, they are said to be associated with hyposegmented neutrophils, not hypersegmented. Hypersegmented neutrophils, you're thinking of like a B12 or folate deficiency or megaloblastic anemia. But if you see like neutrophils and the NBME tells you that they are hyposegmented, you absolutely want to think about the myelodysplastic syndromes. And then one other thing you may see with the myelodysplastic syndromes is something called a sideroblastic anemia, right? Sorry, like a ringed sideroblast.

So a ringed sideroblast does not always mean, oh, I'm just dealing with sideroblastic anemia. Does not always mean, oh, I'm just dealing with lead poisoning. No. You can also find a ringed sideroblast in a myelodysplastic syndrome. Again, I promise you, I promise you.

promise you. These things I'm saying, some of you are going to get this on an exam. I'm going to remember that you heard it in this podcast. So I think those are kind of like the big...

things I want to say with these leukemias and lymphomas, but you know, I kind of wanted to review them really well. Just again, quick highlight for step two CK, step three, and hopefully you'll find this to be, hopefully you'll find this to be, to be helpful. So I'm going to go ahead and, well, I guess maybe, you know, let me kind of end this with these translocations, right?

Just to kind of wrap them up, right? So 814, right? Is Burkitt's lymphoma. I've talked about that. 922 is CML.

I've talked about that. 1517 is AML, right? That's acute promyelocytic leukemia.

1418 is another weird one known as like follicular lymphoma. And then there's one bizarre one, 1122, but it's not a hematologic malignancy. It's more like Ewing's sarcoma, right?

It's more like Ewing's sarcoma, right? So, yeah, so I think I'm going to go ahead and stop here. Like I said, this podcast will be short.

As I do at the end of every podcast, I do offer one-on-one tutoring and also large group tutoring for a ton of exams, right? So. Step one, step two, CK, step two, CS, step three, preclinical med school exams, third year shelf exams.

If you're a college student and you need tutoring for the MCATs, for general chemistry, organic chemistry, physics, biochemistry, histology, physiology, a tutor for all those things. And then if you're a medicine resident and you need tutoring for the ABI-M board exam or the internal medicine in training exam, I'd offer again one-on-one tutoring for that. and then um i offer these booster courses it's like 10 hours for step 2 ck step 3 it's 20 hours for step one basically i review the most notes that you need for those different tests um yeah i review those most i review those uh most notes uh for those exams and then uh um it's something that if you're like you know close to the end of your dedicated period or you just want to to kind of like put everything together relatively quickly.

That's something you're always welcome to reach out to me for. And then, yeah, I feel like if you're also a med student applying to residency, so like an ERASAP or a college student applying to med school, so like an AMCAS application. Again, I do offer one-on-one coaching.

So like personal statement editing, application editing, rec letters, mock interviews. Again, I've worked with a pretty large number of people applying to a pretty large number of residency programs. I kind of know what these residencies kind of look out for. So again, most of the people I've worked with, they've pretty much all matched their first choices. So again, if that's something you're interested in, do feel free to reach out to me and I'll be more than happy to point you in the right direction.

And then the final thing I guess I will say is I'm offering some large group USMLE courses, but I'll need like five to seven people. So if you're a group and you need tutoring, it will probably be like over a two or three week span. Pretty much go over everything you need, either for step one or step two, CK or step three.

If you find a group and you find a location, just let me know and then reach out to me through the website. So you send me an email, Divine Intervention Podcasts with an S at the end at gmail.com. And then we can kind of take things from there.

You know, it's a fairly complicated process, but actually it's not complicated. It's pretty straightforward. You just let me know and then we can set things up.

So have a wonderful rest of your day. I hope you find this podcast to be helpful. This is one of those podcasts that are short.

but powerful. They're very high yield for your exam. So please listen to this stuff before you take any of your USMLE exams or any of your cumulus exams. Okay.

So I'll see you next time in episode 204, I guess. So have a wonderful rest of your day. God bless you.

Thank you for listening. Please subscribe to the YouTube channel. Just search for Divine Intervention USMLE.

You'll find the YouTube channel. Please feel free to subscribe. And also, I have all this on Apple Podcasts, Google Play, Spotify.

and also my wordpress website so you know please subscribe to all these things any positive reviews or negative reviews you leave helps um that's the way i improve and again like i said if there is any specific podcast you want me to make you can either you know shoot me a comment on reddit or something i think people are pretty visible on reddit or you know just send me an email and i'll be happy to again uh if it's a reasonable request and i have the time like really probably the biggest log jam on my time is just biggest in probably one of the bigger impediments to me not making podcasts is just time if i had more time i'd make a lot more podcasts but unfortunately i also have many other life commitments so wonderful rest of your day i'll see you next time time to stop blabbing good night god bless you

Transcript for:Overview of Leukemias and Lymphomas for USMLE

Transcript for:
Overview of Leukemias and Lymphomas for USMLE