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Rad Onc Oral Boards > Lymphoma > Flashcards

Lymphoma Flashcards

1
Q

ABVD chemo

A
  • Adriamycin 25 (Doxorubicin) – heart failure
  • Bleomycin 10 – lung fibrosis
  • Vinblastine 6 – neuropathy, hair loss
  • Dacarbazine 375 – sterility, n/v, immune suppres
  • one cycle is 4 wks, doses q 2 wks
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2
Q

BEACOPP

A 
BEACOPP
Bleomycin
Etoposide
Adriamycin (Doxorubicin)
Cyclophosphamide
Oncovin (Vincristine)
Procarbazine
Prednisone

Brentuximab: anti-CD30 antibody

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3
Q

Reed Sternberg Cell

A

HL:
Reed Sternberg cell – binucleate
CD15+, CD30+
CD20/45-

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4
Q

HL WHO classification

A 
WHO classification:
1) NLPHD – CD45+, CD20+
2) Classic – CD 15+, CD30+
    nodular sclerosing
    mixed cellularity
lymphocyte rich - good

lymphocyte depleted – rare, bad, elderly, HIV
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5
Q

Deauville PET Criteria:

A 
Deauville PET Criteria:
1 – no uptake > background
2 - uptake < mediastinum
      1 or 2 NEGATIVE
3 – uptake < liver
     3 NEG OR POS
4- uptake mod inc compared to liver
5 – uptake markedly inc compared to liver
     4 or 5 POSITIVE
X – new areas of uptake not related to lymphoma
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6
Q

HL H/P

A

H&P:

  • B sx: fevers >38C or 100.5, drenching nightsweats, wgt loss 10%/6mo
  • performance status
  • pruritus

PE – nodal stations, spleen, liver, Waldeyers ring

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7
Q

HL Workup

A

Labs: CBC, CMP, LFTs, ESR, LDH, albumin, pregnancy test, HIV

Imaging: CT n/c/a/p and PET/CT
Splenomegally if >13 cm (on CT)

Bx: excisional preferred (core ok, not FNA) with IHC eval

BM bx: if unexplained cytopenias and PET negative

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8
Q

HL other things to do before treatment

A

Other:

  • fertility eval/banking (2 Gy permanent, 0.5 Gy transient for sperm, 8-10 Gy perm for oocytes)
  • dental eval if H&N
  • PFTs pre/pos
  • MUGA before ABVD
  • vaccines if splenic RT
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9
Q

Ann Arbor system:

A

Ann Arbor system:

I: 1 region or extra-lymphatic site
(cervical + SCV = 1 site)

II: 2 or more regions on same side of diaphragm

B = B symptoms only in HL (HL is either A or B, NHL only uses Bulky and E)
E = extralymphatic ie IIIE
Bulky for NHL:
   >10 cm or
   >1/3 intra-  
     thoracic 
     diameter at  
     T5/T6
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10
Q

HL Management Stage I/II Favorable

A

Stage I/II Favorable: ABVD x 2 ->PET-CT > for D1-3, ISRT 20 Gy to all initially involved sites (Pre-chemo anatomically modified)

If D4 after 2 c, consider ABVD x 2 c (4 total), then 30 Gy

 If D5, go to biopsy > if neg, RT.  If pos,  
 refractory pathway
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11
Q

HL Unfavorable criteria

A 
Unfavorable: 3 BEEs
3+ nodal sites
Bulky disease
ESR (>50 w/ A, >30 w/ B Sx)
Extranodal disease
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12
Q

HL Management Stage I/II Unfavorable

A

Stage I/II Unfavorable: ABVD x 2 c > PET/CT > for D1-3 > ABVD x 2 c (4 total) + ISRT 30 Gy (36 Gy in PR)

if D4, escBEACOPP x 2 > PET/CT > ISRT 30 Gy (36 Gy in PR)

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13
Q

HL Management Stage III – IV

A

Advanced stage III/IV
ABVD x 2 -> PET/CT, if D1-3, AVD x 4 (6 cycles total)
-can escalate to BEACOPP if poor response

– RT to originally bulky (30 Gy) or PET+ residual sites (36 Gy) – otherwise no RT
(also no RT needed if CR to BEACOPP)

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14
Q

GHSG criteria

A

GHSG criteria of 1-2 areas*, no extranodal lesions, MMR<0.33, ESR < 50 no B sx, ESR < 30 w B sx

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15
Q

HL Stage II-Iv OS if CR/PR to chemo

A

CR to chemo:
5 yr OS = 89%
5 yr RFS = 85%
PR to chemo: OS 87%, EFS 80%

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16
Q

HL simulation

A

Supine, hyper-extend neck, PET/CT simulation with contrast, fuse pre-chemo PET/CT. Oral contrast for abd/pelvis. Custom immobilization.

4D and Breathold often useful

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17
Q

HL volumes

A

CTV–pre-chemo volume excluding uninvolved normals like lung, kidneys, muscles + 1.5 margin (pre-chemo GTV_CT and GTV_PET less normal structures previously uninvolved)
4DCT and ITV – if treating mediastinum
If RT alone, use 3-5 cm margins
PTV = CTV + 1 cm (for HN, 3-5 mm)

If < CR (dose 30 Gy + boost to 36 Gy):
CTV initial = pre-CTX tumor volume + 1.5 cm cropped
GTVboost = post-CTX GTV
PTVboost = GTV (or ITV) boost + 5 mm

REMEMBER IF TREATING BOTH SIDES OF DIAPHRAGM, NEED TO STAGE TX WITH 2 WEEK BREAK IN BETWEEN

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18
Q

HL constraints

A

ALARA!

LE/Groin
Femoral Head <25
To Prevent SCFE (slipped capital femoral epiphysis)

Neck
Thyroid V25 <63.5%

Chest:
Breast Mean < 4 Gy

Heart mean <15 Gy and ALARA (<5 Gy ideal)

Lungs mean < 15 Gy

Hotspot < 110%

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19
Q

HL DFS/OS

A

DFS/OS
Early favorable – 90/95
Early unfavorable – 80/85
Advanced – 65/75

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20
Q

HL subacute Side effects

A 
SubAcute:
Lhermites – 15%
Pericarditis
Pneumonitis
Treat with slow prednisone taper over 2-3 mo, 1mg/kg
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21
Q

HL Late Side effects

A

Late:

  • CAD
  • Hypothyroid – annual TSH, neck RT
  • Gastric Ulcer
  • Pulmonary Toxicity
  • Decreased Immunity (spleen)
  • Infertility
  • 2nd Malignancy
    • leukemia (AML) RR 22x
    • solid: breast, thyroid, lung (RR 2)
    • 0.5%/year
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22
Q

HL followup

A

Follow-up:

  • H&P, CBC, ESR q3mo (year 1-2), q6mo (year 2-3), annually after
  • CT c/a/p at 6, 12, 24 mo
  • do NOT routinely do PET
  • TSH annual
  • baseilne echo, stress test at 10 yrs
  • cartoid ultrasound if neck tx
  • Mammogram at 8yrs or age 40 (MRI if XRT b/t 10-30 yrs)
  • Survivorship clinic
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23
Q 
NHL translocations
•Burkitt’s 
•Mantle 
•MALT 
•Follicular
A 
Translocations
•Burkitt’s 8:14
•Mantle 11:14
•MALT 11:18
•Follicular 14:18
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24
Q

NLPHL

A

NLPHL: CD15/30-, CD 20+: 30-36 Gy no chemo

CD 20+!!
No RS cells
Most w early stage disease

I-IIA: ISRT alone 30 Gy (no chemo!)
-10 yr OS > 90%
-10 yr RFS = 75
If doing RT alone, want to use larger margins (4-5 cm)!

B symptoms or bulky (IB-IIB): ABVD + Rituximab + ISRT-> Rituximab because of CD20+

Adv: ABVD + Rituximab + palliative RT

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25
Q

RCHOP

A

R-CHOP
Rituxan: monocolonal antibody to CD 20; 325 mg/m2

CHOP q3 wks
Cyclophos 750mm2
Adriamycin 50mm2
Vincristine 1.4 mg/m2
Prednisone 100 mg day 1 – 5
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26
Q

Hyper CVAD

A

HyperCVAD:
Two alternating courses:
Course 1: cyclo, vincristine, doxo, dexamethasone
Course 2: MTX, cytarabine

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27
Q

NHL low grade

A 
Low Grade:
•Follicular, Grade 1-2 (note 3%/yr risk of DLBCL transformation)
•MALT
•CLL/SLL
•Mycosis Fungoides
28
Q

High Grade NHL types:

A 
High Grade:
•DLBCL
•Follicular 3
•Mantle
•Burkitts
29
Q

DLBCL – IPI

A 
DLBCL -- IPI (NEJM 1993): APLES
Age > 60
PS ECOG ≥2
LDH inc (>250 u/L)
Extranodal site 2 or more
Stage III, IV
IPI with R-CHEMO
	5y OS
0-1	 85%
2-3	60
4-5	35
30
Q

FL – FLIPI:

A 
FL -- FLIPI: 
HASSL
Hgb <12
Age > 60
Stage III, IV
Sites: # nodal >4
LDH increased
0-1 = low; OS5 ~90%
2    = int; OS5 80%
3+  = high; OS5 50%

-10% to 15% undergo “Richter’s transformation” from SLL/CLL to DLBCL. MS 5-8 month

31
Q

NHL H/P

A

History: attention to duration, onset, B symptoms
RFs immunosuppression, HIV status. PS. Waxing and waning nodes suggest indolent/low grade.

Physical: compehensive nodal exam, including all LN sites, waldeyer’s ring, organomegaly, NPL prn

32
Q

NHL workup

A

Labs:
CBC, CMP, LFT, ESR, alk phos, LDH, albumin, B2 micro
Hep B (surface Ag and core Ab), C, HIV
Pregnancy test

Imaging: contrasted PET-CT

Biopsy:
Excisional bx or core bx to architecture and full histology and immunophenotyping.
Bone marrow – for follicular stage I-II

CSF if: 
(•Paranasal sinus)
(•Epidural)
(•Bone marrow with large cell lymphoma)
•Testicular
•HIV lymphoma
•Double hit lymphoma
•4-6 of APLS (IPI), any extranodal, (ad)renal involvement

Other:
Karyotype or FISH for DLBCL: MYC, BCL2, BCL6

Peripheral blood for:
CLL: monoclonal B-cells > 5 x 109 per liter
SLL: LAD or splenomeg w peripheral B-cells < 5 x 109 per liter

Fertility counseling!

33
Q

Low grade NHL man Stage I-II

A

Stage I-II (MS 10-15 yrs, DFS10 50%, OS10 70%)
Stage I/continguous stage II: ISRT alone, 24 Gy (30 gy in bulky)
Stage II/bulky: chemo (R-CHOP, RCVP)->ISRT 30 Gy

34
Q

Low grade NHL man Stage III-IV

A

¬¬¬Stage III-IV (MS 8-9 yrs)

  • Obs if asymptomatic
  • If symptomatic, bulky dz, cytopenias, or steady progression:
    • Chemo (RCHOP or BR, bendamustine-rituxan), or
    • Palliative RT (boom-boom 2x2 or 24/12)
  • not curable

Relapsed: RadioImmunotherapy
- Must biopsy relapsed follicular

35
Q

DLBCL man Stage I-II

A

Stage I-II
Non-bulky: R-CHOP x 3 -> PET -> RT or R-CHOP x 6 (+/- RT)

Bulky (>7.5 cm): R-CHOP x 6 +/- RT

(“High risk:” IPI>1, bulky, double/triple hit, double expression, non-germinal center type)

(30 Gy CR, 36 Gy PR, 45 Gy if bulky)

-if PR, repeat PET/CT after RT. If positive, bx. If positive for tumor, tx as refractory

36
Q

DLBCL man Stage III-IV

A

Stage III-IV

  • RCHOP x 6 alone
  • PET/CT after 2-4 cycles:
    • if responding continue to 6 cycles
    • if no response or progressive, biopsy then tx as per relapsed/refractory
  • RT for limited stage III, bulky disease (30 Gy), persistent, PET positive disease (36 Gy)

Relapsed/refractory (similar to HL)

1) 2nd line chemo
2) high dose chemo (R-ICE) with stem cell transplant
3) ISRT for bulky sites/consolidation (40-55 Gy)

** if using RT without chemo, go to higher doses 45 Gy

CSF treatment: 4-8 cycles IT MTX for testicular, paranasal sinus, epidural, BM involvement

37
Q

MALT

mucosa associated lymphoid tissue trans

A

-Endoscopic bx and H. pylori testing; look for t(11:18)

t(11:18) = poor Abx reponse

38
Q

Gastric MALT man

A

Gastric –

  • H. pylori positive: antibiotics  repeat endoscopy q3 mo, if still+ after 9-12 months, then RT
  • H. pylori positive and t(11:18): antibiotics, endoscopy at 3 mo, if positive, then RT
  • H. pylori negative: RT (30/1.5)
  • 3 drug regimen x 2 wks
  • PPI, amox/metronidazole, clarithromycin
  • LC 95% with 30/1.5 Gy
  • for stage III-IV, tx for sx, bulky dz, steady progression
39
Q

Gastric technique

A

Gastric: 30/1.5 IFRT to entire stomach

  • Arms up, vac lock
  • Fasting CT (4 hr) with oral contrast, 4D CT
  • AP-PA vs 4 fields vs VMAT to empty stomach + gastroduodenal junction + 2 cm (includes perigastric nodes)
  • Give PPI during RT, consider Zofran
  • Daily CBCT

Gastric follow-up:
Endoscopy at 3 months, then every 3-6 months until resolution, then annually

40
Q

Orbital technique

A 
Orbital: treat entire orbit (for low grade can consider partial orbit)
-Ant oblique or en face electrons
- consider hanging lens block
Lacrimal: 
MALT – can treated just gland (24/1.8)
DLBCL – treat whole orbit (30.6 Gy)

Lacrimal gland: 50% < 35 Gy

41
Q

DLBCL bone (IE)

A

R-CHOP x 6 -> ISRT TO 45 Gy (pre-chemo + 0.5-1 cm margin for PTV)

42
Q

DLBCL testicle

A

Elderly gentleman
Get MRI Brain and LP

Orchiectomy -> RCHOP x 6 w/ high dose IT MTX -> RT 30 Gy to contralateral testicle + scrotum

Follow-up: Testosterone

43
Q

Primary mediastinal B-cell lymphoma

A

Young woman CD15-, CD20/30+, compressive symptoms

PET/CT w/ contrast

Preferred: Dose adjusted EPOCH-R x 6 c (NEJM 2013) -> PET/CT, if D1-3, FNT
-> if D4-5, consider bx, ISRT 30 Gy

2.. R-CHOP x 6 + ISRT (30 Gy) for CR

44
Q

Mantle cell

EGD/Cscope to r/o lymphomatous polyposis

A

Stage I/II (rare): IFRT alone (30 Gy)

Stage IIX/III/IV: (HyperCVAD alternating with HD-MTX + ARA-C) + Rituxan → HD CTX + ASCR

Poor Prognosis

45
Q

Nasal NK T cell

A

Stage IE/IIE:
Concurrent RT 50 Gy + DeVIC x3c
(Dex, etoposide, ifos, carbo)

46
Q

MGUS:

A

MGUS:
•serum or urine M protein without lesions
•no end-organ damage,
• < 10% plasma cells in BM

47
Q

Plasmacytoma criteria:

A

Plasmacytoma criteria:
•one lesion +/- M protein
•< 10% plasma cells in BM
•No end ogan damange

48
Q

Smoldering/Active myeloma

ie rule out MM if have Solitary plasma

A

Smoldering myeloma
•M protein in serum
•>10% plasma cells in BM
•No end organ damage

Active meyloma (CRAB)
•Smoldering + end organ
-calcium (>11.5)
-renal insufficiency (Cr>2)
-anemia (Hb<10)
-bone (lytic lesions)
49
Q

Solitary plasmacytoma (10%) man

A

40 Gy with 0.5 - 2cm margin

there is a range but just say 40 Gy, in 2 Gy fractions

50
Q

Solitary plasmacytoma (10%) outcome

A

70% w bone SP progress to MM in 10 yrs
50% OS after tx

30% of extramed SP progress to MM in 10 yrs
70% OS

LC 90%

Prognostic = BLAC (lesions look black on xray)
•Beta2micro
•LDH
•Albumin
•CRP
51
Q

Solitary plasmacytoma tech

A

Bone only:
Gross disease + 2 cm margin

Extramedullary:
Gross disease + 2 cm margin
- can include primary draining LN for H&N

52
Q

`MM/solitary workup

A

Labs:

  • CBC, CMP, LDH
  • Ca++, albumin
  • beta-2 microglobulin
  • serum quantitative immunoglobulins (IgA/IgG/ IgM), SPEP, SIFE
  • UPEP, UIFE, 24 hr urine for Bence-Jones protein
  • M-Protein
  • serum free light chain assay (FLC)

Imaging: skeletal survey
-non-contrast CT or MRI can be useful if sx but no lesion on skeletal survey

  • Bx of lesion if solitary
  • Unilateral BM biopsy w cytogenetics and FISH
  • Bone densitometry if considering bisphosphonate
53
Q

Chloroma (aka myeloid sarcoma, granulocytic sarcoma) man, Type of luekemia

A

24 Gy in 12 fractions

54
Q

ALL man

A

CNS1: negative CNS
CNS 2: + blasts with <5 WBC / ul
CNS 3: + blasts with ≥ 5 WBC / ul or symptomatic CNS disease

Low risk: 
Age 1-10
Initial WBC < 50,000
Rapid early responder, M1 (<5% blasts) on day 15
Negative MRD (<0.1%) on day 29
CNS 1
No testicular disease at diagnosis

T cell ALL:
Intermediate and high risk receive CNS prophylaxis
CNS 1 and 2: 12 Gy/1.5
CNS 3: 18 Gy

B cell ALL

  • low risk CNS3: 18 Gy
  • int/high risk as above
55
Q

Cut Lymph types

A 
T-cell (75%)
     Mycosis fungoides (70%) 
      (indolent)
     Sezary syndrome 
      (aggressive)
     CD 30 positive LPD 
    (30%, includes primary  
    cutaneous anaplastic  
    large cell)

B-cell (follicle, dlbcl,follicular)

56
Q

Cut Lymph MF stage

A 
MF:
T1: patch/plaque <10% BSA
T2: patch/plaque ≥ 10% BSA
T3: cutaneous tumors (≥ 1 cm)
T4: generalized erythroderma ≥ 80% BSA
57
Q

Cut Lymph Workup

A 
H&P
Full skin exam
Labs/CBC
Biopsy
Blood smear for Sezary cells if T cell
Pregnancy test
PET/CT for ≥ T2
BM biopsy if DLBCL/Tcell/MZBcell
Biopsy of any suspicious LN
CT CAP, PET 
Skin lesion -> exc biopsy
Check peripheral smear for Sesary cells

MF/SS - “pantareer’s mircroabscess on path”

58
Q

Cut Lymph outcomes

A

T1 with local RT:
>90% CR rate
50% overall relapse rate

MS:
T1 = same as general population
T2 = 10 yrs
T3-4 = 5 yrs
N+ or M+ = 1 yr

Overall CR rate with TSEBT >80% even for advanced T stage, but very high risk of relapse (palliation)

Patients with T2+ and CR to TSEBT may benefit from adjuvant therapy (ie PUVA, photophoresis, or mechlorethamine)

TSEBT toxicity:
Fatigue, erythema, edema, loss of nails, alopecia, hypohydrosis,

Can repeat TSEBT after 6 – 12 months if needed to 20 – 24 Gy

59
Q

Primary cutaneous anaplastic large cell:

A

Primary cutaneous anaplastic large cell:

RT alone to 40 Gy

60
Q

Mycosis fungoides:

T1:

A

Mycosis fungoides:
T1:
Skin directed therapies (UV, topical)
If unilesional, can treat with definitive RT alone to 24 Gy + 2 cm margin

61
Q

Mycosis fungoides:

T2-4

A

T2 – T4
TSEBT
Low-dose 12 Gy in 6 fractions, re-eval in 8-12 weeks, additional 12 Gy cycles as needed

62
Q

B-cell cutaneous lymphomas:

A

B-cell cutaneous lymphomas:
For follicular, marginal zone: RT alone 24 Gy (definitive) or 2 Gy x 2 Gy (“palliative”- most common)
DLBCL leg type: RCHOP + ISRT to 36 Gy or ISRT to 40 Gy if RT alone

63
Q

total skin tech

A

Treat the patient with a rotating platform technique
to a total dose of 12 Gy using 6MeV electrons and a beam spoiler (4 MeV)
Superior and inferior beams +/- 20 degrees from midline
Internal eye shields daily
Toe/finger nail shields after 9 Gy
Boost shadowed areas with en-face beam

Total skin (FML)
Treat 4 days per week
Stanford technique: 6 field therapy: AP/LPO/RPO on day 1 and PA/LAO/RAO on day 2, alternating
1 week break after 18 Gy
Internal eye shields daily
Toe/finger nail shields after 9 Gy
TLDs placed once prior to break to plan boost
Typical boost regions: perineum, inguinal, axilla, IMF, intergluteal, vertex, soles*
Boost 1 Gy daily starting with 2nd half of radiation
*Soles only boosted to 14 Gy
Typically 6 MEV electron with beam spoiler to make 4 MEV electron
Superior and inferior beams +/- 20 degrees from midline
80% IDL ≥ 4 mm from surface
20% IDL < 20 mm from surface
<10% heterogeneity in air
<15% of dose to eyes

64
Q

Cutaneous outcomes based on type

A

Outcomes FCL> MZL > leg type

65
Q

Follicular translocation and determinants of Grade

A

t(14:18)

# of centroblasts:
G1: <5
G2: 6-15
G3: >15
3A: centrocytes present
3B: all centroblasts

Rad Onc Oral Boards (11 decks)

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