Study guide
7.7 Lymphomas & Plasma Cell Disorders
ABIM Internal Medicine Exam
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1 Chapter 0: The ABIM Exam, Blueprint & Study Strategy
0.1 Exam Format, Question Types & the 2026 Blueprint 0.2 Eligibility, Registration, Fees & Exam-Day Logistics 0.3 Scoring, the Passing Standard & Score Reports 0.4 Building a Blueprint-Weighted Study Plan
2 Chapter 1: Cardiovascular Disease (14% of Exam)
1.1 Ischemic Heart Disease & Acute Coronary Syndromes 1.2 Antithrombotic Therapy, Secondary Prevention & Mechanical Complications of MI 1.3 Atrial Fibrillation, Atrial Flutter & Stroke Prevention 1.4 Supraventricular Tachycardias, Ventricular Arrhythmias & Bradycardias 1.5 Heart Failure: Classification, Staging & Guideline-Directed Medical Therapy 1.6 Device Therapy, HFpEF & the Cardiomyopathies 1.7 Valvular Heart Disease & Endocarditis Prophylaxis 1.8 Pericardial Disease & Acute Aortic Syndromes 1.9 Hypertension: Classification, Diagnosis & Secondary Causes 1.10 Hypertensive Crises & Dyslipidemia 1.11 Adult Congenital Heart Disease & Coarctation of the Aorta 1.12 Syncope: Reflex, Orthostatic & Cardiac Causes 1.13 Cardiac Physical Examination, Murmurs & Antithrombotic Selection
3 Chapter 2: Endocrinology, Diabetes & Metabolism (9% of Exam)
2.1 Diabetes Mellitus: Diagnosis, Glycemic Targets & Pharmacotherapy 2.2 Insulin Therapy, Hyperglycemic Emergencies & Chronic Complications 2.3 Thyroid Function Testing & Hypothyroidism 2.4 Thyrotoxicosis, Thyroid Storm & Thyroid Nodules 2.5 Adrenal & Pituitary Disorders 2.6 Hypercalcemia, Hypocalcemia & Disorders of Mineral Metabolism 2.7 Osteoporosis & Paget Disease of Bone 2.8 Ovarian, Testicular & Reproductive Endocrine Disorders 2.9 Hypoglycemia, Endocrine Tumors, Polyglandular Syndromes & Severe Hypertriglyceridemia
4 Chapter 3: Gastroenterology & Hepatology (9% of Exam)
3.1 Esophageal Disease 3.2 Stomach & Duodenal Disease and Gastrointestinal Hemorrhage 3.3 Inflammatory Bowel Disease 3.4 Celiac Disease & Irritable Bowel Syndrome 3.5 Diverticular Disease & Colorectal Cancer Screening 3.6 Viral Hepatitis, Steatotic & Alcohol-Associated Liver Disease 3.7 Cirrhosis & the Complications of Portal Hypertension 3.8 Acute Pancreatitis 3.9 Chronic Pancreatitis & Biliary Tract Disease 3.10 Inherited, Autoimmune & Drug-Induced Liver Disease 3.11 Small Intestinal Disease, Ischemia & Gastrointestinal Complications of HIV
5 Chapter 4: Infectious Disease (9% of Exam)
4.1 Lower Respiratory Tract Infections & Sepsis Syndromes 4.2 Viral Respiratory Pathogens & Tuberculosis 4.3 Central Nervous System Infections 4.4 Skin, Soft Tissue, Bone & Joint Infections 4.5 Infective Endocarditis & Cardiovascular Infection 4.6 Clostridioides difficile & Catheter-Related Bloodstream Infection 4.7 HIV Diagnosis, Antiretroviral Therapy & Prevention 4.8 Opportunistic Infections & Sexually Transmitted Infections 4.9 Fever of Unknown Origin, Neutropenic Fever & Toxic Shock 4.10 Travel-Related Illness, Vector-Borne Disease & Outbreaks 4.11 Infection Prevention, Nosocomial Infection & Postexposure Prophylaxis 4.12 Rheumatic Fever, Poststreptococcal Disease, Enteric & Hepatic Infections
6 Chapter 5: Pulmonary Disease (9% of Exam)
5.1 COPD: Diagnosis, GOLD Classification & Initial Pharmacotherapy 5.2 Interventions That Reduce COPD Mortality & Exacerbation Management 5.3 Asthma: Diagnosis, Stepwise Therapy & Status Asthmaticus 5.4 Interstitial Lung Disease & Idiopathic Pulmonary Fibrosis 5.5 Sarcoidosis, Hypersensitivity Pneumonitis & Occupational Lung Disease 5.6 Pulmonary Embolism: Diagnosis, Risk Stratification & Anticoagulation 5.7 Pulmonary Hypertension & Sleep-Disordered Breathing 5.8 Acute Respiratory Distress Syndrome & Mechanical Ventilation 5.9 Pleural Disease, Empyema & Pneumothorax 5.10 Bronchiectasis, Cystic Fibrosis & Restrictive Lung Disease 5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule
7 Chapter 6: Rheumatology & Orthopedics (9% of Exam)
6.1 Rheumatoid Arthritis: Diagnosis & Systemic Manifestations 6.2 Antirheumatic Pharmacotherapy & the Spondyloarthropathies 6.3 Gout: Pathophysiology & Acute Management 6.4 Urate-Lowering Therapy & Calcium Pyrophosphate Deposition Disease 6.5 Osteoarthritis 6.6 Systemic Lupus Erythematosus 6.7 Systemic Sclerosis, Sjogren Syndrome & Inflammatory Myopathies 6.8 The Vasculitides 6.9 Regional Musculoskeletal Syndromes, Back Pain & Sports Injuries 6.10 Other Primary Rheumatic Disorders & Mixed Connective Tissue Disease 6.11 Osteonecrosis & Metabolic Bone Disease
8 Chapter 7: Hematology (6% of Exam)
7.1 Approach to Anemia & the Microcytic Anemias 7.2 Macrocytic, Normocytic & Hemolytic Anemias 7.3 Hemoglobinopathies, Thalassemias & Paroxysmal Nocturnal Hemoglobinuria 7.4 Platelet Disorders, Thrombocytopenia & the Bleeding Patient 7.5 Coagulation Factor Disorders, Thrombophilia & Anticoagulant Reversal 7.6 Acute Leukemias, Chronic Leukemias & Myeloproliferative Neoplasms 7.7 Lymphomas & Plasma Cell Disorders 7.8 Myelodysplastic Syndrome, Myeloproliferative Neoplasms & Porphyria 7.9 Transfusion Medicine & Late Complications of Transplantation
9 Chapter 8: Medical Oncology (6% of Exam)
8.1 Breast, Lung, Colorectal & Prostate Cancer 8.2 Oncologic Emergencies 8.3 Genitourinary & Gynecologic Malignancies 8.4 Head and Neck, Bone & Soft Tissue Cancer and Cancer of Unknown Primary 8.5 Complications of Cancer & Its Treatment 8.6 Cancer Prevention, Survivorship & Psychosocial Care
10 Chapter 9: Nephrology & Urology (6% of Exam)
9.1 Acute Kidney Injury: Staging, Etiology & Urine Microscopy 9.2 Glomerular Disorders & Nephrotic Syndrome 9.3 Nephritic Syndromes, RPGN & Indications for Renal Replacement Therapy 9.4 Chronic Kidney Disease: Staging & Progression Retardation 9.5 Complications of Chronic Kidney Disease: Anemia, CKD-MBD & Acidosis 9.6 Hyponatremia, Hypernatremia & Water Balance 9.7 Potassium Disorders & Systematic Acid-Base Analysis 9.8 Renal Tubular Acidosis & Nephrolithiasis 9.9 Prostate Disorders, Urinary Incontinence & Other Urologic Conditions 9.10 Cystic Kidney Disease, Obstructive Uropathy, Tubulointerstitial Disease & Hematuria
11 Chapter 10: Neurology (4% of Exam)
10.1 Acute Ischemic Stroke: Syndromes & Reperfusion 10.2 Transient Ischemic Attack, Secondary Prevention & Hemorrhagic Stroke 10.3 Headache & Facial Pain 10.4 Seizures, Epilepsy & Movement Disorders 10.5 Multiple Sclerosis & Neuromuscular Junction Disorders 10.6 Motor Neuron Disease & Acute Peripheral Neuropathy 10.7 Cranial Neuropathies & Neuro-Ophthalmology 10.8 Peripheral Neuropathies, CNS Tumors & Other Neurologic Disorders
12 Chapter 11: Psychiatry & Behavioral Health (4% of Exam)
11.1 Major Depressive Disorder & Medical Mimics 11.2 Antidepressant Pharmacotherapy & Treatment-Resistant Depression 11.3 Bipolar Disorder, Mood Stabilizers & Lithium Toxicity 11.4 Anxiety, Stress-Related & Obsessive-Compulsive Disorders 11.5 Alcohol Use Disorder & Withdrawal 11.6 Pharmacotherapy for Alcohol & Opioid Use Disorder 11.7 Toxidromes, Psychiatric Emergencies & Suicide Risk Assessment 11.8 Psychotic, Somatic Symptom, Factitious & Personality Disorders 11.9 Eating Disorders, Sleep Disorders & Sexual Health
13 Chapter 12: Dermatology (3% of Exam)
12.1 Dermatitis, Papulosquamous & Inflammatory Dermatoses 12.2 Acne, Rosacea & Cutaneous Infections 12.3 Herpes Zoster & Autoimmune Blistering Diseases 12.4 Nodules, Tumors & Cutaneous Oncology 12.5 Dermatologic Emergencies & Severe Cutaneous Adverse Reactions 12.6 Pigment Disorders, Alopecia, Nail Disease & Photosensitivity 12.7 Vascular Dermatoses, Environmental Injury & Cutaneous Signs of Systemic Disease
14 Chapter 13: Obstetrics & Gynecology / Women's Health (3% of Exam)
13.1 Contraception, Preconception Care & Teratogenicity 13.2 Hypertensive Disorders of Pregnancy & Gestational Diabetes 13.3 Thyroid Disease & Venous Thromboembolism in Pregnancy 13.4 Menopause & Menopausal Hormone Therapy 13.5 Abnormal Uterine Bleeding, Endometrial Disease & Gynecologic Cancer Screening 13.6 Breast Disorders & Diseases of the Vulva and Vagina 13.7 Menstrual Disorders, Fibroids, Endometriosis & Early Pregnancy Complications
15 Chapter 14: Geriatric Syndromes (3% of Exam)
14.1 Comprehensive Geriatric Assessment & Frailty 14.2 Falls, Gait Assessment & Polypharmacy 14.3 Urinary Incontinence & Pressure Injuries in Older Adults 14.4 Mild Cognitive Impairment, Dementia & Its Subtypes 14.5 Delirium & the Pharmacotherapy of Cognitive Disorders 14.6 Palliative Care, Hospice & Advance Care Planning 14.7 Chronic Wounds, Nutrition, Swallowing, Constipation & Hip Fracture 14.8 Sensory Impairment, Dizziness, Elder Mistreatment & Care Settings
16 Chapter 15: Allergy & Immunology (2% of Exam)
15.1 Anaphylaxis: Recognition & Emergency Management 15.2 Urticaria & Angioedema 15.3 Drug Allergy, Desensitization & Adult Immunodeficiency 15.4 Food Allergy, Insect Venom Hypersensitivity, Serum Sickness & Contrast Reactions 15.5 Rhinitis, Conjunctivitis, Eosinophilic & Mast Cell Disorders
17 Chapter 16: Preventive Medicine, Immunization & Clinical Epidemiology
16.1 The USPSTF Framework & Evidence-Based Cancer Screening 16.2 Cardiovascular & Metabolic Screening and Primary Prevention 16.3 Adult Immunization & Vaccines in Special Populations 16.4 Clinical Epidemiology, Biostatistics & Study Design
18 Chapter 17: Miscellaneous - Ethics, Patient Safety & Quality Improvement (2% of Exam)
17.1 Principles of Bioethics & Decisional Capacity 17.2 Informed Consent, Treatment Refusal & Special Scenarios 17.3 Surrogate Decision-Making, Advance Directives & Confidentiality 17.4 Patient Safety Science, Medical Error & Diagnostic Reasoning 17.5 Quality Improvement Methods, Health Disparities & Health Equity
19 Chapter 18: Perioperative Medicine & Medical Consultation
18.1 Preoperative Cardiovascular Risk Assessment 18.2 Preoperative Pulmonary Risk & Perioperative Medication Management 18.3 Perioperative Anticoagulation, Bridging & Postoperative Complications
20 Chapter 19: Ophthalmology (1% of Exam)
19.1 The Acute Red Eye & Ophthalmic Emergencies 19.2 Painless Vision Loss & Chronic Ophthalmic Disease 19.3 Uveitis, Scleritis & Orbital Disease
21 Chapter 20: Otolaryngology & Dental Medicine (1% of Exam)
20.1 Dizziness, Vertigo & Epistaxis 20.2 Ear Disorders, Hearing Loss & Upper Respiratory Infections 20.3 Oral Cavity, Salivary Gland, Laryngeal & Taste and Smell Disorders
7.7 Lymphomas & Plasma Cell Disorders
Key Takeaways Explain This Topic AI
Chronic leukemias, acute leukemia, non-Hodgkin lymphoma, Hodgkin disease and plasma cell disorder are enumerated under hematologic malignancies.
Myeloma-defining end-organ damage is summarized as hypercalcemia, renal insufficiency, anemia and bone lesions.
Monoclonal gammopathy of undetermined significance requires a monoclonal protein below 3 g/dL, under 10% clonal marrow plasma cells and no end-organ damage.
Skeletal survey has been superseded by whole-body low-dose computed tomography, positron emission tomography or magnetic resonance imaging for detecting myeloma bone disease.
Bone scintigraphy is insensitive in myeloma because the lesions are purely lytic without osteoblastic reaction.
Last updated: August 2026
- 1. Lymphomas: Hodgkin vs. Non-Hodgkin
- Hodgkin Lymphoma (HL)
Histopathology: Clonal giant multinucleated Reed-Sternberg (RS) cells (classic "owl's eye" appearance) or mononuclear Hodgkin cells expressing CD15 and CD30 (negative for CD20 and CD45), surrounded by a reactive inflammatory background of lymphocytes, eosinophils, and plasma cells.
Epidemiology & Presentation: Bimodal age distribution (peaks in 20s and 60s). Painless, rubbery cervical or supraclavicular lymphadenopathy (60–80%) and mediastinal widening. Constitutional B symptoms (fever > 38°C, drenching night sweats, unexplained weight loss > 10% in 6 months), severe generalized pruritus, and alcohol-induced lymph node pain (pathognomonic).
Staging & Therapy: Staged using the Ann Arbor system with whole-body 18 F ^{18}\text{F} 18 F -FDG PET-CT.
First-line regimen: ABVD ( A driamycin [Doxorubicin], B leomycin, V inblastine, D acarbazine) or Brentuximab vedotin + AVD (A+AVD).
Drug Toxicities: Bleomycin causes dose-dependent pulmonary toxicity and interstitial fibrosis (monitor DLCO; avoid high-flow O2); Doxorubicin causes cumulative cardiotoxicity (monitor LVEF); Vinblastine causes peripheral neuropathy and paralytic ileus.
Non-Hodgkin Lymphomas (NHL)
NHL Subtype Aggressiveness Histology & Genetics Clinical Features Standard Regimen
Diffuse Large B-Cell Lymphoma (DLBCL) Aggressive (High grade, rapidly growing) Sheets of large atypical lymphoid cells; CD19+, CD20+, CD79a+; rearrangements of BCL6, BCL2, MYC Rapidly enlarging symptomatic nodal mass or extranodal involvement (GI tract, bone, CNS) Curative intent: R-CHOP ( R ituximab, C yclophosphamide, D oxorubicin [Hydroxydaunorubicin], O ncovin [Vincristine], P rednisone) ± \pm ± Polatuzumab vedotin
Follicular Lymphoma (FL) Indolent (Low grade, incurable but prolonged course) Follicular/nodular growth pattern; t ( 14 ; 18 ) ( q 32 ; q 21 ) t(14;18)(q32;q21) t ( 14 ; 18 ) ( q 32 ; q 21 ) translocation causing constitutive BCL2 overexpression (inhibits apoptosis) Waxing and waning painless generalized lymphadenopathy in older adults Asymptomatic: Watchful waiting .; Symptomatic/Bulky: Bendamustine + Rituximab (BR) or R-CHOP. Risk of histologic transformation to aggressive DLBCL
Mantle Cell Lymphoma (MCL) Aggressive Small-to-medium lymphocytes; t ( 11 ; 14 ) ( q 13 ; q 32 ) t(11;14)(q13;q32) t ( 11 ; 14 ) ( q 13 ; q 32 ) translocation causing Cyclin D1 (CCND1) overexpression; CD5+, CD20+, SOX11+ Generalized lymphadenopathy, frequent GI tract polyposis ( lymphomatous polyposis ) Chemoimmunotherapy (Bendamustine-Rituximab or R-CHOP/R-DHAP) followed by ASCT or BTK inhibitors (Acalabrutinib, Zanubrutinib)
Burkitt Lymphoma Highly Aggressive (Doubling time < 24h) "Starry-sky" appearance (sheets of basophilic B cells with tingible-body macrophages); t ( 8 ; 14 ) ( q 24 ; q 32 ) t(8;14)(q24;q32) t ( 8 ; 14 ) ( q 24 ; q 32 ) translocation causing c-MYC overexpression ; Ki-67 ~100% Endemic (jaw mass in African children, EBV+); Sporadic (rapidly growing ileocecal abdominal mass); HIV-associated. Extreme risk of spontaneous Tumor Lysis Syndrome High-intensity multi-agent chemoimmunotherapy (CODOX-M/IVAC or DA-EPOCH-R) + aggressive TLS prophylaxis with Rasburicase and IV hydration
Loading diagram... Diagnostic & Classification Algorithm for Monoclonal Gammopathies & Plasma Cell Disorders
2. Plasma Cell Dyscrasias
Plasma cell neoplasms are characterized by the clonal proliferation of post-germinal center B-lineage plasma cells producing a monoclonal immunoglobulin (M-protein) or free light chains (kappa or lambda).
Spectrum of Monoclonal Gammopathies
Diagnostic Entity Serum Monoclonal M-Protein Bone Marrow Clonal Plasma Cells CRAB Symptoms or Myeloma-Defining Events Clinical Management
MGUS (Monoclonal Gammopathy of Undetermined Significance) < 3.0 g/dL < 10% ABSENT Observation; clinical and laboratory surveillance every 6–12 months (1% per year progression risk to active MM)
Smoldering Multiple Myeloma (SMM) ≥ 3.0 g/dL (or 24h urine M-protein ≥ 500 mg) 10% to 60% ABSENT Active surveillance every 3–6 months; clinical trials (Lenalidomide/Dex) for high-risk SMM
Active Multiple Myeloma (MM) Present (IgG 50%, IgA 20%, Light chain only 20%) ≥ 10% (or biopsy-proven plasmacytoma) PRESENT: ≥ 1 \ge 1 ≥ 1 CRAB feature OR ≥ 1 \ge 1 ≥ 1 SLiM biomarker Systemic induction chemotherapy followed by Autologous Stem Cell Transplantation (ASCT)
Diagnostic Criteria for Active Multiple Myeloma
Diagnosis requires clonal bone marrow plasma cells ≥ 10 % \ge 10\% ≥ 10% (or tissue plasmacytoma) PLUS at least one of the following:
Classic CRAB Criteria:
C — Hypercalcemia: Serum calcium > 11.0 mg/dL (> 2.75 mmol/L) or > 1.0 mg/dL above normal.
R — Renal Insufficiency: Serum creatinine > 2.0 mg/dL (> 177 mcmol/L) or measured/estimated CrCl < 40 mL/min attributable to myeloma cast nephropathy (light chain deposition in distal tubules forming obstructive casts).
A — Anemia: Hemoglobin < 10.0 g/dL or > 2.0 g/dL below lower limit of normal.
B — Bone Lesions: ≥ 1 \ge 1 ≥ 1 osteolytic bone destruction on skeletal radiography, whole-body low-dose CT, or 18 F ^{18}\text{F} 18 F -FDG PET-CT.
SLiM Biomarkers of Malignancy (≥ 80% risk of progression to symptomatic disease within 2 years):
S: ≥ \ge ≥ 60% Clonal Bone Marrow Plasma Cells.
Li: Involved-to-Uninvolved Serum Free Light Chain (FLC) ratio ≥ \ge ≥ 100 (with involved light chain ≥ 100 \ge 100 ≥ 100 mg/L).
M: > 1 Focal Lesion on Whole-Body MRI (lesions ≥ 5 \ge 5 ≥ 5 mm in size).
Comprehensive Management of Multiple Myeloma
Induction Chemotherapy: Quadruplet therapy is current standard of care for transplant-eligible patients: Daratumumab (anti-CD38 monoclonal antibody) + Bortezomib (proteasome inhibitor) + Lenalidomide (immunomodulatory drug / IMiD) + Dexamethasone ( D-VRd ).
High-Dose Chemotherapy & Consolidation: High-dose Melphalan followed by Autologous Stem Cell Transplantation (ASCT) for eligible patients (age < 75–80 without severe prohibitive comorbidities).
Maintenance Therapy: Continuous Lenalidomide maintenance until disease progression.
Bone Disease & Skeletal-Related Events: All patients with active MM requiring therapy should receive monthly bone-targeted antiresorptive therapy: IV Zoledronic Acid (4 mg) or Subcutaneous Denosumab (120 mg) (preferred in severe renal failure) for at least 2 years. Monitor for osteonecrosis of the jaw and hypocalcemia.
Related Plasma Cell Disorders
AL (Primary) Amyloidosis: Deposition of monoclonal immunoglobulin light chain fibrils (lambda > kappa) in tissues exhibiting apple-green birefringence under polarized light with Congo red stain. Manifestations: restrictive cardiomyopathy (low voltage ECG with thickened LV walls), nephrotic syndrome (heavy albuminuria), hepatomegaly, periorbital purpura ("raccoon eyes"), and macroglossia. Treatment: Daratumumab + CyBorD (Cyclophosphamide, Bortezomib, Dexamethasone) ± \pm ± ASCT.
Waldenström Macroglobulinemia (Lymphoplasmacytic Lymphoma): Clonal lymphoplasmacytic proliferation producing an IgM monoclonal gammopathy , strongly associated with somatic MYD88 L265P mutation (> 90%).
Clinical hallmarks: Anemia, lymphadenopathy, hepatosplenomegaly, and Hyperviscosity Syndrome (caused by large pentameric IgM molecules): epistaxis, retinal hemorrhages ("sausage-link" veins), blurry vision, dizziness, ataxia, headache, and stupor.
Emergency Management for Hyperviscosity: Immediate Therapeutic Plasmapheresis to rapidly lower IgM levels, followed by definitive systemic therapy ( Bendamustine + Rituximab or BTK inhibitors [Zanubrutinib / Ibrutinib] ). Rituximab can trigger a transient "IgM flare"; do not give single-agent rituximab if baseline IgM > 4,000 mg/dL without pre-treatment plasmapheresis.