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Hematologic Flashcards

1
Q

History questions for lymphoma

A
  • Duration and rate of growth of palpable masses
  • Tenderness of nodes
  • B symptoms
  • Fatigue
  • Pruritis
  • Performance status
  • Exposure to EBV
  • Smoking history
  • Cardiac and pulmonary history given necessity of chemo
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2
Q

Lymphoma usually painless or painful adenopathy

A

painless

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3
Q

Physical exam for lymphoma

A

Detailed nodal exam

Check for hepatosplenomegaly

If concern for upperaerodigestive involvement –> nasopharyngoscopy of Waldeyer ring

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4
Q

How many patients present with splenomegaly

A

30%

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5
Q

What are the B symptoms

A
  • Fever >38
  • Weight loss >10% over prior 6 months
  • Drenching nightsweats
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6
Q

Discuss lymph node regions and areas

A

17 different Ann Arbor nodal regions

Each of the cooperative groups has different definitions of nodal areas

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7
Q

How does GHSG classify neck?

A

R cervical, occipital, pre-auricular, supraclav, infraclav and subpectoral

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8
Q

What is difference for Ann Arbor staging of neck

A

Cervical, Supraclav, Occipital, PreAuricular

Infraclav, Subpectoral (separate)

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9
Q

How does GHSG classify chest

A

Mediastinum + Bilateral hila

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10
Q

Where do 80-90% of cHL start?

A

SCV and cervical nodes

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11
Q

How to biopsy if suspicion for lymphoma?

A

excisional biopsy preferred

core ok if necessary

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12
Q

For DLBCL, what should the path be sent for?

A

If clinical suspicion of high grade lymphoma send

myc, BCL2 and BCL6 translocation

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13
Q

Which labs should be ordered for suspected lymphoma patient?

A
  • CBC
  • CMP
  • HIV
  • Hep serologies
  • LDH
  • EBV titer
  • ESR
  • PREGNANCY TEST
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14
Q

What other tests should a lymphoma patient be sent for?

A

ECHO

PFTs (if considering bleo)

Fertility

Vaccines if splenic RT

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15
Q

What imaging is needed

A

PET

Consider CT CAP with contrast

Consider MRI given location

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16
Q

Which DLBCL patients need CNS staging?

A

HIV-associated

Testicular or paranasal sinus DLBCL

>2 EN sites with elevated LDH

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17
Q

What is Deauville 1

A

Background avidity

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18
Q

What is Deauville 2

A

Avidity above background below mediastinal blood pool

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19
Q

What is Deauville 3

A

Avidity between mediastinum and liver

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20
Q

What is Deauville 4

A

Uptake above liver, no new sites

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21
Q

What is Deauville 5

A

Update markedly above liver or new site of disease

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22
Q

What Deauville levels should be considered positive for therapeutic de-escalation?

A

3, 4, 5

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23
Q

What is the Lugano staging?

A

Limited = Stage I and II

Advanced = Stage III and IV

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24
Q

What is stage I?

A

One node or one group of adjacent nodes

One lymphoid tissue structure (spleen, Waldeyer, thymus)

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25
Q

What is stage IE?

A

single extra-nodal lesion, without nodal involvement

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26
Q

Stage II

A

Two or more nodal areas and/or lymphoid structures on same side of the diaphragm

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27
Q

Stage IIE

A

One or two node/nodal groups on same side with limited CONTIGUOUS extranodal involvement

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28
Q

What is stage III

A

nodes above and below diaphragm

nodes above diaphragm w spleen involvement

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29
Q

What is stage IV

A

Non contiguous extralymphatic tissues

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30
Q

What is bulky disease for cHL

A

Classically 1/3 intrathoracic diameter between T5 and T6

But ranges 7-10 cm per study

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31
Q

What is bulky for DLBCL?

A

7.5 cm (UNFOLDER definition)

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32
Q

What is bulky for FL?

A

6 cm

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33
Q

How to do ISRT

A
  • Fuse pre-chemo PET and CT to simulation CT
  • Contour several areas to form GTVpre
    • CT abnormality on pre-chemo CT
    • CT abnormality of pre-chemo PET/CT
    • PET abnormality on pre-chemo PET
  • Contour GTV on post chemo sim scan
  • Fuse these images
  • Form a CTV respecting anatomic boundaries (bone, muscle, lung) and generally do 1-2 cm craniocaudal expansion depending on site
    • More uncertainty in setip, the larger the expansion
  • Join CTVs if <5 cm apart
  • Account for motion with ITVs
  • PTV margin of 0.5-1.0 cm depending on site
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34
Q

If two CTVs are > X distance apart, they can remain separate

A

5 cm

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35
Q

Which patients should be referred for protons

A

Mediastinal disease in young women to reduce breast dose

Heavily pre-treated patients with RT-related risk for heart and lung toxicity

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36
Q

Benefits of arms up for treating neck/mediastinum

A

Pulls axillary nodes away from chest wall and gives more lung shielding

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37
Q

Benefits of arms akimbo for treating neck/mediastinum

A

Better humeral head shielding and reduces SCV skin folds

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38
Q

Risk of L’hermitte’s for cHL

A

15-20%

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39
Q

Risk of pneumonitis for cHL treatment

A

15% (due to bleo)

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40
Q

Risk of pericarditis from cHL treatment

A

<5%

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41
Q

Risk of thyroid dysfunction from mediastinal treatment

A

30-50%

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42
Q

Late toxicity risks for cHL treatment

A
  • Hypothyroidism
  • Infertility
  • Secondary malignancies (thyroid, lung, breast)
  • CAD
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43
Q

Which women should get breast screening?

A

Women who got thoracic RT between 10-30

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44
Q

How should women with prior thoracic RT be screened for breast ca

A

Counsel for breast self-exam

Annual mammo

Breast MRI

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45
Q

When should breast screening start for these women?

A

8-10 years after completion of RT or age 40, whichever is sooner

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46
Q

How often should TSH be checked if neck RT?

A

annual

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47
Q

What is immunohistochemistry phenotype of cHL

A

CD15+

CD30+

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48
Q

What subtype of cHL is most common?

A

Nodular sclerosing

70%

Often mediastinum

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49
Q

Characteristics of mixed cellularity cHL

A

20%

Young kids, EBV+

Advanced stage

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50
Q

Lymphocyte rich subtype

A

10%

Best prognosis

Confused with NLPHL

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51
Q

Lymphocyte depleted subtype

A

rarest but worst prognosis

Older patients

B sx

HIV+

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52
Q

What are the German Hodgkin Study group risk factors

A
  • 3 or more nodal areas
  • Extranodal disease
  • ESR > 50 if A, >30 if B
  • Bulky mediastinal mass
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53
Q

What age is considered higher risk for cHL?

A

>50

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54
Q

NCCN defines bulk as X cm for cHL

A

10 cm

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55
Q

What is ABVD?

A

Adrimycin

Bleomycin

Vinblastine

Dacarbazine

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56
Q

How is ABVD given?

A

D1 and D15 of 28 day cycle

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57
Q

What are the toxicities of ABVD?

A

A=cardiomyopathy

B=pulm fibrosis

V=neuropathy and alopecia

D=cytopenia, vomiting, hepatotox

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58
Q

What is BEACOPP

A

B=Bleomycin

E=etoposide

A=adriamycin

C=cyclophosphamide

O=vincristine

P=procarbazine

P=prednisone

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59
Q

What is ICE?

A

Ifosfamide

Carboplatin

Etoposide

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60
Q

After classifying patient as favorable/unfavorable cHL, what is next step?

A

Decide if preference for a chemo only strategy or if combined modality is the intent of treatment

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61
Q

How to decide if good candidate for CMT?

A

Age

Sex

Disease distribution

FHx

Comorbidities

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62
Q

Treatment approach for early stage favorable disease

A
  • PET adapted strategy
  • Start with 2 cycles of ABVD –> PET
  • If Deauville 1 or 2
    • 20 Gy ISRT
    • 1-2 cycles ABVD (per RAPID)
  • If Deauville 3
    • 20 Gy ISRT (if very favorable)
    • 1 cycle ABVD –> 30 Gy
    • AVD x 4
  • If Deauville 4 or 5 –> 2 more cycles of ABVD –> PET
    • If D1-3: ISRT 30 Gy
    • If D4-5: Biopsy –>
      • neg –> ISRT 30 Gy
      • Pos –> salvage ICE
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63
Q

What is the advantage of CMT for early stage favorable cHL

A

Randomized trials show EFS benefit of 7-10%

We cannot omit RT even if PET negative after ABVDx2 without decrement in PFS

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64
Q

Which patients should not be managed with 2 ABVD –> 20 Gy

A

ESR < 50

< 3 nodal areas

No extranodal disease

No bulky mediastinal mass

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65
Q

Management of early stage unfavorable disease

A
  • ABVD x 2 –> PET CT
    • Deauville 1-3
      • ABVD x 2 –> 30 Gy ISRT
      • AVD x 4 (RATHL)
    • Deauville 4-5: escBEACOPP x 2 –> PET/CT
      • Deauville 1-3
        • escBEACOPP x 2
        • ISRT 30 Gy
      • Deauville 4-5 –> biopsy
        • negative –> 30 Gy ISRT
        • positive –> ICE
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66
Q

Outcomes for early stage favorable cHL

A

5 year EFS: 93%

5 year OS: 98%

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67
Q

Outcomes for early stage unfavorable cHL

A

5 year EFS: 85%

5 year OS: 95%

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68
Q

Approach to advanced stage cHL

A
  • ABVD x 2 –> PET CT
    • If Deauville 1-3: AVD x 4 (per RATHL)
    • If D4-5: escBEACOPP x3 –> PET/CT
      • D1-3: eBEACOPP x1
      • D4-5: biopsy
        • neg: eBEACOPP x1
        • pos: r/r
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69
Q

When should RT be used for advanced stage cHL

A

Consolidation ISRT to residual sites (PR) after 6 cycles of chemo) especially if bulky or extranodal

No role for consolidation if CR to ABVD

No role for consolidation if eBEACOPP used

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70
Q

How many patients with early stage cHL will relapse?

A

10-20%

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71
Q

How many patients with advanced stage cHL will relapse

A

30-40%

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72
Q

How to approach relapsed cHL

A

Biopsy

ICE chemo x2 cycles

RT consolidation (150 x 20 BID)

HDT+AutoSCT

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73
Q

What is the risk of second cancers for cHL patient?

A

20-30% over 30 years

74
Q

Risk of breast cancer in cHL survivors

A

15-20% at 30 years

4x SIR

75
Q

What is marker pattern of NLPHL?

A

CD 20+

CD 45+

76
Q

Best treatment for NLPHL early stage

A

ISRT alone

30 Gy standard

36 Gy if bulky

77
Q

How to contour NLPHL ISRT

A

ISRT alone typically so generous margins

Go 2-5 cm sup/inf around affected nodal areas depending on the site

78
Q

What is the relapse pattern for NLPHL?

A

Late, distant and possibility of transformation

79
Q

What is rate of transformation for NLPHL

A

30% at 20 years

80
Q

How to do post treatment imaging for cHL?

A
  • Document CR by PET w/i 3 months of finishing treatment
  • Then CT N/CAP q6 months x 2 years
81
Q

Outcomes for NLPHL

A

10 year OS >90%

10 year RFS 75%

82
Q

What is the marker pattern for DLBCL

A

CD20+

CD45+

83
Q

What is the chemo regimen for DLBCL?

84
Q

What is RCHOP

A

R-rituximab

C-cyclophosphamide

H-doxorubicin

O-vincristine

P-prednison

85
Q

How often is RCHOP given

A

Typically q3w

86
Q

What is the prognostication score for DLBCL?

87
Q

What are the IPI factors?

A

Think APLES

A-Age >60

P-ECOG 2+

L-elevated LDH

E-2+ extranodal sites

S-stage III/IV

88
Q

How to work up a DLBCL patient

A
  • H&P
  • Imaging: PET, ?MRI
  • Labs: CBC, COMP, LDH, Hep serologies
  • Path: excisional bx, bone marrow bx, LP if high risk
  • Develop risk category using IPI
  • Decide if chemoimmunotherapy or CMT
89
Q

What is 4 year OS for DLBCL IPI 0

90
Q

What is 4 year OS for IPI 1-2

91
Q

What is 4 year OS for IPI 3-5

92
Q

What is bulk for DLBCL?

93
Q

What is the approach to stage I/II non bulky DLBCL?

A
  • Options
    • RCHOP alone to 4-6 cycles
    • Combined modality
      • RCHOP x3-4 followed by ISRT
94
Q

What is the dose of RT for combined modality therapy for DLBCL?

A

If CR: 30 Gy

If PR: 36-40 Gy

If no chemo: 45-50 Gy

95
Q

What is the benefit of Rituximab for DLBCL?

A

About 10% improvement in OS

96
Q

What is the management of early stage bulky DLBCL

A

6 cycles RCHOP +/- RT

30 Gy if CR

36 Gy if PR

97
Q

What is the limitation of the UNFOLDER data?

A

No interim PET imaging

Unclear if CR actually needs RT?

98
Q

What are aggressive variant DLBCL

A
  • Double hit
  • Triple hit
  • Burkitt like features
  • Very high IPI
99
Q

How to appoach aggressive variant DLBCL

A

6 cycles R-da-EPOCH

30 Gy if CR to bulky or extranodal sites

100
Q

How to approach stage III/IV DLBCL

A

6 cycles of RCHOP

Consider consolidation RT to sites of bulk, skeletal, PR

101
Q

How does RT help for DLBCL of the elderly

A

Improves EFS, PFS, OS for elderly patients getting 6 cycles of RCHOP for sites of initial bulk and extralymphatic involvement

102
Q

What is an open question about consolidation of DLBCL

A

If bulky but PET CR at the end of therapy still requires consolidation (subject of OPTIMAL 60 study)

103
Q

Which DLBCL cases should get CNS prophylaxis

A

IPI>4

testicular

parameningeal involvement

HIV

adrenal/kidney involvement

consider for high risk histologies (double/triple hit)

104
Q

What is the preferred CNS prophylaxis

A

IT MTX x 4-8 cycles

105
Q

What is the treatment of testicular DLBCL

A
  • Orchiectomy
  • 6 cycles RCHOP
  • IT MTX prophylaxis (4-8 cycles)
  • RT to contralateral testicle (30 Gy/15 fx)
106
Q

What is the treatment of bone lymphomas

A

RCHOP x 3-4

Consolidation RT to 30-36 Gy if CR (prechemo volume using MRI)

107
Q

What is the treatment of gastric DLBCL?

A

RCHOP x 3

Repeat endoscopy

30 Gy/15 fx if CR

More chemo –> RT if PR

108
Q

What is a palliative dose regimen for DLBCL

A

3 Gy x 10-13

4 Gy x 7

109
Q

What virus associated with Burkitt

110
Q

What virus associated with splenic MZL

111
Q

What associated with cutaneous MALT

A

Lyme disease

112
Q

What infection associated with ocular MALT

A

chlamydia psittaci

113
Q

What are the path hallmarks of MCL

A

Cyclin D+

t11:14 associated with activation of BCL1

114
Q

How to treat localized MCL?

A
  • RCHOP x 6 cycles +/- ISRT if PR
  • RT alone to 36 Gy
115
Q

What is approach to treat advanced stage MCL?

A
  • If aggressive: RCHOP –> HDT/ASCT
  • If indolent: observe
  • Palliation: consider 2 Gy x 2
116
Q

What is the translocation hallmark of FL?

A

t14:18

Overexpresses BCL2

117
Q

What share of NHL is FL?

118
Q

What additional workup needed for FL?

A

BONE MARROW BX

119
Q

What is the risk of transformation for FL?

A

3% risk per year

120
Q

How is grade determined for FL?

A

Number of centroblasts per HPF

121
Q

What is grade 1 FL

A

0-5 centroblasts pHPF

122
Q

What is grade 2 FL

A

6-15 centroblasts

123
Q

What is grade 3 FL

A

>15 centroblasts

124
Q

How to assess risk for FL?

A

FLIPI or FLIPI2 score

125
Q

What is FLIPI score?

A
  • NOLASH
    • >4 nodal areas
    • LDH elevated
    • Age >60
    • Stage III/IV
    • Hgb <12
126
Q

What is FLIPI2 score

A

HAS NO BM

  • Hgb < 12
  • Age > 60
  • Serum beta2 microglob elevated
  • Node >6cm
  • BM: bone marrow involvement
127
Q

How many cases of FL are localized

128
Q

What is the treatment strategy for localized FL

A
  • ISRT to 24 Gy in 12 fractions
  • Can consider addition of ritux or RCVP if more extensive disease
129
Q

Contouring for localized FL

A
  • GTV = involved nodes
  • CTV = GTV + 5 cm craniocaudal + 1 cm radially
  • PTV = 0.5 - 1 cm pending location
130
Q

Outcomes for localized FL

A
  • 98% response to RT
  • 90% local control at 5 years with RT alone
  • 75% PFS for stage I
  • 50% PFS for stage II at 5 years
131
Q

How to approach stage II noncontiguous

A
  • Chemo-immunotherapy +/- ISRT
  • Observation
132
Q

How many FL cases are stage III/IV

133
Q

When should we treat stage III/IV FL?

A

Symptomatic

End organ dysfunction

Cytopenias

Bulky disease

Steady progression

134
Q

Options for treatment of advanced stage FL

A
  • Observation
  • Chemoimmunotherapy (R-Benda, RCHOP, Rituximab)
  • Low dose RT
135
Q

What is the success rate of 2 Gy x 2

A

70% local PFS at 5 years

136
Q

What translocation predicts antibiotic resistance for gastric MALT?

137
Q

What workup is necessary for suspected gastric MALT?

A
  • Labs: LDH, beta2microglobulin
  • H Pylori breath or stool test
  • Endoscopy with random biopsies, staining for H Pylori
  • Check 11;18 translocation
  • PET Scan
138
Q

How to approach Gastric MALT

A
  • If H Pylori positive –> triple therapy
    • Recheck endoscopy in 3 months
      • If H Pylori + –> can try second line antibiotics
      • If H Pylori - and persistent MALT –> ISRT
  • If H Pylori negative or if t11;18 positive –> ISRT
139
Q

How successful is antibiotics for H Pylori + gastric malt?

A

2/3 of cases are treated

140
Q

What is triple therapy

A
  • PPI
  • Amoxicillin 1g BID (or metronidazole 500 mg BID if PCN allergy)
  • Clarithromycin 500 mg BID
141
Q

What is the dose of RT for gastric MALT?

A

30 Gy in 20 fx

142
Q

What should be given with RT for gastric MALT?

A

PPI

Zofran

NPO 3 hrs before

143
Q

What is contouring strategy for gastric MALT

A
  • GTV: visible tumor and regional nodes
  • CTV: whole stomach, duodenal bulb
  • ITV
  • PTV: CTV + 1.5 cm
  • Daily CBCT
144
Q

What is the dose for nongastric MALT?

A

24 Gy in 12 if definitive

4 Gy in 2 if palliative

145
Q

Contouring approach for orbital MALT (conjunctival)

A

CTV = Include full conjunctival reflection to fornices

9 MeV with 1 cm bolus

PTV is CTV + 5 mm

146
Q

Contouring approach for orbital MALT (non-conjunctival)

A

CTV = full orbit

PTV = CTV + 5 mm

Use wedge pair or IMRT, opp lats if bilateral

147
Q

What is the workup for a plasma cell neoplasm?

A
  • H&P
  • Labs
    • CBC
    • CMP
    • Beta2 microglobulin
    • Albumin
    • LDH
    • SPEP
    • UPEP
    • Protein immunofixation
148
Q

What is the imaging required for new diagnosis of plasma cell neoplasm

A
  • Plain films or skeletal survey
  • PET
  • MRI/CT of the primary site
149
Q

What is the diagnosis of solitary plasmacytoma

A
  • Negative BM (<10% of plasma cells)
  • Bx proven plasma cell neoplasm
  • No more than 1 lesion on imaging
  • No end organ damage
  • Low IgM or IgA, low serum M spike
150
Q

What is treatment of ossoeus plasmacytoma

A

ISRT to 46 Gy in 23 fractions

151
Q

Margins for osseous plasmacytoma

A

CTV: 2 cm

PTV: 0.5 to 1.0

152
Q

What is the preferred treatment of extramedullar plasmacytoma

A

ISRT to 46 Gy in 23 fractions

Consider treating 1st eschelon nodes (especially if head and neck)

153
Q

What is local control of osseous plasmacytoma

154
Q

Risk of transition to MM from osseous plasmacytoma

155
Q

Local control of extramedullary plasmacytoma after RT

156
Q

Risk of myeloma after RT-treated extramedullary plasmacytoma

157
Q

Myeloma stage I

A

B2 microglob < 3.5

Albumin > 3.5

Normal LDH

158
Q

Myeloma stage II

A

Not stage I or III

159
Q

Myeloma stage III

A

B2microglob > 5.5 and either

High risk chromosomal abnormalities by FISH OR

High LDH

160
Q

Diagnosis of MM requires

A
  • Plasmacytoma or BM plasma cells > 10%
  • Presence of end organ/tissue impairment
    • Anemia (Hgb <10)
    • Hypercalcemia (Ca > 11)
    • Renal insufficiency (Cr >2)
    • Bone lesions - one or more osteolytic lesions > 5mm
  • OR presence of biomarker associated with near inevitable progression to end-organ damage
    • >60% plasma cells in bone marrow
    • FLC ration > 100
    • MRI with more than one focal lesion
161
Q

Treatment for MM

A
  • Chemo: bortezomib containing regimens (melphalan)
    • VCD - lenalidomide, cyclophosphamide, vincristine
  • HDCT+ASCT
  • Bisphosphonates
  • Palliative RT
162
Q

Dose of RT for palliative lesions MM

A

20-30 Gy in 3-4 Gy fractions

163
Q

Dose for primary cutaneous follicle center lymphoma

A

If solitary: 24/12

If diffuse 4/2

164
Q

Control rates for PCFCL

A

99% CR

20-30% fail in skin

165
Q

Typical margins for skin lymphomas

A

1.5 cm margin around the wired lesion

Choose electron with penetration to depth of lesion plus 5 mm

Rx to 90% IDL

Place 1 cm bolus, typically 6-9 MEV

166
Q

Dose for primary cutaneous anaplastic large cell lymphoma

A

36 Gy if solitary

167
Q

Treatment of anaplastic large cell lymphoma

A

BV-CHP if aggressive and systemic

168
Q

Stage IA MF

A

Patches, plaques, papules < 10% BSA

169
Q

Stage IB MF

170
Q

Stage IIA MF

A

N+ or B1 (sezary cells)

171
Q

Stage IIB MF

A

tumors > 1cm

172
Q

Stage III MF

A

confluent erythema >80%

173
Q

Treatment of localized MF

A
  • Topicals
  • RT with electrons
  • Consider systemic therapy +/- RT
  • Consider TSEB for IB
174
Q

What is response rate to TSEB

A

CR 80% but 10 year RFS is 10%

175
Q

Palliative dose of RT for localized MF lesion

A

200 x 6 2-3x per week

176
Q

Curative dose of solitary MF lesion

177
Q

What margin should be used for MF lesions

178
Q

Acute toxicities of TSEB

A

Dermatitis and desquamation

Alopecia

Lymphedema

Nail loss

Anhidrosis

179
Q

Longer term side effects of TSEB

A

2nd skin cancer

cataracts

edema

chronic xerosis

alopecia

telangiectasia

180
Q

What is the setup for TSEB

A
  • Dual fields with a superior and inferior field angled 18 degrees above and below horizontal
  • Treat with 9 MeV
  • Treatment behind a Lucite screen to scatter E- and improve surface dose
  • Treat all 6 positions single session
181
Q

Dose of TSEB

A

16-20 Gy

2x per week in 2 Gy fractions

Consider boosting the higher risk areas

182
Q

Treatment of PMBCL

A
  • If 6 cycles of R-da-EPOCH –> no RT if in CR
  • If 6 cycles of RCHOP –> RT if CR
    • 30 GY if CR

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