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864 > Lymphoma and MM > Flashcards

Lymphoma and MM Flashcards

1
Q

What is Lymphoma?

Malignant transformation of lymphocytes
◦ Solid tumors of the immune system

2 major types of lymphomas
◦ Hodgkin lymphoma (HL): characterized by ___ cells
◦ Non-Hodgkin lymphoma (NHL)
◦ 30 + unique histopathologic diseases
◦ Varied clinical course between subtypes
◦ 90% are ___ -cell

Chemotherapy backbone of treatment

Many subtypes are curable

A
  • Reed-Sternberg
  • B
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2
Q

HL – Epidemiology

if untreated 90% fatal within 2 to 3 years
Median age at diagnosis: ___
bimodal

A

39

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3
Q

HL – Pathophysiology

HL – Pathophysiology ___ cells: multinucleated giant cells, originate from B-lymphocytes

B-cell transcription disrupted
◦ Loss of immunoglobulin expression
◦ Lack of apoptosis pathways
◦ Proliferation of malignant cells

Risk Factors
- viral exposure
- impared immune function
- genetic factors

A

Reed-Sternberg

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4
Q

HL - Presentation

Painless, rubbery, enlarged lymph
node

B symptoms (25-50% of patients)
◦ Fever (greater than 38 C)
◦ Drenching ___ , especially at night
◦ Unintentional weight loss of greater than ___% in < 6 months

Pruritus

A

sweats
10

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5
Q

HL - Diagnosis

___ is the gold standard

A

Excisional biopsy

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6
Q

Staging - Classification

Early-stage favorable
* Stage I-II without unfavorable factors

Early-stage unfavorable
* Stage I-II with unfavorable factors

Advanced-stage
* Stage III-IV

A

Unfavorable Factors:
* Large mediastinal
adenopathy
* Multiple involve nodal
regions
* B symptoms
* Extranodal involvement
* Significantly elevated
erythrocyte sedimentation
rate (ESR)

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7
Q

HL - Treatment

Goal: ___ while minimizing toxicities and long-term
complications

Modalities
◦ Combination chemotherapy
◦ ABVD
◦ Stanford V
◦ BEACOPP
◦ AAVD
◦ Radiation
◦ Autologous stem cell transplant

A

CURE

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8
Q

Treatment by Stage

IA, IIA Favorable

A
  • ABVD + RT
  • Stanford V + RT
  • ABVD
  • ABVD + escalated
  • BEACOPP
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9
Q

Treatment by Stage

Stage I-II
Unfavorable

A
  • ABVD + RT
  • Stanford V + RT
  • Escalated BEACOPP x 2 + ABVD x 2 + RT
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10
Q

Treatment by Stage

Stage III/IV

A
  • ABVD ± RT
  • AAVD
  • Stanford V + RT
  • Escalated BEACOPP ± RT (IPS > 3)
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11
Q

ABVD

A
  • doxorubicin
  • bleomycin
  • vinblastine
  • dacarbazine

cardio and pulm toxicity

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12
Q

ABVD

high amount of neutropenia
low amount of infecction

A

we dont know why

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13
Q

AAVD

A
  • doxorubicin
  • brentuximab vendotin
  • vinblastine
  • dacarbazine
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14
Q

Relapsed HL

  • High dose chemotherapy with ____ stem cell rescue
  • Maintenance therapy if high risk of relapse with brentuximab vedotin following stem cell transplant
A

autologous

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15
Q

HL summary

Early stage disease
◦ Involved-field radiation
◦ 2-4 cycles of ___ chemotherapy

A

ABVD

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16
Q

HL summary

Advanced stage disease
◦ 6-8 cycles of ___ or ___ chemotherapy
◦ ___ preferred in younger patients with Stage III or IV

A
  • ABVD, AAVD
  • AAVD
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17
Q

HL summary

Relapsed disease
◦ High-dose chemotherapy followed by ___ cell rescue

Maintenance therapy (high risk disease post transplant)
◦ ___

A
  • stem
  • Brentuximab vedotin
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18
Q

Non Hodgkin Lymphoma (NHL)- epidemiology

Median age at diagnosis: ___
5-year survival rate: 74.3%

A

68

19
Q

NHL – Pathophysiology

Malignant __ or ___ lymphocytes and ___

Malignant cells proliferate and replace normal cells in the lymph nodes and/or bone marrow

A

B
T
precursors

20
Q

NHL – Presentation

Presentation depends on tumor location
◦ B-cell: lymph nodes, spleen, bone marrow
◦ T-cell: extra nodal sites (skin and lungs)

B symptoms (3)

Diagnosis: ___ biopsy is best

A
  • Fever (greater than 38oC)
  • Drenching sweats, especially at night
  • Unintentional weight loss
    of greater than 10 % in < 6 months
  • excisional
21
Q

NHL: B-Cell Lymphomas

Indolent (25-40%)
- Relatively ___ survival
- Usually ___
- Follicular (Grade 1 or 2)
* Marginal zone
* Small lymphocytic lymphoma

A
  • long
  • incurable
22
Q

NHL: B-Cell Lymphomas

Aggressive (60-75%)
- Rapid growth
- ___ survival if untreated
- Usually ___
- Follicular (Grade 3)
- ___ (DLBCL)

A

short
curable
Diffuse large B-cell

23
Q

NHL: B-Cell Lymphomas

Highly Aggressive
- Doubling time = 18 hours
- Usually ___
- Burkitt’s
- Lymphoblastic
- AIDS-related

A

curable

24
Q

NHL – Treatment Approaches

A

Treatment depends on subtype, staging, and patient factors

25
Q

Follicular Lymphoma

Treated if symptomatic or patient preference 2nd most common type of NHL
- Low grade is not “curable,” so only treat when needed

Indolent: Grade 1 and 2, Median age: 60, Median survival: 8 to 10 years

A

Richter’s Transformation
- Follicular lymphoma can transform into an aggressive NHL!!
- Chemotherapy yields 40% CR (of the DLBCL) but: Still have underlying follicular lymphoma

26
Q

Diffuse Large B-Cell Lymphoma

(DLBCL)

30% of NHL

Median age of diagnosis: ___

30 to 40 % present with extranodal disease:
◦ Head/neck, GI tract, Skin, Bone, Testes, CNS

A

70

27
Q

NHL Multi-Agent Chemotherapy

R-CHOP

A
  • rituximab
  • cyclophosphamide
  • doxorubicin
  • vincristine
  • prednisone
28
Q

NHL Multi-Agent Chemotherapy

DA-EPOCH +
rituximab

A
  • Etoposide 50
  • Prednisone 60
  • Vincristine 0.4
  • Doxorubicin 10
  • Cyclophosphamide
  • rituximab

*Dose-adjustment paradigm based on twice weekly CBC (nadir ANC count

29
Q

NHL Multi-Agent Chemotherapy

Pola + R+ CHP

A

Polatuzumab vedotin

Rituximab

Cyclophosphamide
Doxorubicin
Prednisone

30
Q

DLBCL Treatment

  • ___ and ___ mostly
A

R-CHOP
Pola - R -CHP

31
Q

NHL – Rituximab and Hepatitis B

Hepatis B viral ___ seen in patients receiving anti-CD20 monoclonal antibody-based therapy
- Hepatitis B ___ antigen (HBsAg) and hepatitis B ___ antibody (HBcAb) prior to anti-CD20
directed therapy

Treatment with pre-emptive therapy: ___ 0.5 mg daily

A
  • reactivation
  • surface
  • core
  • entecavir
32
Q

Anti-CD20 antibody late neutropenia

Occurs in approximately 20% of patients

Onset is delayed, weeks to months after last exposure to CD20 monoclonal antibody therapy

Can be severe, but generally do not present with infections
Treatment: ___ (G-CSF)
◦ Intravenous immunoglobulins (IVIG) for refractory

A

gram colony stimulating factors

33
Q

Relapsed DLBCL/Aggressive NHL

___ intent
- ___ chemotherapy followed by ___ stem cell rescue
- Chimeric Antigen Receptor (CAR) T-cell therapy

Palliative chemotherapy
- Bendamustine + Rituximab + Polatuzumab

Bispecific T-cell Engagers
◦ Epcoritamab
◦ Glofitamab

A

Curative
- salvage, autologous

34
Q

CAR T-cell in NHL

3 drugs
all target ___

A

CD19
- Tisagenlecleucel
- Axicabtagene ciloleucel
- Lisocabtagene
maraleucel

35
Q

Bispecific T-cell Engagers

Third line option
◦ After at least 2 lines of systemic therapy
◦ Includes patients who progressed after CAR-T or stem cell transplant

Epcoritamab and glofitamab
◦ Receptor for CD3 on T-cell and ___ on B-Cells

Mechanism:
◦ Activation of T-cell = proinflammatory cytoxine release = B-cell lysis

A

makes T cell and cancer hold hands

36
Q

Bi-Specific T-Cell Engager & CAR

T-cell Unique Toxicities

Cytokine Release Syndrome (CRS)
- Cytokines are released when CAR T cells bind to their target antigen or T cells activated by binding to receptor and cause cancer cells destruction. Turns ___ the immune system

Treatment is emergent!
◦ Tocilizumab: anti-interleukin-6 (IL-6) (grade 2 or higher)
◦ Does not have impact on the efficacy of CAR-T-cell
therapy
◦ Corticosteroids (grade 3 or higher)
◦ ___ T-cell function

A
  • on
  • impairs
37
Q

Bi-Specific T-Cell Engager & CAR T-cell Unique Toxicities

Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS)
- Specific neurological assessments needed = immune effector cell encephalopathy (ICE) scores, which
include hand writing
- Underlying mechanism is not fully understood
- Treatment must be with ___

A

corticosteroids

38
Q

Lymphoma Summary

Most common hematologic malignancy

2 types:
◦ Hodgkin lymphoma
◦ Non-Hodgkin lymphoma

Treatment with multi-agent chemotherapy
◦ HL: ___
◦ NHL: ___

5-year overall survival is greater than 70%

A
  • ABVD
  • R-CHOP
39
Q

Multiple Myeloma (MM)

the ___ cells are messed up

A

plasma

40
Q

MM – Pathophysiology

Abnormal clonal ___ cells infiltrating the ___
◦ Plasma cells and MM cells produced from differentiated B-cells (after antigen stimulation

Secrete immunoglobulins
◦ 60% IgG, 20% IgA, 20% light chain only

A

plasma
bone marrow

41
Q

MM – Presentation

CRAB
- ___ >11.5 mg/dL
- ___ dysfunction SCr > 2 mg/dL or CrCL < 40 mL/min
- ___ < 10 g/dL or 2 g/dL
below normal
- ___ : one or more osteolytic lesions or pathologic fracture

A
  • calcium
  • renal
  • anemia
  • bone
42
Q

MM – Treatment Overview

  • disease is ___
  • Goal: disease control
A

incurable

43
Q

MM - induction therapy

A

MM – Agents

44
Q

Summary of Multiple Myeloma

disease is ___
- ___ drugs better than 2 drugs for induction

Corner stone of therapy: high dose chemotherapy followed by ___ stem cell rescue
◦ Induction -> consolidation -> maintenance
◦ Better outcomes to transplant with better disease control

Several regimens used in the relapse and refractory setting

A

incurable
3
autologous

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