Lymphoma Flashcards
Chemotherapy for DLBCL
R-CHOP
rituximab, cyclophosphamide, doxorubicin
vincristine
prednisone
DLBLC IPI prognostic score
AND DLBCL Risk Factors
“PLEAS” (pleaing to live bc this is an aggressive cancer):
- Performance status: ECOG ≥2
- LDH > ULN
- Extranodal sites: ≥1
- Age: over 60
- Stage III/IV (for stage modified early treatment, this is a point for Stage II)
Risk Factors: (PMH) BLEAS
IPI factors:
- bulk (tumor size > 7cm)
- LDG abnormal
- Extranodal: testes, stomach, breast, bone
- Age > 60
- Stage II
Follicular lymphoma prognosis score (FLIPI-2)
Follicular lymphoma IPI: (BASH’D with a 2x2 board)
B:bone marrow involvement
A: Age > 60
S: Serum beta-2-microglobulin elevated
H: Hg < 120
D: Diameter of largest LN > 6cm
Hodgkin Lymphoma IPS prognosis
HALSWAM: think lake HALstat SWAM: 45M swimming tired by anemia buoyant because albumin <40 causing edematous legs
- Hg <105,
- Albumin < 40g/l
- lymphopenia,
- stage 4 disease by Ann arbor classification
- WBC >15
- Age ≥45
- male
Most common chemotherapy for HL
ABVD:
- Adriamycin, bleomycin, vinblastine, DTIC (dacarbazine)
BEACOPP: now used for high-risk patients:
- Bleomycin, Etoposide, ADRIAMYCIN (DOXOrubicin), Cyclophosphamide, ONCOVIN ®
(VinCRIStine), Procarbazine, Prednisone
Lymphoma Staging
Stage I = single LN region or extra-lymphatic site/lymphoid structure (ex: basically only the spleen, thymus, and waldeyer’s ring)
Stage II = ≥2 LN regions or lymphoid structures on the same side of the diaphragm (ex: hilum and mediastinum are two different LN regions)
Stage III = LN regions or lymphoid structures on both side of the diaphragm
Stage IV = diffuse involvement of ≥1 extra-lymphatic organ or site (liver, lung, bone marrow, CSF) Ex: axillary LN with erosion into the bone: this is NOT stage 4. This would be 2E because it is local. If locoregional involvement and not in the liver then chances are it is not stage 4.
HL risk factors (affect treatment)
Think: almost stage III if rules of 3’s:
- 3 areas involved
- ESR ≥30 w/ B symptoms otherwise ≥50
- Greater than 1/3 thoracic diameter
-Extranodal disease
Treatment HL Stage I/II
Favourable (no risk factors);
- ABVD x 2 + 20Gy/10 ISRT
- OR ABVD x 2 then PET, if CR additional 2x (otherwise, 6 cycles total ABVD)
Unfavourable:
- ABVD x 4 (can give x6 if bulky disease) + 30Gy/20 ISRT
- OR ABVD x 2 then PET, additional 2-4 if CR (not for bulky disease).
Treatment DLBCL early stage and advanced stage
No RF: RCHOP x 4. If PET negative, observe. If positive, ISRT 36Gy/20#
If RF: RCHOP x 6. If PET negative, observe. If bulk, then give 30Gy/20# if CMR. If PR, give 40Gy/20#.
Advanced stage (III-IV):
- RCHOP x 6
Treatment double hit B cell lymphoma and what does this entail?
C-MYC and BCL2 and/or BCL6 translocation by FISH
Treat with Dose adjusted (DA) - R - EPOCH x 6. No XRT afterwards. Give MTX for CNS prophylaxis.
Treatment of primary mediastinal B cell lymphoma
RCHOP x 6 -> ISRT 30Gy/20 if CMR, 36Gy if otherwise. We usually always give rads!!! Alternative: DA-R-EPOCH x 6 with no rads afterwards.
Management Follicular Lymphoma:
24Gy/12 ISRT for localized disease. No chemo.
Advanced: treat if GELF criteria (Bendamustine + Rituxumab x 6)
Subtypes of DLBCL :
- Germinal Center B cell (most common)
- Activated B cell (second most prominent); worse prog
- Primary mediastinal B cell lymphoma
PMH guidelines for Risk factors in DLBCL
IPI factors: age> 60, abnromal LDH, Stage II, Tumor size > 7cm, Extranodal involvement
Treatment high grade B cell lymphoma and what characterizes this
double hit: C-MYC and BCL2 or BCL6: DA-R-EPOCH x 6 , MTX for CNS prophylaxis
Primary mediastinal B cell lymphoma treatment
RCHOP x 6 -> ISRT 30-36/20. Alternative: DA-EPOCH x 6, no rads afterwards
Indication for TBI
Mantle cell lymphoma: advanced stage <65. RCHOP alternating with R-DHAP x 6 -> ASVT (TBI 12Gy/6 BID then cytarabine/melphalan) then ASCT followed by maintenance ritux
GELF criteria
1) involvement of 3 nodal sites each with diamter of 3cm
2) any nodal or extra-nodal mass 7cm in diameter
3) B symptoms
4) splenomegaly
5) pleural effusion or ascites
6) cytopenias: WBC < 1.0 or plt < 100
7) leukemic phase of disease with >5.0x10^9
FLIPI-1: know this as well!
Four nodal areas or more
Ldh greater than normal
Age >60
Stage III or IV
Hb> 120
1) Prognosis for HL/NHL
2) prognosis pre rituximab
for simplicity, will say:
0-1 RF points: 90%
2-3: 80%
4-5: 60%
2: subtract
What to do for refractory HL?
High dose chemo with autologous BMT
What percent does adding RT to HL, DLBCL offer
decreases LR by 60%, absolute OS benefit like 5%
Criteria for diagnosis of MM, SP
Criteria for Dx of MM:
o Clonal plasma cells of ≥10% (on either BM Bx or a Bx from other tissue)
o Monoclonal protein in Serum protein electrophoresis (SPEP) or urine protein electrophoresis (UPEP)
o Evidence of end-organ damage that can be attributed to the underlying plasma cell proliferative disorder, specifically: Hypercalcemia, Renal insufficiency, Anemia,Bone lesions, Clonal bone marrow plasma cell percentage ≥60%, involved:uninvolved serum free light chain ratio ≥100, >1 focal lesions on MRI studies
Criteria necessary for the Dx of SP:
o Solitary bone lesion on skeletal survey
o Histologic evidence of plasmacytoma by bx
o <5% plasma cells on marrow aspirate
o No other end organ damage attributable to plasma cell dyscrasia
INvestigations to order: do not forget to test for:
MUGA
Pregnancy/fertility banking
