Hematologic Malignancies

Question 1

Lymphomas

Answer 1

2 major types
Hodgkins lymphoma which is characterized by reed-sternberg cells
AND
Non-Hodgkins lymphoma which has 30+ unigue histopathologic diseases
90% are B cells

Chemotherapy is backbone of treatment

Question 2

Hodgkins lymphoma

Answer 2

Reed-sternberg cells that originated from B-lymphocytes
B cells lose ability to do apoptosis, and cause proliferation of the cells

Question 3

Hodgkins lymphoma Risk factors

Answer 3

Viral exposure
- EBV infection
patient older than 50

impaired immune function
- congenital immunodeficiencies
- solid organ transplant
- HIV infection

genetic factors
- ataxia telangiectasia

Question 4

Hodgkins lymphoma symptoms

Answer 4

tends to be painless rubbery enlarged lymph nodes

Patients may present with B symptoms: fever over 100.4, drenched night sweats, unintentional weight loss of greater than 10% in less than or equal to 6 months

also can present with itching but does not have any rash visible on skin

Question 5

Hodgkins lymphoma - diagnosis

Answer 5

Excisional biopsy should be preformed which is removal of the entire lymph node

in advanced stages you can do a bone marrow biopsy to see if disease is stage 4

Question 6

Staging HL

Answer 6

Early-stage favorable (stage I-II without unfavorable factors)

Early stage unfavorable (Stage I-II with unfavorable factors)

Advanced stage (Stage III-IV)

Unfavorable factors include:
B symptoms, Elevated ESR, large mediastinal adenopathy, multiple invovled nodal regions

Question 7

Early stage disease treatment HL

Answer 7

ABVD chemotherapy regimen for 2-4 cycles

Question 8

Advanced stage treatment HL

Answer 8

6 cycles of ABVD or AAVD chemotherapy

Question 9

Relapsed disease treatment HL

Answer 9

Autologous stem cell rescue
- high dose of chemo followed by patients own stem cells as a rescue dose

Question 10

Maintenance therapy treatment HL

Answer 10

Brentuximab Vedotin

Question 11

ABVD chemo regimen HL

Answer 11

Doxorubicin
Bleomycin
Vinblastine
Dacarbazine
- can cause cardiotoxicity, pulmonary toxicity, myelosupression, peripheral neuropathy, nausea and vomiting

Question 12

AAVD chemo regimen HL

Answer 12

Doxorubicin
Brentuximab vendotin
Vinblastine
Dacarbazine

can cause cardiotoxicity, myelosupression, peripheral neuropathy, nausea and vomiting

Question 13

Non-hodgkins lymphoma

Answer 13

malignant B or T lymphocytes

Question 14

Non-hodgkins lymphoma Presentation

Answer 14

depends on tumor location
B symptoms are present in 40% of patients
primary CNS lymphoma
Extranodal involvement in 10-35% of patients with GI, skin, testes, and bone

Question 15

NHL - diagnosis

Answer 15

Excisional biopsy is best
bone marrow biopsy
lumbar puncture in patients at high risk or who have testicular involvement because the testes have similar barrier to the brain so if they lymphocytes are able to get into the testes theres a high probability they are in the brain as well

Question 16

Follicular Lymphoma - NHL

Answer 16

2nd most common NHL
indolent grade 1-2
median age 60
median survival: 8-10 years

treated if symptomatic or patient preference becuase studies have shown patients who get chemo with follicular lymphoma has the same survival rate as those who go untreated so no point unless symptoms or patient got that money money

Question 17

Richters transformation - NHL

Answer 17

follicular lymphoma that can transofrm into a more agressive NHL known as DLBCL

Question 18

DLBCL treatment - NHL

and relapse DLBCL

Answer 18

median age is 70
30-40% present with extranodal disease

6 cycles of R-Chop

Curative - CART therapy
Palliative - Brentuximab + Rituximab + Polatuzumab regimen
BITE - Epcoritamab
Glofitamab

Question 19

R-CHOP

Answer 19

for treatment of DLBCL
rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone

thrombocytopenia, infection, anemia, peripheral neuropathies

Question 20

NHL - rituximab and Hepatitis B

Answer 20

Hepatitis B surface ANTIGEN and Hepatitis B CORE ANTIBODY must be tested prior to anti-CD20 directed therapy

Question 21

CAR-T cell process

Answer 21

1. Take the patients cells through leukapheresis
2. activate the patients T cells outside of the body
3. allow T cells to grow and multiple outside the patient
4. chemotherapy to get rid of the patients T cells that are not activated in the body
5. T-cell infusion - add the active cells back into the patient so they will attack the cancer

Question 22

What to Car-T therapy target

Answer 22

CD19 on B cells

Question 23

Cytokine release syndrome (CRS) and Immune effector Cell associated neurotoxicity syndrome (ICANS)

Answer 23

cytokine release in the body and patients have fever, tachycardia, and hypotension
Treat CRS with Tocilizumab (does not affect the activation and action of the Car-Tcell or BiTe drugs)

ICANS - symptoms include tremor, confusion, altered mental status, seizures - patient should be asked to write and if handwritting is altered usually a sign
treat ICANS with corticosteroids (downside that this will effect the T cell treatment that patient just spend their damn life saving on but cannot use tocilizumab because it doesnt cross BBB)

If patient is presenting with both of these they must be treated with corticosteroids

Question 24

Multiple Myeloma Presentation (CRAB)

Answer 24

hyperCalcemia - calcium greater than 11.5

Renal dysfunction SCr greater than 2 or CrCl less than 40

Anemia Hgb less than 10 or 2 below normal level

Bone: one or more osteolytic lesions or pathologic fractures

Question 25

Multiple myeloma treatment overview

Answer 25

1. Induction therapy
2. Consolidation therapy
3. maintenance therapy

Question 26

Multiple Myeloma induction therapy

Answer 26

If patient is a canidate for transplant give the autologous stem cell transplant
after transplant give 3 drug regimen for 3 to 4 cycles

if not a candidate give 3 drug regimen

These agents are dexamethasone, lenalidomide, and bortezomib