Lymphoma Flashcards
Ann Arbor system:
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
HL Management Stage I/II Favorable
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
HL Unfavorable criteria
Unfavorable: 3 BEEs
3+ nodal sites
Bulky disease
ESR (>50 w/ A, >30 w/ B Sx)
Extranodal disease
HL Management Stage I/II Unfavorable
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)
HL Management Stage III – IV
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)
GHSG criteria
GHSG criteria of 1-2 areas*, no extranodal lesions, MMR<0.33, ESR < 50 no B sx, ESR < 30 w B sx
HL constraints
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%
NLPHL
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
DLBCL – IPI
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
FL – FLIPI:
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
Low grade NHL man Stage I-II
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
Low grade NHL man Stage III-IV
¬¬¬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
DLBCL man Stage I-II
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
DLBCL man Stage III-IV
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
DLBCL bone (IE)
R-CHOP x 6 -> ISRT TO 45 Gy (pre-chemo + 0.5-1 cm margin for PTV)
DLBCL testicle
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
Primary mediastinal B-cell lymphoma
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
Mycosis fungoides:
T1:
Mycosis fungoides:
T1:
Skin directed therapies (UV, topical)
If unilesional, can treat with definitive RT alone to 24 Gy + 2 cm margin
Mycosis fungoides:
T2-4
T2 – T4
TSEBT
Low-dose 12 Gy in 6 fractions, re-eval in 8-12 weeks, additional 12 Gy cycles as needed
