Lymphoma Flashcards by Chelsea Luedtke

Lymphoma pathophysiology

heterogenous group of malignancies that arise from malignant transformation of immune cells that reside in lymphoid tissue

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How do lymphomas commonly present?

as solid tumor

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How is lymphoma classified?

Hodgkin’s (HL)

Non-Hodgkin’s (NHL)

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Are there more new estimated cases of HL or NHL?

NHL

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Are there more estimated deaths of HL or NHL?

NHL

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T/F the prognosis for HL is not good

False!

It is good!

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How is HL classified?

4 prognostic groups

Early favorable/unfav

Advanced favorable/unfav

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Is HL more common in males or females?

What is the age of incidence?

males

Bimodal: 3rd decade of life; after 50

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HL is commonly linked with what disease?

EBV

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Etiology of HL

Infectious

Immunosuppressed patients at higher risk

Genetics: twins 100x increase risk

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Reed-Sternberg cells are with what cancer?

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HL patient presentation

Lymphadenopathy

Mediastinal mass

“B” symptoms (fever, weight loss, night sweats)

Hepatosplenomegaly

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Lymph nodes in HL

Most commonly cervical and supraclavicular

Painless, rubbery

Pain after alcohol consumption

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Diagnosis of HL

Physical exam

LDH

PET scan

Lymph node biopsy

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What is the Ann Arbor Staging System for?

Lymphomas

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Stage I Ann Arbor

1 lymph node area involved

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Stage II Ann Arbor

2 or more lymph node areas involved on same side of diaphragm

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Stage III Ann Arbor

Lymph node invovlement on both sides of diaphragm

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Stage IV Ann Arbor

Extranodal involvement (bone marrow, liver, spleet etc)

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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

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What is IPS used for?

Advanced HL

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Goal of HL

maximize cure!

minimize short and long term tx complications

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Treatment options of HL

Surgery: limited role

Chemo: backbone

Radiation: some role

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Involved field radiation

Single field that contains HL

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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 ## Footnote **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