Lymphoma

Question 1

Chemotherapy for DLBCL

Answer 1

R-CHOP
rituximab, cyclophosphamide, doxorubicin
vincristine
prednisone

Question 2

DLBLC IPI prognostic score

AND DLBCL Risk Factors

Answer 2

“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

Question 3

Follicular lymphoma prognosis score (FLIPI-2)

Answer 3

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

Question 4

Hodgkin Lymphoma IPS prognosis

Answer 4

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

Question 5

Most common chemotherapy for HL

Answer 5

ABVD:
- Adriamycin, bleomycin, vinblastine, DTIC (dacarbazine)

BEACOPP: now used for high-risk patients:
- Bleomycin, Etoposide, ADRIAMYCIN (DOXOrubicin), Cyclophosphamide, ONCOVIN ®
(VinCRIStine), Procarbazine, Prednisone

Question 6

Lymphoma Staging

Answer 6

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.

Question 7

HL risk factors (affect treatment)

Answer 7

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

Question 8

Treatment HL Stage I/II

Answer 8

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).

Question 9

Treatment DLBCL early stage and advanced stage

Answer 9

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

Question 10

Treatment double hit B cell lymphoma and what does this entail?

Answer 10

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.

Question 11

Treatment of primary mediastinal B cell lymphoma (think: monique ray)

Answer 11

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.

Question 12

Management Follicular Lymphoma:

Answer 12

24Gy/12 ISRT for localized disease. No chemo.
Advanced: treat if GELF criteria (Bendamustine + Rituxumab x 6)

Question 13

Subtypes of DLBCL :

Answer 13

• Germinal Center B cell (most common)
• Activated B cell (second most prominent); worse prog
• Primary mediastinal B cell lymphoma

Question 14

PMH guidelines for Risk factors in DLBCL

Answer 14

IPI factors: age> 60, abnromal LDH, Stage II, Tumor size > 7cm, Extranodal involvement

Question 15

Treatment high grade B cell lymphoma and what characterizes this

Answer 15

double hit: C-MYC and BCL2 or BCL6: DA-R-EPOCH x 6 , MTX for CNS prophylaxis

Question 16

Primary mediastinal B cell lymphoma treatment

Answer 16

RCHOP x 6 -> ISRT 30-36/20. Alternative: DA-EPOCH x 6, no rads afterwards

Question 17

Indication for TBI

Answer 17

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

Question 18

GELF criteria

Answer 18

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

Question 19

FLIPI-1: know this as well!

Answer 19

Four nodal areas or more
Ldh greater than normal
Age >60
Stage III or IV
Hb> 120

Question 20

1) Prognosis for HL/NHL

2) prognosis pre rituximab

Answer 20

for simplicity, will say:
0-1 RF points: 90%
2-3: 80%
4-5: 60%

2: subtract

Question 21

What to do for refractory HL?

Answer 21

High dose chemo with autologous BMT

Question 22

What percent does adding RT to HL, DLBCL offer

Answer 22

decreases LR by 60%, absolute OS benefit like 5%

Question 23

Criteria for diagnosis of MM, SP

Answer 23

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

Question 24

INvestigations to order: do not forget to test for:

Answer 24

MUGA
Pregnancy/fertility banking