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Thiopurine-Associated Lymphoma — RACP Adult Medicine MCQ

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HardGastroenterology & HepatologyThiopurine-Associated LymphomaRACP Adult Medicine

A 45-year-old man with Crohn's disease on azathioprine for 3 years develops EBV-positive diffuse large B-cell lymphoma. What is the relationship between azathioprine and this lymphoma?

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Correct answer: B — Azathioprine is protective against lymphoma

Long-term thiopurine use (azathioprine, mercaptopurine) increases the risk of lymphoproliferative disorders, particularly EBV-driven lymphomas, by approximately 4–5 fold. EBV-seronegative patients starting thiopurines are at highest risk. The CESAME study confirmed this association. The decision to continue or cease thiopurines after lymphoma diagnosis depends on the clinical situation. EBV serostatus should be checked before commencing thiopurines, and alternative biologics considered for EBV-seronegative patients.

Reference: eTG – 2025 – Gastrointestinal; ECCO – 2024 – Safety of IBD Therapies