HL Flashcards
Typical immunophenotype for CHL:
CD15+, CD30+, PAX-5+ (weak)
CD3-, CD20- (majority), CD45-, CD79a-
Typical immunophenotype for NLPHL:
CD20+, CD45+, CD79a+, BCL6+, PAX-5+
CD3-, CD15-, CD30-
Epstein-Barr encoding region in situ hybridization (EBER-ISH)
CHL:
NLPHL:
CHL: EBER+/-
NLPHL: EBER-
In general, a DLCO threshold of ____ % is acceptable for use of bleomycin.
≥60%
TRUE OR FALSE
Routine use of growth factors is not recommended with ABVD.
TRUE
Routine use of growth factors is not recommended with ABVD.
Neutropenia is not a factor for delay of treatment or reduction of dose intensity with ABVD
If there are multifocal (________________) skeletal FDG-PET/CT lesions, marrow may be assumed to be involved.
Three or more
In general, bone marrow biopsies are no longer indicated
Unfavorable Risk Factors for Stage I–II Hodgkin Lymphoma
GHSG (German Hodgkin Study Group)
- ESR >50 if A; >30 if B
- MMR >0.33
- # Nodal sites: >2
- Any E lesion
Unfavorable Risk Factors for Stage I–II Hodgkin Lymphoma
EORTC (European Organization for Research and Treatment of Cancer)
- Age ≥50
- ESR >50 if A; >30 if B
- MTR >0.35
- # Nodal sites: >3
Unfavorable Risk Factors for Stage I–II Hodgkin Lymphoma
NCCN
- ESR ≥50 or any B symptoms
- MMR >0.33
- # Nodal sites: >3
- Bulky >10 cm
International Prognostic Score (IPS)
1 point per factor (advanced disease)
- Albumin <4 g/dL
- Hemoglobin <10.5 g/dL
- Male
- Age ≥45 years
- Stage IV disease
- Leukocytosis (white blood cell count ≥15,000/mm3)
- Lymphocytopenia (lymphocyte count <8% of white blood cell count, and/or lymphocyte count <600/mm3)
Primary treatment for Stage IA/IIA Favorable (Non-bulky) CHL Initial
ABVD x 2 cycles (category 1)
Restage with FDGPET/ CT
Primary treatment for Stage IA/IIA Favorable (Non-bulky) CHL post 1st interim PET CT
Chemotherapy alone
* 1-2: ABVD x 4 cycles
* 3: ABVD x 2 cycles + AVD x 4 cycles
Combined modality therapy
* 1-3: ABVD x 2 cycles + ISRT
* 1-2: ABVD x 3 cycles + ISRT
* 3: ABVD x 4 cycles + ISRT
* 4-5: ABVD x 4 cycles + ISRT
Consider PFTs after ____ cycles of ABVD.
4 cycles
Primary treatment for I-II Unfavorable (B-symptoms or bulky mediastinal disease or >10 cm adenopathy)
Chemotherapy alone’
* 1-3: ABVD x 2 cycles + AVD x 4 cycles
* 4-5: ABVD x 2 cycles + escalated BEACOPP x 4 cycles
Combined modality therapy
* 1-3: ABVD x 4 cycles + ISRT
* 4-5: ABVD x 2 cycles + escalated BEACOPP x 2 cycles + ISRT
Primary treatment for Stage III–IV
ABVD
* 1-3: ABVD x 2 cycles + AVD x 4 cycles
* 4-5: ABVD x 2 cycles + escalated BEACOPP x 4 cycles OR ABVD x 2 cycles + escalated BEACOPP x 4 cycles + ISRT
BV-AVD
* 1-5: Brentuximab vedotin + AVD x 6 cycles
BrECADD
* 1-3: BrECADD x 4 cycles OR BrECADD x 4 cycles + ISRT
* 4-5: BrECADD x 6 cycles OR BrECADD x 6 cycles + ISRT
Nivolumab +AVD
* Nivolumab + AVD x 6 cycles
Regimen contraindicated in those with neuropathy
Brentuximab vedotin (BV) + AVD
Clinical Trial for BV + AVD
ECHELON-1
Clinical Trial for Nivolumab
SWOG S1826
Characteristics of CHL in older patients
- B symptoms
- Poor performance status
- Mixed cellularity histologic subtype
- EBV+ disease
- Medical comorbidities are more frequent
Regimens for Adults Age >60 Years or Adults With Poor Performance Status or Substantial Comorbidities
Stage I–II Favorable Disease
* A(B)VD (2 cycles) ± AVD (2 cycles) + ISRT (preferred)
* CHOP (4 cycles) + ISRT
Stage I–II Unfavorable or Stage III–IV Disease
* * A(B)VD (2 cycles) followed by AVD (4 cycles), if FDG-PET scan is negative after 2 cycles of ABVD.
* BV followed by AVD, conditionally followed by BV in patients with CR or PR and no neuropathy
* CHOP (6 cycles) ± ISRT
Bleomycin should be used with caution as it may not be tolerated in patients >60 years, and it should not be used beyond 2 cycles.
Regimens for: Patients with Low EF
BV-DTIC (dacarbazine)
Add dexrazoxane to ABVD or CHOP, with close cardiology follow-up
In times of vinblastine shortage, consider capping the dose at ____ mg to avoid wasting a vial.
10 mg
Consideration can also be made for substituting vinblastine with vincristine 1 mg.
In times of both vinblastine and dacarbazine shortage, consideration can be made for substituting ABVD with CHOP temporarily.
Radiologic staging during pregnancy
Single view (posteroanterior [PA]) chest X-ray with abdominal shielding and an abdominal ultrasound or MRI without gadolinium
FDG-PET and CT imaging should be avoided.
ABVD can be safely administered in the_________________ trimesters with excellent maternal and fetal outcomes.
Second and third trimesters
TREATMENT APPROACH BY GESTATIONAL AGE
First Trimester
- If asymptomatic or minimally symptomatic: delay treatment with close observation until second or third trimester
- If severe symptoms or organ compromise: consider referral to center with expertise, consider pregnancy termination and urgent treatment, or single-agent vinblastine followed by ABVD after end of first trimester
TREATMENT APPROACH BY GESTATIONAL AGE
Second or Third Trimester
- If asymptomatic or minimally symptomatic: delay treatment with close observation until after delivery
- If severe symptoms or organ compromise: treat with ABVD; work with high-risk obstetrics to avoid delivery while at nadir
NLPHL
Characteristics of high risk for initial or later transformation to large cell lymphoma
- Bulky disease
- Subdiaphragmatic disease
- Splenic involvement
NLPHL
Primary treatment: Stage IA, IIA (Non-bulky)
- ISRT (preferred or stage IA orcontiguous stage IIA)
- Observe (stage IA patients with a completely
excised solitary lymph node.)
NLPHL
Primary treatment: Stage IB, IIB or Stage IA (Bulky)/Stage IIA (Bulky or noncontiguous)
Chemotherapy + Rituximab + ISRT
* ABVD/Rituximab + ISRT
* CHOP/Rituximab + ISRT
* CVP/Rituximab + ISRT
Rituximab
NLPHL
Primary treatment: Stage III–IV
- Observe, if asymptomatic
- Chemotherapy + Rituximab + ISRT
- Rituximab
- Local RT (palliation of locally symptomatic disease)
Complete response (CR) should be documented including reversion of FDG-PET/CT to “negative” within ____ months following completion of therapy.
3 months
Patients with 2 or more of the following risk factors are considered to be at high risk for relapse:
- Remission duration <1 year
- Extranodal involvement
- FDG-PET–positive response at time of transplant
- B symptoms, and/or
- > 1 second-line/subsequent therapy regimen
