Lymphoma Flashcards
Types of Lymphoma
Hodgkin’s lymphoma
Non-Hodgkin’s Lymphoma
- Diffuse large B-cell lymphoma
- follicular lymphoma
NHL grading
indolent
aggressive
very aggressive
Signs and Symptoms
Lymphadenopathy
B-symptoms:
- fevers
- night sweats
- weight loss
may mimic other cancers sx/imaging
laboratory abnormalities: SCr, LFTs, Uric acid
NHL stage 1
single lymph nide or group of adjacent lymph nodes
NHL stage 2
two or more groups of lymph nodes on same side of diaphragm
NHL stage 3
Lymph nodes on both sides of the diaphragm
lymph nodes above the diaphragm with spleen involvement
NHL sage 4
widespread disease in lymph nodes and organ involvement
Diffuse Large B-cell lymphoma (DLBCL) Cytogenetics
BCL2 -> resistance to chemo
BCL6
MYC: rearrangement within an IgG gene
- double/triple hit: MYC + BCL2 +/- BCL6 (high grade lymphoma)
TP53
R-CHOP
Gold standard in fit patients
- R: Rituximab 375 mg/m2 IV day 0
- C: Cyclophosphamide 750 mg/m2 IV day 1
- H: Doxorubicin 50 mg/m2 IV day 1
- O: Vincristine 1.4 mg/m2 IV day 1
- P: Prednisone 100 mg PO daily days 1-5
Given every 21 days x6 cycles
Rituximab
MOA: chimeric monoclonal antibody binds to CD20
Admin: IV or SQ
ADE:
- TLS
- infusion reactions
- GI perforation
- hepatitis reactivation
- progressive multifocal leukoencephalopathy: JK virus, rare but fatal
- vaccinations less effective
Pearls:
- test for HBV and HCV prior to initiation
- infusion rxn risk highest cycle 1
- hold first cycle if disease in GI tract
Cyclophosphamide pearls
contributes to alopecia
N/V: high risk antiemesis reg
Hemorrhagic cystitis: HYDRATE OR DIE-DRATE
Doxorubicin pearls
- Lifetime cap dose 450 mg/m2
- monitor for cardiac dysfunction
- ejection fraction < 50% consider risk v benefit
- N/V and mucositis
Vincristine pearls
- Dose/cycle capped at 2mg
- Fatal if given intrathecally
- Neuropathy
- sensory neuropathy: taste, smell, touch
- constipation
Prednisone pearls
100mg daily
Hyperglycemia
Steroid induced psychosis
Insomnia
CHOP: Supportive Care
Emetogenic Risk: high
- NK1 antagonist or olanzapine
- additional prednisone not necessary
Febrile neutropenic risk 11%
- growth factors routinely given
Viral reactivation (rituximab)
- give antiviral therapy for any patients who have had HBV (entecavir)
Tumor lysis syndrome
- aggressive hydration
- allopurinol 1st cycle
- hold rituximab?
R-CHOP alternatives:
Poor LVEF and other CI to doxorubicin therapy:
- R-CEOP (rituximab, cyclophosphamide, etoposide, vincristine, prednisone)
- R CEPP (rituximab, cyclophosphamide, etoposide, procarbazine, prednisone)
- R CDOP (rituximab, liposomal doxorubicin, cyclophosphamide, vincristine, prednisone)
- R GCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, prednisone)
- R DA EPOCH (continuous infusion of doxorubicin)
NB: Anthracycline intensity tied to benefit
- can always consider using dexrazoxane
Pola-R-CHP
Frontline option for DLBCL
Add Polatuzumab Vedotin and subtract vincristine from R-CHOP
ADE:
- higher FN
Polatuzumab Vedotin
Antibody drug conjugate
ADE:
- peripheral sensory neuropathy
- neutropenia
- infusion related reactions
DA-R-EPOCH
preferred over R-CHOP for:
- Double/Triple Hit Lymphoma
- Primary Mediastinal Lymphoma
- HIV-associated DLBCL
basically R-CHOP with continuous infusion of doxorubicin
R-DHA
- R-DHAP (dexamethasone, high dose Ara C, CISplatin)
- R-DHAC (dexamethasone, high dose Ara C, CARBOplatin)
- R-DHOX (dexamethasone, High dose Ara C, Oxaliplatin)
DLBCL Consolidation therapy
Preferred:
- R DHA
- R GDP (Gemcitabine, Dexamethasone, CISplatin)
- R ICE (Ifosfamide, CARBOplatin, Etoposide)
Can be used for CAR T-cell therapy
- R GemOX (Gemcitabine, Oxaliplatin)
- Pola BR (Polatuzumab, Bendamustine, Rituximab)
CAR T-cell therapy
Indication: relapsed after 2 prior therapies, refractory to frontline regimen
sorta like a “vaccine”
ADE:
- infections
- neutropenia
- cytokine release syndrome (Hypotension, fevers, CIRS)
- neurotoxicity (HA, delirium, seizures, edema)
Follicular lymphoma 1st line treatment: Stage I, II
