Lymphoma Flashcards
What are the risk factors for developing lymphoma? (3)
Immunosuppression: transplant, immunosuppressants, HIV, congenital immune deficiency
Virus & bacteria: HIV, EBV, HTLV-1 (T-cell lymphoma), H.pylori (GALT)
FH of Lymphoma
Lymphoma - common presentations? (P; 3)
Peripheral lymphadenopathy (i.e. palpable lumps)
Intravacity lymphadenopathy (mediastinal widening, intra-abdominal LN in scan performed for other reasons)
B- symptoms (weight loss, fever, night sweats)
What investigations would you like to review for this patient with Lymphoma? (4)
LN biopsy (not FNAB, the definitive dx should be made on excision biopsy) - to confirm the dx (e.g. RS cells in HL) and identify the subtype
BM aspirate/biopsy - to exclude BM involvement
CT Neck+CAP (ask for CXR first - look for hilar lymphadenopathy) & PET scan for staging (combined scan is readily available)
Bloods: FBC (cytopaenia -?BM involvement), LDH, ESR - (disease activity)
Ask if patient had LP (important in high-grade lymphoma)
Lymphoma staging?
Ann-Arbor classificaiton (I-IV + A/B).
I: single LN region or a single extra-lymphatic site
II: ≥2 LN regions on the same side of diaphragm - with/without spleen (IIs)
III: both sides of diaphragm - with/without spleen involvement (IIIs)
IV: extra-lymphoid tissues (e.g. bone/lung) in addition to lymphoid tissue
A = No constitutional symptoms
B = B symptoms present
What are the long-term management issues in patients with Lymphoma and how would you manage them? (this is essentially the same questions as “Non-pharmacological Mx of Lymphoma patients”
(7 key elements, 4 minimum)
Monitoring for relapse & complications. Key issues to discuss are - Cancer, Cardiac, Endocrine, Neuropsychiatric.
1. Monitoring for Relapse
- 3-6 monthly first few years (depends on subtypes). History & Examination (important as relapses are usually symptomatic and rarely identified on imaging alone) and FBC, LDH and electrolytes.
2. Malignancy surveillance (risk continues at least 30y or more)
- Educate/counsel yearly to improve Risk awareness, encouraging them to report symptoms
- Breast***: surveillance from 40y or 8y from irradiation. Annual Mammogram + consider annual MRI (if irradiated 10-35yo).
- Lung Ca: annual CXR, smoking cessation
- Skin Ca: annual complete skin exam, sun-screen advice
- Annual FBC (Leukaemia, MDS), Routine age-appropriate cancer surveillance: exception. Consider early colonoscopy.
3. Cardiovascular +Respiratory health
- Risk comes from Adriamycin, -Rubicins & RTx (usually 10y after)
- Minimise CV risk factors: exercise, w.loss, Mediterranean diet, smoking cessation), manage HTN and Dyslipidaemia
- Refer to Cardiology for baseline evaluation
- Resting + stress TTE: frequency based on baseline finding + CV risk factors.
- If patient had RTx to lung fields, do annual spirometry/PFT.
4. Fertility
- Offer counselling and referal for sperm/ovum banking
- Refer to reproductive endocrinologist
- Consider HRT in premature ovarian failure + DEXA screen
5. Thyroid
- Monitor for Hypothyroidism for those who had RTx to the neck or WBI - annual thyroid examination + TSH
6. Psychiatric/cognitive/Neuro evaluation
- Monitor for depression, PTSD and neurocognitive impairment, especially those at increased risk (Cranial irradiation, intrathecal therapy)
- Prompt referral to AH if developing cognitive impairment.
- Vinblastine/Vincristine: painful PN with loss of deep tendon reflexes.
7. Written information & support
- All of these issues can be overwheling and may cause a great deal of anxiety
- Support them, provide them with written documentation of treatment summary, surveillance…etc.
What are pharmacological options for Hodgkin’s Lymphoma?
Based on staging: I-II (RTx or abbreviated chemo), III-IV (full chemo + consolidation RTx)
Field RTx +
a) 4-6 cycles of ABVD (Adriamycin, Bleomycin, Vinblastine, Dacarbazine) - less BM toxicity, less infertility
b) BEACOPP (bleomycin, etoposide, Adriamycin, Cyclophosphamide, Oncovin (vincristine), prednisolone, procarbazine - more toxic, more infertility, but MORE effective.
Hence if patient had HL - must mention Cardiovascular + Pulmonary + PN + Osteoporosis (if BEACOPP) surveillance.
Do you know of any pharmacological therapies that could be used in patients with Hodgkin’s Lymphoma who failed ABVD or BEACOPP? (2)
PD-1 blockade (Nivolumab): since RS cells expresses PDL1. Recent study demonstrated good response rate with complete remission.
Brentuximab (anti-CD30) in relapse/refractory Hodgkin’s.
Risk of secondary Cancers in Hodgkin’s lymphoma:
AML: what are the risk factors? (3)
Risk is about 2-10% at 10y
Risk factors: alkylating/etoposide chemo, age of treatment, combined modality therapy. (basically +++ chemo burden + young age)
What 2 solid tumours are patients at most risk following tx for Hodgkin’s lymphoma involving radiation?
Depends on Radiation dose + Field size.
Breast: RR upto 75
Thyroid: RR upto 30.
Lymphoma - PRIC MCP?
P: lymphadenopathy, B-symptoms, incidental from imagings
R: immunosuppression, FH, micro (EBV, HTLV-1, HIV, H.pylori)
I: LN biopsy, CT, PET, BM biopsy, LP
C: disease = relapse? therapy = secondary Ca? cardio/resp toxicity? thyroid? PN? depression/PTSD? fertility?
M: which chemo, how many, radiation - where? dose? WBI?
Is patient on appropriate malignancy surveillance? annual blood test, mamogram, CXR, cardiac investigations. Has patient has had banking done (if younger patient)
C: remission or refractory?
P: insights into the survivorship issues relating to Lymphoma. Does the patient have a good understanding?
What are the treatment options for Relapsed Hodgkin’s lymphoma? (3)
If relapsed >1y after → retreatment with original regime
If <1y → second line therapy
Can consider Autologous SCT after high-dose chemotherapy.
What are the risk factors for poor outcome in patients with Lymphoma? (5)
Age > 60
Raised LDH
Low ECOG
Ann-Arbor stage III-IV
More than 1 extra-nodal site
What are indications to treating SLL/CLL (mature B-cell neoplasm)?
These are most common: 75% of NHL.
Observe if only BM inovlvement + lymphocytosis (survival >10y).
If liver or spleen involved, especially if BM failure present, treatment usually indicated.
Pharmacological options for NHL: mature-B cell neoplasma (CLL/SLL - chronic lymphocytic leukaemia, small lymphocytic lymphoma - 4)?
Options are;
- Oral Chlorambucil (4)
- IV Fludarabine (more potent) + Rituximab
- BM transplant in young.
- Newer anti-CD20 in elderly with multiple comorbidities (e.g. obinutuzumab or ofatumumab)
Treatment (4) and prognosis of MALT-Lymphoma?
8% of NHL.
Curable when localised
Eradication of H.pylori will induce remission in 75%.
Otherwise RTx.
For more widespread disease/resistant disease: Rituximab.
Treat Hepatitis C.
