Lymphoma and MM Flashcards
what is lymphoma
group of lymphoproliferative disorders originating in lymphocytes/ lymphatic tissue
what is the defining feature of hodgkin’s lymphoma
reed-sternbery cell
describe hodgkin’s lymphoma
B cell only, aggressive
3RF for hodgkin’s lymphoma
prolonged EBV infection, family Hx, (siblings of same sex), HIV
nonhodgkin’s lymphoma RFs
HIV, FHx (first degree), EBC, H pylori, MALD, burkitt, weakened immune sx, autoimmune disease
types of NHL
B (DLBCL), T, or NK/T cell
can be indolent or aggressive
diagnosis of B cell lymphoma rquires
Excisional lymph node biopsy of preferably largest regionally involved lymph node
For extranodal lymphomas = use sizable biopsy from organ of origin
Fine needle biopsy inadequate for initial diagnosis
when the excised lymph node is examined by the pathologist, what will they look for?
phenotyping- CD20 on B cells
gene rearrangements
EBV
what additional workup may be done for lymphomas besides lymph node examination
CT/PET
IPI score
lab chemistries
testing for comorbidities- pregnancy, HIV, EBV, hep B, pulmonary and ECHO/MUGA test if bleomycin or anthracyclines
stage of lymphoma if Single lymph node region (I) or one extralymphatic organ
1
stage of lymphoma if local extralymphatic extension plus lymph nodes, same side of diaphragm
2
stage of lymphoma if 2 or more lymph node regions, same side of diaphragm
2E
stage of lymphoma if local extra lymph extensions
3E
stage of lymphoma if lymph node regions on both sides of the diaphragm either alone
3
stage of lymphoma if Diffuse involvement of one or more extralymphatic organs or sites
4A (if no B sx)
stage of lymphoma if Diffuse involvement of one or more extralymphatic organs or sites with unexplained weight loss >10% from baseline within 6 mths of staging, unexpected fever >38C, or drenching night sweats
4B
list the 3 B sx
unexplained weight loss >10% from baseline in 6mths
unexpected fever >38C
drenching night sweats
what is treatment for DLBCL
RCHOP
rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone
rituximab 3 sus MOA
binds CD20 and cells die either by being recognized by effector cells, complement activation, or direct cell death
most common rituximab AE + what to do to prevent it
infusion reaction
premedicate with acetaminophen, diphenhydramine or loratidine, hydrocortisone, ranitidine or famotidine
hold ACEi/ARBs 24hrs pre
how should rituximab therapy be initiated
first dose should always be given IV, if no AEs, next dose can be given SQ
if first dose was not complete due to AEs, must have one full IV dose before SQ possible
what is the difference between IV and SQ rituximab
IV is dosed by 375mg/m2, SQ is a fixed flat dose of 1400mg
cyclophosphamide AEs
hemorrhagic cystisis
N/V- HEC with doxorubicin in RCHOP
myelosuppression, alopecia, fertility suppression
cyclophosphamide MOA
Alkylating agent- nitrogen mustard type: binds to DNA + cross links DNA and RNA = no protein synthesis
doxorubicin MOA
Anthracycline: inhib TP2 and prevents relegation of DNA during replication
Damages DNA and cell membranes by producing free radicals
doxorubicin AEs
cardiotoxicity
- late onset: reduced LVEF or CHF (more common)
- early onset: acute transient ECG changes to arrhythmia
myelosuupression
HEC with cyclophosphamide in RCHOP
alopecia
discoloration of urine
what must be done before initiating doxorubicin in RCHOP
ECHO or MUGA- LVEF must be =>50%
vincristine MOA
Vinca alkaloid - binds to tubulin (protein on spindle) and prevents mitosis
IV admin only (fatal if intrathecal)
vincristine AEs
Neurotoxicity
Peripheral neuropathy
Autonomic neuropathy- constipation (may require stool softeners and laxatives prophylactically)
what to monitor for prednisone in RCHOP
blood glucose- diabetics esp
mood changes
insomnia- may require zopiclone on prednisone days
GERD- take with food
what is included in supportive care for RCHOP
antinauseants
infection prevention (entecavir or tenofovir for HepB prophylxis)
prophylaxis for tumor lysis syndrome
factors reducing chances of cure in hodgkin’s lymphoma
Stage IV, ≥3 extranodal sites
Age ≥45yrs old
Male gender
Albumin <40
High WBC count (≥15)
Lymphocytopenia (lymphocytes <8% or <0.6%)
Hg <105
factors that reduce ability to tolerate intense chemo in hodgkin’s
≥60yrs old
ECOG >2
HIV +
2 treatments for hodgkin’s
Esc-BEACOOP
ABVD
what is Esc-BEACOOP for HL
(BLEHCOPP)
bleomycin
etoposide
doxorubicin
cyclophosphamide
vincristine
procarbazine
prednisone
what is ABVD
(DBVD)
doxorubicin
bleomycin
vinblastine
dacarbazine
the A in HL treatments stand for
doxorubicin
bleomycin MOA
Causes DNA strand scission through formation of an intermediate metal complex
bleomycin AEs
respiratory effects- pulmonary tests + CXR before and periodically
derm effects
mucositis and stomatitis
loss of appetite
vinblastine MOA
vinca alkaloid that binsd to tubulin and prevents mitosis
AEs of vinblastine
less neurotoxicity than vincristine
more myelosuppression
which is more myelosuppressive
1. vincristine
2. vinblastine
2
which is more neurotoxic
1. vincristine
2. vinblastaine
1
dacarbazine MOA
Prodrug for MTIC -cytotoxicity thought to be due to methylcarbonum ions that attach nucleophilic groups in DNA
dacarbazine N/V severity
HEC
procarbazine MOA
Alkylating agent- MOA not clear, could be free radical damage
what to watch out for with procarbazine
MAOi activity = avoid high tyramine content foods and alcohol- disulfaram reaction
avoid sympathomimetic drugs
procarbazine AEs
infertility (ovarian failure, azoospermia), bone marrow suppression, secondary malignancies
T or F: MM is curable with transplant
F- incurable
what is CRAB in MM
calcium >2.75
renal function (Cr >176)
anemia
bone lesions or osteopenia with compression fractures
what is a common symptom of MM
hypercalcemia
hypercalcemia is an oncologic emergency when
it causes sig phys dysfxn like: dehydration, mental status changes, cardiac arrhythmias, renal insuff or failure
what is a normal serum Ca level
2.2-2.6
what is important to consider when reading a pt’s calcium level
most labs report Ca as total calcium both bound and unbound
those with hypoalbuminemia may have high unbound, but total still looks normal
use corrected calcium for estimation of phys active calcium
corrected calcium equation
Corrected calcium (mmol/L) = measured calcium (mmol/L) + ([40-albumin (g/L)]x0.02)
tx of hypercalcemia
hydration with NS
bisphosphonates (promotes Ca elimination + inhibits further Ca release from bone)
calcitonin (promotes excretion of Ca)
malignant expansion of plasma cells usually in bone marrow, monoclonal protein (M-protein) in serum or urine.
multiple myeloma
what is the marker in multiple myeloma
CD38 o nplasma cells
is MM aggressive or indolent
aggressive
what type of cell does MM affect
plasma cells
what type of cells does lymphoma affect
lymphocytes
what is the M protein
monoclonal protein secreted by malignant plasma cell- can be produced uncontrollably + not functional
what is the problem in MM with having too many malignant plasma cells
crowding of bone marrow = pancytopenia
bone damage from bone marrow crowding- increased osteoclast function and decreased osteoblast function = bone weakening and hypercalcemia
no normal plasma cell functioning = inefctions
what is the issue in MM with haaving too many monoclonal proteins
too many proteins in bloodstream = kidney damage = cast nephropathy, anemias
increased serum viscosity
what is the diagnostic criteria for MM
M protein in serum and/ or urine
Clonal bone marrow plasma cells or plasmacytoma
Presence of myeloma sx
what is the ß2M (Beta-2-microglobulin)
protein on membrane of nucleated cells that becomes elevated with high cell turnover. Elevated levels = poor prognostic factor in MM
which of the following is not a goal of therapy with MM
1. cure
2. disease control
3. improve QoL
4. prolong survival
1
treatment for MM typically include ________ for transplant eligible pts
induction, consolidation, autologous transplant, maintenance
what is the treatment for MM if pt is not eligible for transplant
pharmacotherapy to reduce tumor burden
4 drugs for transplant ineligible MM pts
bortezomib
dexamethasone
daratumumab
lenalidomide
bortezomib MOA
reversible inhibitor of the 26S proteasome- inhibition alters regulatory proteins = cell cycle arrest + apoptosis
Can be given IV or SC, fatal if given intrathecally
AEs of bortizomib
herpes zoster reactivation (all pts should be given HSV/VZV prophylaxis with acyclovir or valacyclovir), neuropathy, thrombocytopenia, constipation/ diarrhea
bortezomib interacts with
green tea- lowered bortezomib’s antiproliferative effect of myeloma cells
dexamthasone MOA in MM
cytotoxic to myeloma cells likely via apoptosis
Pulse dosing (ex 40 mg po once weekly)
daratumumab MOA in MM
monoclonal abx that targets CD38
daratumumab AEs and how to deal
infusion rxn in 50% = premedicate with antihistamines, acetaminophen, corticosteroids, H2 acid inhibitors
lenalidomide MOA
thalidomide derivative = immunomodulatory, antiangiogenic, and antineoplastic characteristics via multiple mechs
lenalidomide AEs
teratogenic, DVT/PT, edema, thrombocytopenia and neutropenia
Requires renal dosing adjustment if kidney fxn poor
T or F: with the REVAID program, pharmacists must counsel with every rx, even a refill for thalidomide derivatives
T
what do BPs do in MM
prevent hypercalcemia by enhancing Ca elimination and preventing further skeletal release of Ca
less vertebral fractures, skeletal related events, pain
bisphosphonate AEs
osteonecrosis of jaw precipitated by dental work involving manipulation of mandibular and maxillary bones
how to minimize risk of ONJ with BPs
Prior to initiating therapy with bisphosphonates, a comprehensive dental evaluation should be performed and all invasive dental procedures be completed.
Annual dentist visits and maximal preventive care.
Avoid dental extractions if possible.
what to do if a pt on BPs with MM needs a dental extraction
hold BPs 1mth before procedure and resume after recovery
all _______ pts should receive prophylaxis for shingles with acyclovir or valacyclovir
bortezomib
what is used to mobilize stems cells into peripheral blood for an autologous stem cell transplant
filgrastim or chemo or both
