Lymphoma Flashcards

Question

lymphocyte predominant HL: characteristics

Answer 1

A HL. Markers similar to PMBCL except CD30. CD20+, CD15-, CD30-(very rarely CD30+). Path: popcorn cells (large cells with multilobulated or round nuclei) and nodularity and replacement of nodal architecture. 80% present as early stage. Usually peripheral adenopathy with central sparing. Often extranodal. Some will relapse but relapse survival still better than HL.

Answer 2

30 Gy if \<5 cm, 36 Gy if \>5 cm treatment is RABVD or RCHOP +/- xrt for IB/IIB or bulky disease

Answer 3

(marginal zone or follicular) Standard H&P with attention to full skin exam. Biopsy (punch, excisional, or incisional). For T cell get peripheral smear for Sezary cells (necessary for staging) CT C/A/P and/or PET. BM Bx useful for select cases 5-10% present with sezary syndrome: \>1000 cells/uL usually with generalized erythroderma

Answer 4

I would position the patient at 3 m SSD with beam spoiler 1 cm thick placed in front of the patient. I would treat 3, out of total 6, positions per day for 4 days per week, delivering 1 Gy per day, ensuring to boost areas of possible underdosage including soles, perineum, scalp, under breasts and pannus. I would place TLDs to confirm adequate dosage. The beam would be moved + and – 20 degrees.";;Treat in 6 positions to cover total skin, 3 positions per day, 4 days per week. Boost to soles, perineum, and scalp. Also need to boost "shadow areas" under breast, pannus, etc. Can shield eyes. Can intermittently shield nail beds and tops of feet to reduce risk of edema. Put TLDs on areas at risk of underdosage such as scalp vertex, axilla, inframmary folds, perineum, intergluteal cleft, medial thighs, soles of feet, palms (patient usually is supported by handles).;;A beam spoiler 1 cm thick is placed in front of patient to increase large angle scatter and improve dose homogeneity. The beam is positioned 3 m SSD and moved +/- 20 degrees (angles reduce photon contamination to less than 1%). Goal is to achieve dose homogeneity in the coronal plane. Rx and Dmax are at skin surface, and 80% dose is at 0.7-1.0 cm depth

Answer 5

Generally only local RT for B cell; never total skin. 1.0-1.5 cm margin Low grade: 24-40 Gy Int grade: RCHOP x3 + RT up to 36 Gy Palliative: 2x2 Gy gives CR in 70%

Answer 6

Localized: electrons to 20-24 Gy with at least 2 cm margin. Some treat up to 36 Gy. Generalized: TSEBT to 10-12 Gy (1 Gy per day, 4 days per week, for 3 weeks) per guidelines. With this regimen retreatment is allowed Palliation: 2x2 Gy repeated until good response or single dose 8 Gy. Margin 1-2 cm (ILROG guidelines)

Answer 7

intralesional steroids, R,topicals, other systemic therapy such as is used for follicular lymphoma

Answer 8

Localized options: topical corticosteroids, nitrogen mustard, imiquinod, retinoids, phototherapy Systemic options (localized or diffuse): retinoids, interferon, HDAC inhibitors (vorinistat), electrocorporeal photophoresis, methotrexate

Answer 9

desquamation, hair loss, lymphedema, nail loss, loss of sweating, second malignancy

Answer 10

H&P per lymphoma. Imaging: CT C/A/P. Upper endoscopy, EUS and biopsy. FISH for t(11;18). Look for H pylori on path (use modified Geimsa stain). If negative, get blood Ab test, urea breath test, or stool Ab test. Labs: CBC, LDH, CMP. Consider BHCG Staging imaging: CT C/A/P and PET (PET is now rec on NCCN, but caution: often not FDG avid)

Answer 11

1st line triple therapy: PPI, clarithromycin, amoxicillin. ("CAP") 2nd line quadruple therapy: PPI, bismuth, metronidazole, tetracycline. ("P BMT");

Answer 12

H. pylori positive after failure with antibiotics H. pylori negative t(11;18) positive more likely to fail antibiotics but still try

Answer 13

Endoscopy with bx in 3 mos. General guide: if still H pylori+ give 2nd line abx, if lymph+ give RT: pylori/lymph- ---\> no further therapy H pylori+/lymph- ---\> 2nd line abx (PBMT) H pylori-/lymph+ ---\> RT lymph+/H pylori+ ---\> 2nd line abx PBMT if stable. If symptoms or progessive dz give RT + 2nd ABX PBMT

Answer 14

supine, wingboard, 4DCT, optional 10 cc oral contrast, empty stomach (treat in AM or NPO for 3 hours).

Answer 15

30Gy/20fxs CTV: EGD to duodenal bulb, also including any positive nodes ITV: add another 1-2 cm per extranodal guidelines PTV: add another 1 cm Might be able to reduce margins with daily CBCT IMRT or 4-field

Answer 16

MALT 5-yr OS 95% 90% MALT are H pylori +

Answer 17

Include evaluation of nasopharynx with flexible scope, testicular exam, skin exam, CSF analysis, EBV viral load, MRI nasopharynx

Answer 18

stage I: radiation alone (50Gy + boost) stage II-IV: chemoradiation VIPD then 45Gy 40Gy with concurrent cisplatin then VIPD x3 cycles (Korea)

Answer 19

etoposide, ifosfamide, cisplatin, dexamethasone

Answer 20

steroid dex, MTX, ifosphamide, pegaspargase, etoposide

Answer 21

Always include bilateral nasal cavity, bilateral anterior ethmoid, hard palate and ipsilateral maxillary sinus. Bilateral maxillary sinus tumor of bilateral or posterior nasal cavity. Include adjacent structures or nodes only if these are involved No elective neck radiation, even if nodes involved. Use ISRT. Waldeyers ring location: cover entire ring.

Answer 22

3yr OS 85% 3yr LC 60%

Answer 23

In follicular lymphoma, excisional biopsy still recommended as in all lymphomas. If excisional bx not feasible, can do core needle bx with immunohistochem, flow cytometry, FISH. FISH testing: if 1p36 translocation positive, disease will be localized and no staging studies are needed Labs: Hep B, B2 microglobin plus standard BM bx (still required in follicular with Lugano)

Answer 24

stage I-II, grade 1-2: xrt alone (24Gy) stage I-II, grade 3: treated like DLBCL (R-CHOP + xrt)

Answer 25

LNASH LDH elevated Nodal areas \> 4 Age \> 60 stage III-IV Hgb \< 12

Answer 26

5yr OS: 0-1 points 90% 2 points 80% 3-5 points 50%

Answer 27

BBLAH B2 microglobin elevated bone marrow positive ymph node \> 6cm age \> 60 Hgb \< 12

Answer 28

Standard workup and PET plus: LP and CSF MRI brain skin exam (bilateral involvement is still stage I)

Answer 29

orchiectomy -\> 6 cycles RCHOP + 4 cycles intrathecal MTX -\> RT to contralateral testicle, scrotum 25-30 Gy in 1.5-2 Gy per fx, use electrons. Include nodes only if involved

Answer 30

5yr OS 85%

Answer 31

For MALT: upper and lower endoscopy CT C/A/P Consider PET

Answer 32

30 Gy for CR if after chemo. For residual disease consider 40-45 Gy. Include entire orbit. May boost to gross disease

Answer 33

vitreous biosy 36Gy to globe and optic nerve extending to chiasm

Answer 34

PET. BM bx is required per Lugano. An Indolent lymphoma per ILROG extranodal guidelines RT alone to 24 Gy (20-30 Gy) Per NCCN surgery alone is allowed for parotid, breast, lung, thyroid

Answer 35

Standard workup Examine H&N area including waldeyer ring, size of liver and spleen EGD to look for MALT is optional PET BM bx in all Extremely rare to see localized disease

Answer 36

induction hyper-CVAD 30Gy ISRT

Answer 37

CT and MRI of affected area. Consider MRI spine H&P, CBC, CMP (Calcium, albumin), LDH, beta-2 microglobulin, SPEP, UPEP, serum and urine immunofixation, skeletal survey, bone marrow bx with IHC + flow, cytogenetics, FISH analysis, serum free light chain, 24 hr urine protein For multiple myeloma need all of: - BM plasma cells \>10% OR plasmacytoma - serum or urine monoclonal protein - CRAB: one of calcium, renal insufficiency, anemia, osteolytic bone lesions Multiple skeletal lesions also diagnoses MM

Answer 38

40-50Gy Osseous: involved lesion plus margin Extraosseous: involved lesion, and consider adding regional lymph nodes Conservative: Give 2-3 cm to block edge. If vertebral body, treat that entire vertebra, 1 level only Other strategy: Treat whole bone. Treat one vertebral body above and below

Answer 39

osseous: 60% extraosseous: 40%

Answer 40

I would position the patient at 4 m SSD standing, treating AP/PA. I would have measured the patient to create compensators and I would place a beam spoiler in front of the patient for appropriate dose distribution. Lead would be used to protect the lungs. (ablative) I would deliver 1.5 Gy BID for four days total to total 12 Gy, 5-10 cGy/min for ablation, with fludarabine and cyclophosphamide chemotherapy and nausea prophylaxis. I would keep the lung dose \<10 Gy.

Answer 41

Treat AP/PA - Treat at 400 cm SSD - I would first measure the patient to create compensators for appropriate dose distribution. I would give zofran for nausea prophylaxis - Patient standing - Treat at extended SSD with beam spoiler - Treat with 12 Gy, BID dosing, 5-10 cGy/min, lung dose \<10 Gy for ablative with fludarabine/cyclophosphamide

Answer 42

General indications: Localized relapse Bulky disease Persistent FDG uptake after ICE or ASCT Critical for LC (nerve compression, SVC compression, airway compression, lymphedema, hydronephrosis) Desseminated disease may be all treated with RT of toxicity profile is reasonable

Answer 43

(ILROG guidelines) ISRT is appropriate with autologous SCT and can be given before or after SCT. **CR after salvage chemo (often ICE):** CR Deauville 1-3: consider 30 Gy, or 36 Gy for Deauvile 3 CR on PET (D score 1-3) but \>2.5 cm on CT: 36 Gy Previously irradiated: ≥18 Gy as dosimetry allows Prior to ASCT or 4-12 weeks after **PR (Deauville 4) after salvage chemo:** PR sites to 36-40 Gy and CR sites to 30-36 Gy May treat only PR sites if volume is large TLI: 18 Gy in 1.8 Gy BID over 1-2 weeks to refractory disease followed by 18 Gy in same fx to TLI Give RT prior to ASCT with goal of minimal residual disease May also consider further chemo **Deauville 5 after salvage chemo:** If limited refractory, consider RT as above RT not rec for disseminated disease RT before ASCT is favored consider 40-45 Gy

Answer 44

(ILROG guidelines) **CR (Deauville 1-3) to salvage chemo:** 30-36 Gy / 1.5-2.0 Gy per fx pre- or post-transplant 30 Gy / 1.5 Gy BID is an option for urgency pre-transplant Post-transplant is done within 4-12 wks after Pre-transplant is done ASAP, within 4 weeks after chemo Volume: ISRT. Can consider including adjacent nodes that responded to first line chemo **PR (Deauville 4-5) residual focus after salvage chemo:** 36 Gy / 1.8-2 Gy per fx with boost to 40-45 Gy / 1.8-2.2 Gy per fx to PR site Volume and timing as above

Answer 45

1. No uptake 2. Uptake ≤mediastinum 3. Uptake \>mediastinum but ≤liver 4. Uptake moderately \>liver 5. Uptake markedly \>\>liver Score of 4 and 5 are always positive. In some situations, 3 is considered positive.