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Hematology, oncology > BMT > Flashcards

BMT Flashcards

1
Q

What is an ommaya reservoir?

A

Plastic device that’s implanted under your scalp. It’s used to deliver medication to your cerebrospinal fluid (CSF),

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2
Q

Chemo that may be administered intrathecally

A

methotrexate
cytarabine (Ara-C)
hydrocortisone

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3
Q

What does DLI stand for?

A

Donor leukocyte infusion

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4
Q

What is DLI? When given?

A

Patients who have received a blood and marrow transplant (BMT) from a related or unrelated donor could still experience a relapse of their underlying disease/cancer. A donor leukocyte infusion (DLI) is a possible strategy for managing a patient in relapse. In this procedure, the patient receives a boost of immune cells from the original donor’s blood. In certain circumstances, it may be extremely effective in controlling recurrent cancer in a patient.

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5
Q

Indications for CAR T cell therapy

A
  • In general–aggressive, relapsed or refractory NHL
    1) DLBCL
    2) Primary mediastinal B-cell lymphoma
    3) high grade B-cell lymphoma
    4) transformed follicular lymphoma
    5) mantle cell lymphoma.
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6
Q

For how long are you at risk of invasive fungal infection following transplant?

A

Risk remains elevated for first few months, even after recovery of neutrophil counts (so you need to continue anti fungal prophylaxis during this time)

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7
Q

Vyxeos is

A

daunorubicin and cytarabine

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8
Q

Haploidentical means

A
  • half- matched donor to replace the unhealthy ones.

- donor is typically a family member

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9
Q

Cell line that is first to recover

A

monocytes

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10
Q

How DA-EPOCH-R is referred to

A

Dose adjusted EPOCH-R

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11
Q

DA-EPOCH-R contains

A

Etoposide, prednisone, oncovin (vincristine), doxorubicin hhydrochloride, cyclophosphamide, rituximab

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12
Q

DA-EPOCH-R used for

A

NHL + b-cell lymphoma

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13
Q

Use of VDT PACE

A

RRMM

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14
Q

VDT PACE is

A 
Bortezomib
Dexamethasone
Thalidomide
Doxorubicin
Cyclophosphamide
Etoposide
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15
Q

To know about MTX use

A

order level 24h after last dose (typically by pharmacy as part of orderset)
Repeat MTX level daily (often a send out)
IF high → uptitrate leucovorin
Give leucovorin until MTX level >0.1
Discharge when level is >0.1

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16
Q

Leucovorin dosing with MTX

A

q6h

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17
Q

Common etiology of fevers post transplant

A

Engraftment

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18
Q

HCT means

A

hematopoietic cell transplantation

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19
Q

Transfusion goals

A

Hgb <7

Plt <10

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20
Q

Ppx during leukemia induction

A

(bacterial + HSV)
Acyclovir 400 mg PO BID
IF high risk (expected ANC<500 for 7 days (induction for AML or HCT)) → Start levoquin 500 mg PO daily on first day of start of cytotoxic chemo

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21
Q

TBI stands for

A

total body irradiation

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22
Q

VOD prophylaxis

A

ursodiol

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23
Q

Hepatic SOS (veno-occlusive disease) timing + context

A

Occurs days or weeks after HCT

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24
Q

Hepatic SOS or VOD clinical features

A

Thrombocytopenia + hepatomegaly + ascites + jaundice

- can rapidly progress to multiorgan dysfunction and death

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25
Q

Age cutoff for myeloablative transplant

A

65 (in europe, 77 in us)

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26
Q

Treatment of EBV post transplant

A

Rituxan

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27
Q

Order of recovery of cell lines after engraftment

A

neutrophils, then T cells, RBC’s, platelets

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28
Q

Clinical features of primary graft failure

A

cell lines continue downtrending and don’t respond (no engraftment)

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29
Q

management of primary graft failure

A

do bx → then usually have to repeat graft

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30
Q

Transplant referred to as

A

infusion

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31
Q

Presentation of CMV

A
  • mono like syndrome + organ specific involvement (hepatitis, colitis, pneumonitis)
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32
Q

When CMV typically occurs after solid organ transplantation

A
  • within first few months
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33
Q

Explanation for why CMV-positive recipients may still develop CMV from CMV-positive donors

A
  • several strains of CMV don’t confer cross-immunity
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34
Q

1st and second best CMV status

A

1) seronegative donor and recipient
2) seropositive donor and seronegative recipient (a seropositive donor has immunity that can be transferred to recipient and recipient does not have dormant CMV that can be reactivated)

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35
Q

Preferred conditioning regimens at UMass for allo’s

A

1) Flu/cy + TBI

2) Bu/Flu + TBI

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36
Q

Flu/cy is

A

Fludarabine + high dose cytoxan

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37
Q

Bu/Flu is

A

busulfan + fludarabine

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38
Q

Preferred prophylaxis for GVHD at UMass + other 2 medications used for GVHD prophylaxis

A
  • Cytoxan

- Mycophenolate + tacrolimus

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39
Q

When cytoxan is given after transplant for GVHD prophylaxis

A

D+3/4

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40
Q

tacro level goal, generally speaking

A

5-10

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41
Q

first and second line for chronic GVHD

A

1 mg/kg prednisone
- ???

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42
Q

“death from transplant” term in malignant heme

A

Relapse free mortality

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43
Q

mortality rate of allo transplant

A

Around 10%

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44
Q

Percentage of allo transplant recipients who get GVHD

A

50%!

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45
Q

Conditioning regimen for autos + dose

A

melphalan 200 mg/m2

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46
Q

Indications for auto transplants

A

1) Multiple myeloma
2) MCL
3) RR lymphoma (DLBCL and t cell)
4) Refractory HL

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47
Q

conditioning regimen typically used in auto transplants for RR lymphoma

A

BEAM

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48
Q

when myeloma patients are taken for transplant typically

A

CR1

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49
Q

beta d glucan tests for

A

candida

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50
Q

test for aspergillus

A

galactomanan

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51
Q

fluconazole covers and does not cover

A

candida, does not cover molds

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52
Q

Standard of care antifungal prophylaxis for leukemics + patients with long duration of neutropenia

A
  • posaconazole

- cresemba (broader coverage)

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53
Q

Problem with voriconazole

A

side effect profile + need to check levels frequently

54
Q

Most common transplant donor + recipient for CMV infection

A

D+/R-

55
Q

Medication used to prevent CMV reactivation

A

Letermovir

56
Q

Common viral infections in post-transplant

A
  • CMV

- HHV8

57
Q

HHV8 clinical presentation

A

meningoencephalitis

58
Q

BK virus presentation

A

Hemorrhagic cystitis

59
Q

Treatment of BK viremia at UMass

A

Cedofovir

60
Q

Induction regimen at UMass for AML

A

Mitoxantrone + cytarabine

61
Q

Consolidation therapy for AML

A

IF moderate or high risk – allo transplant

All others – High dose ara C (HIDAC)

62
Q

HiDAC stands for

A

High dose cytarabine

63
Q

Most common precipitants of CRS

A

1) CAR-T

2) Bispecifics

64
Q

Drugs commonly implicated in differentiation syndrome

A

1) ATRA+arsenic for APL patients

2) IDH inhibitors

65
Q

Medications for post transplant TMA

A

1) Narsoplumab

2) Eculizumab

66
Q

clinical presentation of engraftment syndrome

A
  • around D10

- inflammatory syndrome that looks like mild HLH (effusions, edema, fevers, dyspnea, LFT bump)

67
Q

management of engraftment syndrome

A

High dose steroids for 3-7 days

68
Q

when VOD happens

A

allo transplants D1-20

69
Q

first line for VOD

A

defibrotide

70
Q

key pieces of information to know about every transplant patient

A

1) transplant type
2) graft source
3) HLA typing

71
Q

What are the aggressive b cell lymphomas?

A

1) DLBCL
2) Primary mediastinal B-cell lymphoma
3) high grade B-cell lymphoma
4) transformed follicular lymphoma
5) mantle cell lymphoma.

72
Q

Immunophenotype of stem cells

A

CD34+

73
Q

When risk of infection increases dramatically

A

ANC below 500

74
Q

basic process for auto transplant

A
  • patient gets chemo and goes into remission – get chemo and GSCF to mobilize stem cells into peripheral blood – cells are frozen – patient gets admitted a week or two later for transplant – patient gets chemo followed by autologous stem cell infusion
75
Q

Best choices for HLA matched donor AND why

A

1) Young matched sibling (least transplant related mortality)
2) Matched unrelated donor (high number of cells compared to cord blood and hence quicker engraftment and less risk of viral infection)
3) Cord blood donor (less GVHD but high risk of viral infection)

76
Q

Types of HLA matching

A

1) Matched sibling
2) Matched unrelated donor
3) Cord blood
4) Haplo identical donor

77
Q

Top two choices for CMV status

A

1) CMV + and +

2) CMV - and -

78
Q

Donor features associated with less risk of GVHD

A
  • younger age
  • male
  • nulliparous female donor
79
Q

Allo transplant indications

A
  • AML (intermediate or high risk)
  • ALL
  • MDS
  • Myelofibrosis or CMML
  • CML not responding to TKI
  • Lymphoma (relapse after an auto)
  • MM (high risk and young)
  • AA (age less than 40)
  • Beta thalassemia major
80
Q

What is allogenic effect?

A

Graft vs. leukemia affect

81
Q

Point of a conditioning regimen

A

Even when a patient is in clinical remission, leukemia cells might be present below the threshold of detection. Myeloablation eradicates both normal and abnormal stem cells

82
Q

When does post transplant TMA happen?

A

A long ways out (day 100+)

83
Q

Mucositis peak after myeloablative regimen

A

Day 7-15

84
Q

Diarrhea distinguishing feature in terms of timeframe

A

Typically non-infectious before day 15

85
Q

Concept of reduced intensity conditioning

A
  • Less intense regimen to improve post-transplant immune suppression
  • DLI used to eliminate residual disease (instead of conditioning regimen)
86
Q

Indications for reduced intensity preparative regimen

A
  • age over 60
  • CR
  • Slow growing disease (follicular NHL)
  • heavily treated with chemo
  • borderline PS
87
Q

RIC stands for

A

Reduced intensity conditioning

88
Q

Timeframe of when patient is at increased risk of infection post transplant for viruses, fungi, and bacteria

A 
Bacteria = hours to days
Fungal = days to weeks
Viral = weeks to months
89
Q

T cell depletion methods

A
  • Campath
  • ATG
90
Q

Prophylaxis after allo transplant at UMass and dosing

A

Acyclovir 400 mg PO TID OR valacyclovir 500 mg BID
Levoquin 500 mg PO daily on first day of start of cytotoxic chemo
DC when ANC>500
Posaconazole 300 mg PO daily OR cresemba (until immunosuppression discontinued)
Start Bactrim DS BID on Saturday or Sunday only 30 days after transplant for 6 months

91
Q

Prophylaxis after auto transplant at UMass

A

Acyclovir 800 mg PO BID (400 mg BID if renal insufficiency)
Levoquin 500 mg PO daily (renally dosed) on first day of start of cytotoxic chemo
Fluconazole 400 mg PO daily for 1 month
Bactrim 1 DS tablet 3x/week for 1 year

92
Q

NRM stands for? Means?

A

non-relapse mortality, refers to death after transplant from disease unrelated cause (eg conditioning regimen)

93
Q

Types of conditioning regimens

A

1) myeloablative conditioning (MAC)
2) nonmyeloablative (NMA)
3) reduced intensity conditioning (RIC)

94
Q

Caveats about hydrea dosing (onset, effect after stopping)

A
  • onset is 3-5 days
  • effect is short lived after HU is stopped, thus shouldn’t make dose adjustments more often than once per month to prevent fluctuations in platelet count
95
Q

campath generic name

A

alemtuzumab

96
Q

cresemba generic name

A

Isavuconazole

97
Q

what is a haplo SCT?

A
  • type of allotransplant

— Uses stem cells from a half-matched donor (typically a family member)

98
Q

Duration of increased infectious risk after transplant

A
  • up to 2 years after a transplant
99
Q

when can live vaccines be used in transplant patients

A

2 years after transplant (risk of infection is highest 2 years after transplant, even if they’ve been weaned off immunosuppression)

100
Q

Problems with using cord blood

A
  • limited number of stem cells in a single cord-blood unit so you can’t use in recipients with larger body mass
  • studies have shown superiority, however, over single cord-blood unit transplants over double cord blood unit transplants
101
Q

benefits of using single cord blood unit allo transplant

A
  • improved platelet recovery

- lower incidences of grade III and IV GVHD

102
Q

clinical features of Cryptogenic organizing pneumonia after transplant

A
  • bilateral GGO’s
  • PFTs with restrictive pattern + reduced DLCO
  • rapid improvement with steroids
103
Q

clinical features of bronchiolitis obliterans after transplant

A
  • airflow obstruction (due to bronchiectasis from small airway inflammation and narrowing due to fibrous scar tissue formation)
104
Q

antifungals with invasive mold coverage

A

posaconazole (not fluconazole)

- others…

105
Q

T cell markers

A 
CD2
*CD3
CD5
CD7
CD30
106
Q

B cell antigens

A

CD19, CD20, CD22, CD79a, CD22, PAX5

107
Q

Significance of MPO+

A

Myeloid marker, excludes B-ALL

108
Q

blast markers

A

CD34+
CD117+
CD123+
HLA-DR

109
Q

Myeloid lineage (AML) markers

A

CD13
CD33
MPO+
CD11b+

110
Q

Manifestations of CMV reactivation

A
  • hepatitis
  • pneumonia
  • retinitis
  • encephalitis
111
Q

Definition of preengraftment period

A

less than 30 days following transplant

112
Q

most common infections during preengraftment period

A
  • bacterial + HSV + candida and aspergillus (due to neutropenia)
113
Q

How is postengraftment period defined?

A

30-100 days post transplant

114
Q

most common infections during postengraftment period

A
  • CMV, PJP, aspergillus
115
Q

late phase of engraftment period refers to

A

100 days following HSCT

116
Q

most common infections during late phase

A
  • aspergillus, PCP, encapsulated bacteria, VZV
117
Q

Drugs that can cause TMA’s

A
  • cyclosporine (transplant-associated TMA)
  • tacrolimus
  • gemcitabine
118
Q

unique management of drug-induced TMA

A
  • unclear if plasma exchange is helpful
119
Q

transplant periods in which autotransplant recipients are at increased risk of infection

A

pre- and immediate postengraftment periods

120
Q

common pathogen in oral mucositis in transplant patients

A

strep viridans

121
Q

when to start + duration of PJP prophylaxis in allos

A

Start Bactrim DS BID on Saturday or Sunday only 30 days after transplant for 6 months or completion of immunosuppressive regimen (whichever comes first)

122
Q

difference in azoles in fungal coverage

A
  • fluconazole = yeast/candida

- posa and vori = cover molds

123
Q

infection common with iron overload

A

gram negative bacteria

124
Q

Inqovi includes

A

Decitabine/cedazuridine

125
Q

cedazuridine mechanism

A

cytidine deaminase inhibitor

126
Q

Engraftment syndrome clinical features

A

fever + skin rash + pulmonary symptoms

127
Q

Management of engraftment syndrome

A

Observation or steroids depending on severity

128
Q

Differentiation syndrome occurs with which drugs?

A

1) IDH inhibitors
2) FL3 inhibitors
3) ATRA

129
Q

Drug interaction to know with posaconazole + management

A

1) venetoclax
2) dose reduce venetoclax

130
Q

Standard of care drug used for CMV prophylaxis

A

Letermovir

131
Q

RF’s for VOD/SOS

A
  • High dose myeloablative conditioning regimens (particularly busulfan)
  • Certain drugs in induction, consolidation, and salvage (gemtuzumab, inotozumab)

Hematology, oncology (218 decks)

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