Lymphoma Flashcards
**What 4 major factors must a doctor consider when he/she decides if cure is possible for a patient with lymphoma?
- Tumor Histology
- Tumor Stage
- Condition of Patient
- Available Therapies
**Name the most common indolent lymphoma.
The most aggressive lymphoma?
Most Common Indolent Lymphoma:
- FOLLICULAR LYMPHOMA
Most Common Aggressive Lymphoma:
- DIFFUSE LARGE B CELL (DLBC) Lymphoma
**What staging is used with the different types of lymphoma?
IPI - 4 stage system is used with all lymphomas BOTH Hodgkins and Non-Hodgkins
RAI - used for CLL
**What is the mechanism and site of action for rituximab?
• Ibrutinib?
Rituximab
• Binds to CD20
• Fc region recognized by MACROPHAGES, NK CELLS, and C3 complement
Ibrutinib
• Inhibits BTK in the B-cell receptor pathway
**What is the name of the most common cutaneous lymphoma and what cell can you find in the blood of some of these patients?
Mycosis Fungiodes
*If this has progressed to SEZARY you’ll find malignant T cells in their blood
**What is a common complication of radiation therapy in young Hodgkin’s Lymphoma Women?
Breast Cancer
possible infertility
**What are the two complications of CLL (chronic lymphocytic leukemia)?
OFTEN Asymptomatic BUT sometimes show complications
Complications: • ANEMIA***From bone marrow replacement OR AUTOIMMUNE HEMOLYTIC ANEMIA • SPLENOMEGALY • THROMBOCYTOPENIA • Hypogammaglobulinemia • Lymphocytosis • Lymphadenopathy
**What are some poor prognostic abnormalities in CLL?
Deletion of 17p
Deletion of 11q
**When is BMT (bone marrow transplant) used in lymphomas?
Used after RELAPSE
*allows them to give you insanely high doses of chemo that almost cause bone marrow failure
*Autologous transplants are often performed by kicking a patients blasts out into peripheral blood so you don’t have to do a bone marrow biopsy for a transplant
What determines what kind of lymphoma you have (at the most fundemental level)?
The site of B-cell arrest
What are some symptoms/complications of the actual masses of cells that have proliferated in lymphomas?
• What issues are you likely to see on CBC?
Masses of Cells cause:
• Lymphadenopathy
• Ureteral Obstruction (uric acid)
• Spinal Cord Compression
Issues on CBC:
•Pancytopenia
What paraneoplastic syndromes are associated with lymphomas?
- Autoimmune Hemolytic Anemia
- Immune Thrombocytopenia Purpura
- Neuropathy
T or F: monoclonal expansions of lymphocytes can cause hypogammaglobulinemia by causing there to be less diversity in the B cell repertoire.
True, I THINK, Hypogammaglobulinemia is definitely a complication of lymphomas though (per Wier)
In what 3 ways may you be able to help a lymphoma pt. even if you can’t cure their disease?
- Help them liver longer
- Improve Quaility of Life
- Prevent disaster that may happen from tumor mass
What categorizations do we give to Lymphomas to get an idea of how they will behave?
- Indolent
- Aggressive
- Highly Aggressive
- B or T cell
*What can be said about the following factor for an indolent lymphoma? • Stage • Progression • Response to Therapies • Curability • Survival and Early Intervention • WHEN to treat
INDOLENT LYMPHOMAS
• Stage: HIGH
• Progression: SLOW
• Responds to SIMPLE therapies
• Curability: NOT VERY CURABLE UNLESS IN STAGE I or II
• Early Intervention: DOES NOT really affect pt. survival
• Treatment: ONLY WHEN SYMPTOMATIC
What are the 4 most common type of indolent lymphoma?
• Which is most prevalent?
- FOLLICULAR lymphoma (most prevalent)
- CLL CHRONIC LYMPHOCYTIC LEUKEMIA/ SLL
- MALT lymphomas
- Mycosis Fugoides
Where do you commonly see MALT lymphomas?
GI Tract and SCLERA
* Compare the following factors in a high grade AGGRESSIVE lymphoma to an indolent lymphoma. • Stage • Progression • Response to Therapies • Curability • Survival and Early Intervention • WHEN to treat
- Stage: Lower stage (1 or 2)
- Progression: RAPID
- Responds to COMPLEX therapies
- VERY CURABLE - with aggressive therapy early on
- Early Therapy Required - DO NOT WAIT FOR SYMPTOMS
• Define stages I-IV in lymphoma.
Stage I:
Single Node or Lymphoid Structure involved
Stage II:
Two or More lymph regions on ONE SIDE OF DIAPHRAGM
Stage III:
BOTH sides of DIAPHRAGM affected
Stage IV:
Extranodal - disease has metastasized out of nodes
T or F: you can have stage I and II extranodal cancers if the cancer arises outside of lymph nodes and spreads only to adjacent lymph nodes
True, this is Stage I or II “E”
When Lymphomas metastasize outside of lymph nodes where are they most likely to go?
- Liver
- Spleen
- Bone marrow
T or F: we stage Hodgkin and Non-Hodgkins lymphomas the same way
TRUE
What tests will you do to try and stage someone’s lymphoma?
- History and Exam
- CAT scan chest, abdomen, and Pelvis
- Bone marrow aspirate and biopsy with flow cytometry
- PET scans
- Chemistries, CBC, LDH
- CSF
When would you do a spinal tap to see if someone has metastasis to the meninges or not?
only test CSF if high risk
What the point of doing both a PET scan and a CAT scan.
- In addition to seeing nodules PET scans will detect the level of activity in lymph nodes/affected sites.
- Can ALSO detect cancer growing the bone marrow which isn’t readily detected by a CAT scan
**We do this by giving the patient Sucrose then tracking areas of high sucrose metabolism
T or F: Follicular lymphoma and Chronic Lymphocytic Lymphoma would show up brightly on a PET scan.
FALSE, these are indolent, slowly progressing cancers, thus it is unlikely that they would metabolize fast enough to see any real difference on the PET scan
How do you acquire the numbers to determine a patients 5 year survival rate for lymphomas?
• what lymphoma is not graded this way?
Use APLES, each positive category counts as a point
Age>60 = 1 Stage III or IV = 1 LDH elevated = 1 Performance Status > 1 = 1 Extranodal Sites > 1 = 1
***For those that are > 1 (P status and Extranodal sites) add 1 for every node for E-sites
Based on the International Prognostic Index (IPI) what grades determine if a patient is Low, Low Intermediate, High Intermediate, or High Risk?
• Predict the Pts. 5 yr. survival based on this risk.
Low Risk: 0-1 = 73% % 5yr survival
Low Intermediate Risk: 2 = 51% 5yr survival
High Intermediate Risk: 3 = 43% 5yr survival
High Risk: 4-5 26% 5yr survival
WHEN INDOLENT LYMPHOMAS become symptomatic, what therapies do we use?
- Local Irradiation (treat symptomatic areas)
- Alkylators and Prednisone
- Anthracyclins (DOXYRUBICIN)
- Fludarabine (purine analog)
- Antibody Therapy
- Radiation Labeled Antibodies
COMBINATION THERAPIES
• CHOP (cyclophosphamide, hydroxydaunrubicin, oncovin, and prednisone)
• Fludarabine + Mitoxantrone
What does CHOP therapy stand for?
CHOP (cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone)
*note: oncovin = vinblastin
What Therapies might you consider for an aggressive lymphoma?
**Remember aggressive cancer, aggressive treatment
COMBINATION CHEMOTHERAPIES
• CHOP, HyperCVAD
• Ab. therapy (rituximab) + CHOP
• Radio-immunotherapy
• Short course chemo and radiation for (Stage I and II)
RELAPSE:
• BONE MARROW TRANSPLANT (autologous or allogeneic)
T or F: there is no evidence to support that using rituximab with CHOP therapy is beneficial.
FALSE, in R-CHOP therapy there is a much greater chance or the patient surviving more than 5 years
What are your options after lymphoma relapse?
• which has been shown to improve survival rate?
2 line chemo or Bone marrow transplant (autologous or allogenic)
Survival Rate Better with BMT
What does aletuzumab target?
• which cell types is this found on?
CD52 found on B and T cells
**Note: this drug causes severe immunosuppression
**What lymphomas are associated with the following infections? • HIV • HH8 • HTLV-1 • EBV • H. Pylori
HIV - Primary CNS lymphomas HH8 - primary plural effusion lymphomas (and kaposi's) HTLV-1 - T cell Lymphomas EBV - Burkitt's Lymphoma H. Pylori - MALT lympomas
Where would you be most likely to see someone with an HTLV-1 infection
Japan
Caribbean
Southern USA
**What are the 4 types of Hodgkins Lymphomas?
• Best Px –> Worst Px
• Adults vs. Kids
Kids: Lymphocyte Rick (BEST Px) Nodular Sclerosis (Good Px)
Adults: Mixed Cellularity (Not Good Px) Lymphocyte Depleted (BAD Px)
How does the mode of progression of Hodgkin’s differ from most cancers?
• How does staging differ?
Moves from one node to the next so that you can predict its progression.
**STAGING IS THE SAME IN EVERY WAY for Hodgkin and Nonhodgkins
What treatment if given to people with late stage Hodgkins?
ABVD - CHEMOTHERAPY
Adreomycin
Bleomycin or Brentuximab
Vinblastin
DTIC (dacarbazine)
What does Brentuximab target?
CD30
What is a common problem that people who have been cured of Hodgkins are now facing as they grow older?
They are Developing NEW Cancers as a result of Treatment
- Acute Leukemias and Myelodysplasias
- Solid Breast, Lung, stomach, bone, tumors
- CORONARY ARTERY DISEASE
- INFERTILITY
- Hypothyroidism
**What method of staging is used for CLL?
• when do we treat?
**RAI method is used
DON’T treat stage 0, 1,and 2, Treat 3 and 4
0 - lymphocytosis 1 - enlarged nodes 2- hepatosplenomegaly 3 - Hgb below 10 (non-immune) 4 - Platelets (less than 100,000; non-immune mediated)
