Lymphoma Flashcards
Lymphoma pathophysiology
heterogenous group of malignancies that arise from malignant transformation of immune cells that reside in lymphoid tissue
How do lymphomas commonly present?
as solid tumor
How is lymphoma classified?
Hodgkin’s (HL)
Non-Hodgkin’s (NHL)
Are there more new estimated cases of HL or NHL?
NHL
Are there more estimated deaths of HL or NHL?
NHL
T/F the prognosis for HL is not good
False!
It is good!
How is HL classified?
4 prognostic groups
Early favorable/unfav
Advanced favorable/unfav
Is HL more common in males or females?
What is the age of incidence?
males
Bimodal: 3rd decade of life; after 50
HL is commonly linked with what disease?
EBV
Etiology of HL
Infectious
Immunosuppressed patients at higher risk
Genetics: twins 100x increase risk
Reed-Sternberg cells are with what cancer?
HL
HL patient presentation
Lymphadenopathy
Mediastinal mass
“B” symptoms (fever, weight loss, night sweats)
Hepatosplenomegaly
Lymph nodes in HL
Most commonly cervical and supraclavicular
Painless, rubbery
Pain after alcohol consumption
Diagnosis of HL
Physical exam
LDH
PET scan
Lymph node biopsy
What is the Ann Arbor Staging System for?
Lymphomas
Stage I Ann Arbor
1 lymph node area involved
Stage II Ann Arbor
2 or more lymph node areas involved on same side of diaphragm
Stage III Ann Arbor
Lymph node invovlement on both sides of diaphragm
Stage IV Ann Arbor
Extranodal involvement (bone marrow, liver, spleet etc)
Predicting prognosis of HL
>65 yo lower cure rate
Limited disease (stage I or II): higher cure rate
Advanced disease (II or IV): lower cure rate
What is IPS used for?
Advanced HL
Goal of HL
maximize cure!
minimize short and long term tx complications
Treatment options of HL
Surgery: limited role
Chemo: backbone
Radiation: some role
Involved field radiation
Single field that contains HL
Extended field radiation
Radiation to involved field + 2nd uninvolved area
AKA sub-total nodal
Total nodal radiation
radiation of all areas
What are the 2 frontline therapies for HL?
ABVD
B-AVD
When is Brentuximab vedotin indicated?
New diagnosis stage III-IV HL
**Given in combo!
Refractory CHL, refractory anaplastic large cell lymphoma
What is brentuximab CI with?
bleomycin!
Risk of pulmonary toxicity
Specific ADE of brentuximab
- Peripheral neuropathy: cause of discontinuation
- Neutropenia
- severe infections
For early favorable disease IA or IIA in HL what are your treatment options?
2-4 cycles ABVD
Involved field radiation
For early unfavorable disease in HL what are your treatment options?
Combo therapy
4-6 cycles of ABVD (or Stanford)
Involved field radiation
MOPP, Stanford V, ABVD, BEACOPP
Which has the least amount of toxicities and most commonly used?
ABVD
What are the common ADEs of MOPP that ABVD does not have?
sterility
secondary leukemia
peripheral neuropathy
What are the Stanford V and BEACOPP main toxicities?
Both: myelosuppression, FN
BEACOPP: sterility, secondary leukemia
For Advanced staged unfavorable disease in HL what are your main treatment options?
6-8 cycles ABVD
B-AVD
BEACOPP
Stanford V
What drugs are in ABVD?
What is different in B-AVD?
Doxorubicin
Bleomycin
Vinblatine
Dacarbazine
Brentuximab instead of bleomycin
Relapsed HL treatment
More chemo
if remission <12 months: autologous HSCT
PD1 inhibitors role in HL
for relapse or refractory disease they are an option
Which PD1-inhibitors are used in HL?
Nivolumab
Pembrolizumab
What are the most common secondary malignancies caused by HL treatment?
breast and lung cancer
What are some main ADEs of HL treatment?
Sterility
Secondary malignancies
CV effects
Hypothyroidism
Pulmonary toxicity
Is NHL more common in males or females?
What is the average age of diagnosis?
Males
67 yo
can occur at any age
What infections are associated with etiology of NHL?
EBV
Human T cell lymphotropic virus type I
HSV 8: Kaposi)
Etiology of NHL
Genetic: congenital and acquired immunodef
Environmental: herbicides
Infections
Pathophysiology of NHL
Monoclonal proliferation of B or T lymphocytes
*most are B cell lymphomas
How is NHL classified?
it keeps changing!
Most recent WHO classification (it is complicated)
Presentation of NHL
Peripheral lymphadenopathy
Rapid and progressive disease
Waxing and waning
Fatigue, malaise, pruritis
B- symptoms
Lymph nodes in NHL
painless, rubbery, discrete
Non-contiguous spread
Diagnosis of NHL
Biopsy
Physical exam
LDH
PET/CT scan
T/F Ann arbor staging has poor correlation between stage and prognosis for NHL
True
NHL goals
Cure
alleviate symptoms
minimzie toxicities
Treatment choices for NHL
radiation
chemo
biologics
What is IPI used for?
DLBCL
T/F DLBCL is curable and most common type of NHL
true!
What is 1st line for DLBCL?
R-CHOP
R-EPOCH
What is in R-CHOP?
Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisone
What is in R-EPOCH?
Etoposide
Prednisone
Vincristine
Cyclophosphamide
Doxorubicin
What is R-CHOP used for?
DLBCL NHL
Boxed warnings of rituximab
infusion related reactions
hep B reactivation
severe mucutaneous reactions
PML
Watch for TLS
Benefits of R-CHOP vs CHOP
Ritux: increased outcomes significantly
Durable responses
Effective
Can use in elderly
Acceptable toxicity
Patient friendly
DLBCL variants
MYC rearrangement
BCL2 or BCL6 rearrangement
T/F in DLBCL double hit variants you should use R-CHOP
False!
Resistant to R-CHOP
Use DA-EPOCH-R
How is DA-EPOCH-R dose adjusted?
based on how the 1st cycles went
based on ANC
T/F CART can be used in HL
False
Used in relapsed DLBC NHL
CART cells in DLBC
Target CD19
Avoid tumor evasion of immune system
Median time to response ~1 month
When can you use CART in NHL?
relapsed DLBCL
Must have failed 2 prior therapies
Management of CRS
Supportive care
Tocilizumab
High dose steroids: if life threatening
Main toxicities of CART
CRS
Neurologic toxicities
How do you treat neurologic toxicities associated with CART?
Dexamethasone
Keppra: seizure prophylaxis
Toclizumab: not as effective
Is FL more common in males or females?
What is the median age of diagnosis?
females
60 yo
Presentation of FL
Waxing and waning
Primarily lymph nodes, spleen, marrow
Indolent
T/F FL is curable
False
typically NOT curable
What is FLIPI used for?
Follicular lymphoma
Treatment of stage I/II FL
if local: radiation
can observe
Treatment of stage II bulky/III/IV FL
chemo only if causing symptoms
Who should get upfront treatment in FL?
No convincing data of improved survival
Watch and wait for asymptomatic patients
If symptomatic: may consider therapy
Rituximab role in FL
2nd line therapy
P13K inhibitors role in lymphomas
2nd line to treat FL if refractory to rituximab
Treat FL if refractory to rituximab
P13K inhibitors
Main treatment for FL
BR or R-CHOP
