Lymphoma Flashcards

Question

Early stage favorable HL: treatment paradigm

Answer 1

ABVD x 2 cycles then obtain post-chemo PET. Deauville ≤3 give 20 Gy/ 10 fx Deauville 4 give two more cycles and reassess Deauville 5, biopsy first, and if positive see refractory pathway

Answer 2

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 3

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

Answer 4

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 5

steroid dex, MTX, ifosphamide, pegaspargase, etoposide

Answer 6

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 7

≥3 nodal sites bulky ≥1/3 chest extranodal involvement ESR ≥30 with B and ≥50 without B

Answer 8

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

Answer 9

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 10

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

Answer 11

10yr OS 94% 10yr PFS 87%

Answer 12

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 13

H&P, family history, B symptoms (fever, weight loss, nightsweats) performane status, complete LN exam, Waldeyer's ring, palpation of abd/spleen/liver Excisional biopsy of node. IHC. Karyotype or FISH for double hit (BCL2, BCL6, myc) Labs: CBC w/ diff, LFTs, CMP, **uric acid**, LDH, beta-HCG, HIV test, Hepatitis B Studies: CXR, CT C/A/P, PET. BM bx if PET negative and cytopenias present (always do BMbx for follicular, MZL, and Burkitts) Pre chemo assessment: Echo/MUGA, PFTs dental eval if treating neck fertility counseling LP in DLBCL for testicular, paranasal sinus, epidural, or HIV assoc lymphoma, or if more than 2 extranodal sites and elevated LDH (NCCN)

Answer 14

5yr OS: score 0: 95% score 1-2: 80% score 3-5: 55%

Answer 15

Rituximab 375 mg/m2, d1 Cyclophophamide 750 mg/m2, d1 Doxorubicin 50 mg/m2, d1 Vincristine 1.4 mg/m2 (max 2 mg), d1 Prednisone 100 mg po qd d1-5 Q3w x 6-8 cycles

Answer 16

H&N: do dental eval first. Use bite block to divert tongue away from field if possible. Mask. Chest: 4DCT, vac loc. Breath hold increasing in use to spare heart and lung Abdomen: 4DCT. Empty stomach and treat at same time each day. If using oral contrast also sim without contrast. Daily CBCT. Pelvis: If young age, do pregnancy testing and fertility testing. Consider sperm banking, egg banking, ovarian transposition, testicular clamshell

Answer 17

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

Answer 18

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 19

36Gy for bulky tumor or bony disease 40Gy for partial response on PET

Answer 20

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 21

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

Answer 22

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

Answer 23

(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 24

(DA) R-EPOCH x6 is often used (NIH), then assess response with PET. Consider RT 30-36 Gy for Deauville 4-5 Consider RT to 36 Gy for bulky 5yr OS 95%

Answer 25

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 26

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 27

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

Answer 28

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

Answer 29

(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 30

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.

Answer 31

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 32

H&P, family history, B symptoms (fever, weight loss, nightsweats) performane status, complete LN exam, H&N exam noting Waldeyer's ring, eyes, and salivary glands, palpation of abd/spleen/liver Labs: CBC, LDH, CMP. Consider BHCG 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. Staging imaging: CT C/A/P and PET (PET is now rec on NCCN, but caution: often not FDG avid)

Answer 33

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 34

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

Answer 35

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 36

Doxorubicin 25 mg/m2, d1 and 15 Bleomycin 10 U/m2, d1 and 15 Vinblastine 6 mg/m2, d1 and 15 Dacarbazine375 mg/m2, d1 and 15 Q4w

Answer 37

An NHL. Distinct from DLBCL by CD markers, often CD20+. CD15- and CD30 weakly + or -. BCL6 positive. Path: fibrosis, necrosis, and thymic cells. No nodularity (nodularity is seen in classical HL and NLPHL). Sheets or irregular clusters of large cells, may resemble R-S cells. Arises in thymus (extranodal), common in women, usually stage I-II. Arises in anterior MS, sometimes also with cervical and SCV nodes. More common in females 2:1, usually age 30s

Answer 38

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

Answer 39

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 40

5yr OS 94% 5yr PFS 87%

Answer 41

H&P, family history, B symptoms (fever, weight loss, nightsweats) performane status, complete LN exam, Waldeyer's ring, palpation of abd/spleen/liver Excisional biopsy of node. IHC. May require FISH and cytogenetics Labs: CBC w/ diff, LFTs, CMP, ESR, LDH, beta-HCG, HIV test, Hepatitis B Studies: CXR, CT C/A/P, PET. BM bx if PET negative and cytopenias present Pre chemo assessment: Echo/MUGA, PFTs dental eval if treating neck fertility counseling

Answer 42

R-CHOP x 3-6 cycles. Some give 6 if IPI score ≥2 or bulky. 3 cycles with RT if Deaville 1-3

Answer 43

Dose Adjusted based on ANC and platelet counts rituximab etoposide prednisone vincristine cyclophosphamide doxorubicin

Answer 44

age\>60 PS\>1 LDH\>1.5x nl extranodal dx in more than one site stage III/IV