Heme Malignancies Flashcards
Risk Factors for Heme Malignancies
age > 65 exposure to environmental toxins family history of blood disorders smoking white race (except MM) exposure to high dose RT inherited genetic syndromes male sex previous chemotherapies autoimmune diseases
BMI and weight in relation to Heme Malignancies
WHO and AICR completed a meta-analysis and found that a higher BMI in adulthood and in early adulthood is associated with an increased risk for:
- NHL
- HD
- AML
- CML
- CLL
- MM
Leukemias
caused by increased production of white blood cells. Overproduction impairs the body's ability to fight infection as well as make RBCs and platelets 4 types: ALL- acute lymphoblastic leukemia AML- Acute Myeloid Leukemia CML- chronic Myeloid Leukemia CLL- Chronic Lymphocytic Leukemia
S/e: joint pain, decreased appetite, enlarged lymph nodes, fatigue, swears. shortness of breath, signs of bleeding, abdominal swelling, weight loss, anemia, splenomegaly
Lymphoma
begins in lymphatic system- because it’s bodywide, can originate in multiple sites
2 types:
HD- Hodgkin’s Disease/ Lymphoma (rare)
NHL- Non-Hodgkin Lymphoma, 60 subtypes, most common is DLBCL which is fast growing and follicular lymphoma which is slow growing
Plasma Cell Neoplasms
plasma cells develop from B-cells in the bone marrow in response to infection
Types:
MGUS- monoclonal gammopathy of undetermined significance (precancerous)
Plasmacytomas
MM- multiple myeloma (90% of plasma cell neoplasms) M-proteins build up in the body and cause damage
Amyloidosis- rare, amyloid proteins builds up and forms deposits in vital organs
Heme cancers- Diagnosis
physical exam, bone marrow aspirate and biopsy, imaging, and serum blood analysis - sometimes a blood smear is enough, sometimes it’s more involved
CT, MRI and PET used to determine metastasis
some other tests run occasionally, ex. colonoscopy for mantle cell lymphoma or EGD from mucosa associated lymphoid tissue lymphoma
Classification and staging
TNM is not used
leukemia is staged based on blood counts and the accumulation of leukemia cells in other organs
HL/ NHL uses Lugano Classification System- looks at number and location of cancerous nodes, whether they’re on one or both sides of the diaphragm, and if the disease has metastisized outside of the lymph system
Acute Myeloid Leukemia (AML) treatments
chemo is gold standard , but some targeted therapies
In 2 phases: induction and consolidation (post remission)
induction of remission is evaluated using bone marrow aspirate 2-3 weeks after therapy intitiation
Almost always reoccurs without consolidation therapy. 2nd round induction timing is controversial. If 2 consolidation tx don’t work, it’s considered induction failure.
Next line for refractory or relapse AML is salvage chemo, clinical trial or HCT
Consolidation is chemo, auto HCT or Allo HCT. HCT is the best tx for relapsed AML and is the only cure.
Acute Lymphoblastic leukemia (ALL) treatments
also includes different stages, typically takes place over years.
includes induction, consolidation and long-term maintenance therapies.
Goal of induction is remission
Many of the same chemos are used for induction are used for consolidation
HCT can be used in high risk patients, RT is not used unless it’s spread to the CNS
Chronic Myeloid Leukemia (CML) treatment
depends on disease phase- chronic, accelerated or blastic
Chronic phase: standard tx is TKI
If progresses to accelerated phase, goal is to prevent it from reaching blastic phase. Clinical trial is the standard tx for accelerated CML
Blastic phase: needs Allo HCT. Induction chemo used is similar to the chemo for pre-transplant AML with the addition of a TKI
Chronic Lymphoblastic Leukemia
Many patients live a long time, but difficult to cure
immediate tx is not always indicated- various tx options include chemo, monoclonal antibodies, and targeted therapies. If high risk, HCT may be suggested
localized RT could be used on swollen spleen or lymph nodes
If present in very high amounts, leukapheresis can be used before chemo to increase effectiveness.
If unresponsive or relapsed, targeted therapies and monoclonal antibodies are common, alone or in combination. Could also use HCT
Multiple Myeloma (MM) treatment
standard systemic first line treatment is alkylating agents, immunomodulatory drugs and proteasome inhibitors (Bortezomib (Velcade)) + steroids
RT used for symptom management like bone pain
pts with good response to chemo after 4-6 cycles then move on to Auto HCT, high dose Melphalan is currently the most widely used conditioning regimen for auto HCT in pts with MM
Non- Hodgkin Lymphoma (NHL treatment)
typically chemo, targeted therapy, immunotherapy, or RT, alone or in combo. IT chemo also used to treat lymphoma that’s reached the CNS.
RT can be primary tx in early stages, tumors respond very well- typically tumors or large nodes. Can also be palliative RT.
within immuno, monoclonal antibodies and CAR-T (chimeric antigen receptor therapy) are used.
Consolidation with an auto or allo HCT withor without RT can be used to tx refractory lymphoma
Hodgkin Lymphoma Treatment
similar to NHL, but different drug combos. Chemo RT and surgery are the standard therapies.
Early favorable HL is treated with combo chemo, combo chemoRT or RT alone to the affected areas of mantle
Early unfavorable HL may include combo chemo or combo chemoRT
advanced HL is tx with combo chemo.
HCT used for progressive or relapsed lymphoma
Indolent Lymphoma therapy
slow progressing subtype of NHL and does not need tx if patients are asymptomatic. “Watchful Waiting”
Chimeric Antigen Receptor T-cell (CAR-T) therapy
T-cells are collected from the patient, sent to a lab and altered to have specific receptors designed to seek out lymphoma cells once replaced in a patient’s blood- emerging treatment.
Displayed significant success in treating large B-cell lymphoma and B-cell precursor ALL.
Tocicities include cytokine release syndome (fevers, HTN, hypoxia, end-organ dysfunction, cytopenias, coagulopathy, and hemophagocytic lymphohistiocytosis) and CAR-T related neurotoxicity
Heme onc- Nutrition Assesment
prevalence of malnutrition is 27-50.4%
Tumor related malnutrition is possible with some lymphomas and with amyloidosis.
Most of NIS happen with treatment or the patient’s physiological reaction to disease.
Undernutrition in these patients increases risk for infections
Malnutrition screening
early screening is key plus ongoing routine follow up
In one study, MST showed positive score for 37.8% of patients, total rate of malnutrition is ~25%.
PG-SGA is also effective- studies of this showed that pts with high risk acute leukemias had higher scores. Worst was AML (typically uses cytarabine which is super tox plus pancytopenia)
weight loss of >10% pre-HCT has been shown to negatively effect outcomes
Chemo induced N/V (AML tx)
Very common side effect of AML because of particular chemos- 7 +3 chemo (7 days cytarabine + 3 days daunorubicin) is usually given inpatient
These patients are usually younger which also increases risk of nausea
Bone Health
nutrition assesmment and intervention for patients with MM should include a focus on bone health- up to 80% of patients will have osteolytic bone lesions at dx and 60% will develop pathologic fractures.
Over 75% of patients have osteopenia and osteoporosis.
MNT- well balanced diet with sources of calcium and vitamin D. Should supplement if dietary sources are inadequate, especially if patients are receiving biphosphate therapy.
men 50-70 yo: 1000 mg Ca daily
men 71+ and women 51+ need 1200 mg
adults <50 yo: 400-800 IU Vit D
adults >50 yo: 800- 1000 IU
Vitamin D
Low Vit D levels are associated with poorer prognosis, higher rates of relapse, longer LOS and decreased rates of remission for patients with heme malignancies like HL, MDS, NHL, MM and leukemia
No large scale studies looking into if Vit D supps actually improves outcomes yet
RDNs should advocate for evaluation of vit D status in patients with heme malignancies
Renal disease
acute and chronic renal insufficiencies common in patients with MM. AKI is common because of the protein build ups, volume depletion, hyper calcemia, or TLS. So common, it’s one of the componenets used to diagnose MM.
these patients should be monitored frequently
MNT: limit sodium to <2300 mg/d eat enough protein but not too much choose heart healthy foods restrict phos and potassium if elevated At risk for deficiencies: B6, K, selenium, zinc, and C
Hyperglycemia
can result from pre-existing DM but also steroids.
Dexamethasone and prednisone are patrt of tx for lymphoma, leukemia, and MM
Heme onc- Hypertriglyceridemia
Rare but can occur in patients with ALL who receive a peds regimen that includes PEG-L-Asparaginase
