πŸ“‹ MOCK OSCE Β· FCPS, MCPS, MD PAEDIATRICS ⏱ 10 min Β· ABDOMINAL MASS (LYMPHOMA)

Lymphoma Β· Short Case

Candidate task: perform focused clinical examination (GPE + abdomen) on a child with suspected lymphoma.
Then discuss differential diagnosis, investigations, management & follow‑up.
Pre‑exam Protocol
⏀ Β· Wash, Warm, Introduce, Position, Expose, Approach β–Ύ

Standard pre‑examination protocol – must be demonstrated:

πŸ– Wash hands with sterilizing solution.
πŸ”₯ Warm hands and stethoscope.
πŸ‘‹ Introduce yourself to child & parent.
🧍 Position child: standing β†’ sitting β†’ supine.
πŸ‘• Exposure β€” shirt off, trousers rolled.
➑️ Approach from the right side.
βœ” CPSP marker: Pre‑exam Protocol is observed and scored.
1. Clinical Examination (β‰ˆ6 min)
02 General Look (Inspection from end of bed) β–Ύ

Key observations:

  • Abdomen: asymmetrical distension, visible mass (often right lower quadrant / ileocecal in Burkitt).
  • Constitutional: fever, weight loss, night sweats (B symptoms).
  • Lymphadenopathy: cervical, axillary, inguinal (may be palpable).
  • Skin: pallor (anaemia), jaundice (liver involvement), petechiae (bone marrow infiltration).
  • Respiratory: dyspnoea, stridor (mediastinal mass – common in lymphoblastic lymphoma).
  • Facial: facial oedema (superior vena cava syndrome).
πŸ‘ Red flags: abdominal mass + B symptoms + lymphadenopathy + mediastinal mass β†’ lymphoma.
03 General Physical Exam (Hands β†’ Face β†’ Chest β†’ Limbs) β–Ύ

Systematic examination:

  • Hands: clubbing (rare), pallor (anaemia), leuconychia (if liver involvement).
  • Face: facial oedema (SVC syndrome), pallor, jaundice.
  • Chest: mediastinal mass signs (dullness, stridor, SVC syndrome – facial plethora, dilated neck veins).
  • Abdomen: see next step.
  • Lower limbs: oedema (if retroperitoneal mass causing venous obstruction), bone pain (bone marrow involvement).
  • Lymph nodes: palpate cervical, axillary, inguinal – firm, rubbery, non-tender, fixed.
πŸ“ Anthropometry: weight, height, BMI – plot growth; weight loss is a B symptom.
04 Abdominal Examination β–Ύ

Systematic approach:

  • Inspection: distension, visible mass (often right lower quadrant/ileocecal in Burkitt), ascites.
  • Auscultation: bowel sounds (may be absent/obstructive if intussusception or obstruction).
  • Palpation: firm, non-tender, fixed abdominal mass – may be right lower quadrant (ileocecal) or diffuse. Hepatosplenomegaly (if extensive).
  • Percussion: dull over mass; shifting dullness if ascites.
  • Rectal: if indicated – pelvic mass, perianal disease (rare).
πŸ” Key: right lower quadrant mass + B symptoms + lymphadenopathy β†’ Burkitt lymphoma.
05 Developmental Assessment & Associated Signs β–Ύ

Assess:

  • Neurological: CNS involvement – cranial nerve palsies, headache, vomiting, seizures (meningeal infiltration).
  • Eyes: proptosis, ptosis (orbital involvement – rare).
  • Growth: may be delayed due to chronic disease.
  • Pubertal: delayed puberty (chronic illness).
🧠 CNS lymphoma: check for cranial nerve palsies, papilloedema, meningeal signs.

πŸ“‹ Case Presentation – (fill in during exam)

This is a _____-year-old _____ child, brought with _____ (abdominal pain / abdominal swelling / fever / weight loss). On examination, the child appears _____ (well/unwell/cachectic), with _____ (pallor / jaundice / facial oedema / lymphadenopathy). There is a _____ (firm / non-tender) mass in the _____ (right lower quadrant / abdomen), measuring approximately _____ cm. The mass _____ (is / is not) mobile, and _____ (does / does not) cross the midline. _____ (Hepatosplenomegaly / Ascites / Lymphadenopathy) is present. Growth parameters: weight _____ percentile, height _____ percentile. Additional findings: _____ (B symptoms – fever / night sweats / weight loss).

2. Viva Discussion (β‰ˆ4 min)
06 Viva Β· Differential, Investigations, Management, Follow‑up β–Ύ
πŸ”Ή Differential Diagnosis

β€’ Non-Hodgkin lymphoma – Burkitt, DLBCL, lymphoblastic, ALCL
β€’ Hodgkin lymphoma – usually nodal, mediastinal, cervical
β€’ Neuroblastoma – adrenal/retroperitoneal, crosses midline, catecholamines
β€’ Wilms tumor – renal, does NOT cross midline, haematuria
β€’ Hepatoblastoma – right upper quadrant, AFP elevated
β€’ Germ cell tumor – pelvic/sacral, AFP/Ξ²-hCG
β€’ Mesenteric adenitis – inflammatory, tender, fever
β€’ Appendiceal abscess – tender, fever, WBC elevated
β€’ Intussusception – colicky pain, currant jelly stool
β€’ Celiac disease – chronic, malabsorption, TTG positive
β€’ Inflammatory bowel disease – Crohn’s/UC, diarrhoea, perianal disease

πŸ”Ή Investigations – Diagnosis

β€’ CBC with differential – anaemia, thrombocytopenia, leucocytosis/leukopenia
β€’ Serum LDH – elevated (tumour burden marker)
β€’ Uric acid, phosphorus, potassium – tumour lysis risk
β€’ LFTs – liver involvement (elevated transaminases, bilirubin)
β€’ CT abdomen & pelvis – defines mass, nodes, organ involvement
β€’ Chest CT – mediastinal mass, pulmonary nodules
β€’ PET/CT scan – staging and response assessment (FDG-avid)
β€’ Lymph node biopsy – excisional biopsy for histology, immunophenotyping
β€’ Bone marrow biopsy – staging (marrow involvement)
β€’ CSF analysis – CNS involvement (if indicated)

πŸ”Ή Investigations – Aetiology

β€’ Immunophenotyping – B-cell (CD19, CD20), T-cell, ALCL (CD30)
β€’ Cytogenetics – t(8;14) in Burkitt, t(2;5) in ALCL
β€’ EBV serology – associated with Burkitt, DLBCL, Hodgkin
β€’ HIV testing – immunodeficiency predisposes to lymphoma
β€’ MYC, BCL2, BCL6 FISH – double/triple-hit lymphomas
β€’ ALK testing – ALCL (t(2;5)) – ALK positive (better prognosis)
β€’ TP53 mutation – poor prognosis

πŸ”Ή Investigations – Exclude Others

β€’ Urine VMA/HVA – exclude neuroblastoma
β€’ AFP, Ξ²-hCG – exclude hepatoblastoma/germ cell
β€’ Stool culture – exclude infectious enteritis
β€’ Tissue transglutaminase IgA – exclude celiac disease
β€’ ESR, CRP – inflammatory markers (elevated in lymphoma and infection)
β€’ Blood cultures – if fever and suspicion of sepsis

πŸ”Ή Investigations – Rule Out Complications

β€’ Tumour lysis syndrome – uric acid, potassium, phosphorus, calcium
β€’ Superior vena cava syndrome – chest CT, urgent management
β€’ CNS involvement – CSF cytology, MRI brain
β€’ Bone marrow failure – CBC, reticulocyte count
β€’ Intestinal obstruction – abdominal X-ray, CT
β€’ Ascites – abdominal US, diagnostic tap if needed
β€’ Sepsis – blood cultures, CRP, procalcitonin

πŸ”Ή Management – Across Organ Systems

Chemotherapy

Risk-adapted multi-agent: Burkitt/DLBCL: FAB/LMB 96 (COPADM, CYVE). Lymphoblastic: ALL-type therapy. ALCL: APO/ALCL99. Intrathecal chemo for CNS prophylaxis.

Immunotherapy

Rituximab (anti-CD20) for B-cell lymphomas. Brentuximab vedotin (anti-CD30) for ALCL and Hodgkin. Crizotinib for ALK-positive ALCL.

Surgical

Diagnostic biopsy only. Complete resection if isolated and feasible (stage I). For intestinal obstruction, emergency surgery may be needed.

Radiotherapy

Limited role in NHL – used for CNS prophylaxis (lymphoblastic) or bulky residual disease. Rarely used in Burkitt.

Tumour Lysis Syndrome

Aggressive hydration, allopurinol or rasburicase (if high risk). Monitor uric acid, potassium, phosphorus, calcium, renal function.

Supportive Care

Transfusions (PRBC, platelets). G-CSF for neutropenia. Anti-emetics, pain management. Nutritional support. Infection prophylaxis (co-trimoxazole).

Stem Cell Transplant

Autologous or allogeneic SCT for relapsed/refractory disease, high-risk ALCL, and lymphoblastic lymphoma.

CNS Prophylaxis

Intrathecal methotrexate, cytarabine, hydrocortisone. High-dose methotrexate (systemic) for CNS penetration.

πŸ“ˆ Prognosis

  • Burkitt – Stage I/II: 4-yr EFS ~95–100%, OS ~100%.
  • Burkitt – Stage III/IV: 4-yr EFS ~85–90%, OS ~90–95% (with rituximab).
  • DLBCL: 5-yr EFS ~80–85% (pediatric protocols).
  • Lymphoblastic: 5-yr EFS ~80–90% (ALL-type therapy).
  • ALCL – ALK positive: 5-yr EFS ~80–90%.
  • ALCL – ALK negative: 5-yr EFS ~60–70%.
  • Relapse: salvage with SCT – 30–50% long-term survival.

πŸ“‹ Follow‑up Schedule

  • During treatment: weekly CBC, LFTs, renal function, uric acid; BP monitoring.
  • After treatment (first 2 yr): clinical exam, imaging (CT/PET) every 3–6 months.
  • Years 2–5: imaging every 6–12 months.
  • Late effects screening: cardiac (anthracyclines), fertility (alkylators), secondary malignancies, hypothyroidism (if radiation).
  • Immunoglobulin replacement: if B-cell depletion (rituximab).
πŸ’‘ Examiner expectation: logical differential (lymphoma vs other masses), systematic investigation (diagnosis β†’ aetiology β†’ exclude others β†’ complications), and a management plan covering chemotherapy, immunotherapy, and supportive care. Know the subtypes and risk-adapted therapy.
πŸ“š Visit paeds.online for more CPSP resources
Mock OSCE Β· Lymphoma (Abdominal Mass) Β· Based on Wyne‑Harris, Nelson & Pediatric Clinical Advisor