Background and recommendations Flashcards
What is considered an lymphatic organ?
- Thymus
- Spleen
- Waldeyer’s ring
- Appendix
- Peyer’s patches
What is the definition of bulky disease per the mediastinal mass ratio (MMR)?
Mass more than 1/3rd widening of the greatest thoracic width on CXR
For the IP scores 0, 1, 2 what are the associated 5 year PF survivals?
0 - 84%
1 - 77%
2- 67%
What are the NCCN designated negative factors for Stage I to II patients?
- B symptoms present or ESR > 50
- MMR > 1/3 or any mass more than 10 cm
- More than 3 nodal sites
- 2 or more extralymphatic sites
What are NCIC designated negative factors for Stage I to II?
- Age 40 or more
- MC or LD
- B symptoms present or ESR > 50
- MMR > 1/3rd or any mass > 10 cm
- More than 3 extranodal sites
For what stages are the IP score useful?
Stage III and IV
What are the constituents of the IP score?
- Male
- Age > 45
- Stage IV
- Hemoglobin < 10.5
- < 4 g/dl
- Lymphocytes < 600/ml or 15K
For the IP scores 3, 4, 5+ what are the associated 5 year PF survivals?
3 - 60%
4 - 51%
5+ 42%
What are GHSG designated negative factors for Stage I to II?
- ESR > 50 if A or ESR > 30 if B
- MMR > .33
- Any extralymphatic site
- More than 2 nodal sites
Deauville 1-3 PET/CT response criteria
Uptake at the primary site is less than or equal to that of the liver
Deauville 4 PET/CT response criteria
Uptake at the primary site is moderately increased compared to the liver
Deauville 5a PET/CT response criteria
Uptake at the primary site is markedly increased compared to the liver
Deaville 5b PET/CT response criteria
New sites of disease are evident
Stanford V regimen
- Doxorubicin
- Vinblastine
- Mechlorethamine
- Etoposide
- Vincristine
- Bleomycin
- Prednisone
Add VEP and switched out dacarbazine
What is ABVD?
- Doxorubicin
- Bleomycin
- Vinblastine
- Dacarbazine
What is escalated BEACOPP?
- Bleomycin
- Doxorubibin
- Procarbazine
- Vincristine
- Etoposide
- Prednisone
- Cytoxan
Got rid of V, switched out dacarbazine, added VEPC
What are the GHSG unfavorable risk factors?
ESR > 50 if A, or > 30 if B
MMR > 0.33
Nodal sites > 2
E lesion any
What are the EORTC unfavorable risk factors?
Age 50 or older
ESR > 50 if A, > 30 if B
MTR > 0.35
>3 nodal sites
What stages are the Unfavorable risk factors helpful for?
Stage I to II
Treatment recommendation for patient with Stage IA to IIA Nodular lymphocyte predominant HL?
- Observe if complete resection has been performed
2. ISRT to 30.6 Gy at 1.8 Gy/fx
Treatment recommendation for patient with Stage IB to IIB or bulky Nodular lymphocyte predominant HL?
- Chemotherapy + ISRT
What labs are needed at work up?
CBC with diff ESR LDH LFT BMP Pregnancy test for women of childnearing age
What imaging is needed for work up?
PET/CT scan
Diagnostic CT of the neck, chest, abdomen and pelvis
CXR
What tissue diagnosis is needed?
Excisional biopsy
BM bx for B symptoms or Stage III-IV
What special studies are needed up diagnosis?
MUGA scan
PFTs
HIV test
What is the recommended treatment for Stage IA-IIA, favorable?
- ABVD for 2 cycles
- PET/CT
3a. If Deauville 1-3 or partial response on CT, give ISRT to 20 Gy at 2 Gy/fx
3b. If Deauville 4, consider ISRT or biopsy. If negative then continue with ISRT or if positive treat with refractory disease.
3c. If Deaville 5a, biopsy and if negative give ISRT
3d. If Deaville 5b, biopsy and if negative observe with short interval follow up.
If any biopsy is positive, treat that patient as if he/she has refractory disease
What is the recommended treatment for Stage IA-IIA, unfavorable bulky?
- ABVD x 4 cycles and restage with PET/CT
2a. If Deauville 1-3, treat with 2 more cycles of ABVD - ISRT
2b. If deauville 4, treat with 2 more cycles of ABVD and if now Deaville 1-3 on restaging PET/CT then ISRT
When do you get a follow up set of PFTs when delivering ABVD?
After the 4th cycle of bleomycin, if more is being planned
Deaville Score 1
No uptake beyond background
Deaville Score 2
Uptake at or below that of mediastinum
Deaville Score 3
Uptake above that of mediastinum but below at or liver
Deaville Score 4
Uptake moderately increased compared to liver at any site
Deaville Score 5
5a. Uptake markedly increased compared to liver at any site
5b. no metastatic sites
What is recommended treatment for Stage III-IV?
- ABVD x 2 cycles then restage with PET/CT scan
- If deauville 1-3 then give 4 more cycles
3a. If CR, observe or give ISRT to initially bulky sites
4a. If PR, give ISRT
What is the follow up after treatment?
H&P every 4 months for 2 years with CBC, BMP and ESR if initially elevated
CT chest/abdomen/pelvis every 6 months for 2 years
After 2 year, do H&P every 6 months until year three when follow up becomes yearly. Continue to order labs. No imaging.
When should annual breast screening be recommended for women treated with RT?
8-10 years after treatment or at age 40, whichever comes first.
Get a breast MRI and mammography for women treated with chest RT between ages 10-30.
What alternative treatment is available for patients with Stage III-IV disease?
Stanford V for 12 weeks and restage with PET/CT scan
If Deaville 1-3, then treat with ISRT to 30 Gy to all sites initially 5 cm in size or greater.
If Deaville 4 ot 5a, either treat with ISRT to 36 Gy or rebiopsy and if negative treat to ISRT to 36 Gy . If the biopsy is positive treat as if there is refractory disease.
