Lymphoma in children: Viva

This is a branching oral built to probe the reasoning that holds the mediastinal mass and the tumour lysis syndrome at the centre, and to expose the candidate who has memorised the headline without the safety-critical corners. The questions escalate from the framing to the airway protection, the diagnosis, the staging and the definitive management, with deliberate probes into the pitfalls and the subtypes. ^[1]

Opening question: framing the problem

The examiner opens with the chest radiograph and the node and asks: how do you frame this problem in a single sentence, and what is your first priority? ^[1]

A strong answer names the classical Hodgkin lymphoma from the painless supraclavicular node, the B symptoms and the anterior mediastinal mass, and states that the first priority is the airway, because the mediastinal mass with the tracheal deviation places the boy at risk of the airway compromise under the sedation and the supine position. ^[8]

Model answer. This teenager has a classical Hodgkin lymphoma from the painless supraclavicular node, the B symptoms and the anterior mediastinal mass. My first priority is the airway: the boy is assessed for the stridor, the orthopnoea and the superior vena cava syndrome, kept upright, and given no sedation before the airway is secured in a controlled setting. ^[8]

Probe one: the airway-protective diagnosis

The examiner presses: tell me exactly how you take the biopsy of a mediastinal mass, and why. ^[8]

A strong answer reproduces the airway-protective principle. The excision biopsy of the supraclavicular node is taken under the local anaesthesia where possible, because it preserves the architecture and it avoids the general anaesthetic. The general anaesthetic for a mediastinal node is reserved for the airway assessed as safe by the anaesthetic, the ENT and the cardiothoracic teams together, with the rigid bronchoscope and the ECMO on standby, the spontaneous ventilation maintained and the supine position avoided. The steroids are reserved for the life-threatening obstruction, because they lyse the lymphoma and confound the biopsy. ^[8][9]