Lymphoma Management

Question 1

How is lymphoma disease managed?

Answer 1

• very chemo sensitive
• systemic disease
• chemo is first line of treatment, typically
• can be followed by RT

Question 2

How is early hodgkins lymphoma managed?

Answer 2

• (Stage 1 or 2, no B-symptoms)
  -Combined modality chemo followed by RT
• Chemo drugs used are ABVD (first line)

Question 3

What is ABVD chemo?

Answer 3

• A–doxorubicin(Adriamycin®)
  Thrombocytopenia, Anaemia, Nausea, Fatigue, mouth ulcers, hair loss, liver and kidney function
• B–bleomycin
  Thrombocytopenia, Anaemia, nausea, loss of appetite, hair loss, mouth ulcers, lung damage
• V–vinblastine(Velbe ®)
  Thrombocytopenia, Anaemia, Nausea, Fatigue, constipation/ diarrhoea, hairloss, peripheral neuropathy, head ache, jaw pain
• D–dacarbazine(DTIC)
  Thrombocytopenia, Anaemia, Nausea, loss of appetite, fatigue, sensitivity to sunlight (rare)

Question 4

What is the HD10 study?

Answer 4

• German
• Research indicated that chemo + RT gives best chance of cure
• Chemo first
• IFRT (involved field)

Question 5

What is IFRT?

Answer 5

• Involved field
• includes mantle, inverted Y with extended FSD
• All nodes in area are treated
• Mantle includes square from chin to diaphragm
• Mantle would include breast, mouth, lung, oesophagus - SE bad, now include MLCs not one big square
• Tends to be used with as small a field as possible

Question 6

What is ISRT?

Answer 6

• Involved site
• Uses imaging data before chemo
• Smaller CTV

Question 7

What is INRT?

Answer 7

• Involved Node
• Use PET scan from pre-chemo

Question 8

What is EFRT?

Answer 8

• Extended field
• No survival benefit between EF and IF

Question 9

Is radiotherapy beneficial in early stage?

Answer 9

• Inconclusive
• Some results show slight benefit
• Still recommended for early stage HL
• Can be before or after due to the use of pre-chemo scans anyway

Question 10

What is Deauville criteria?

Answer 10

• Looks at FDG uptake
• FDG uptake looks at the degree of malignancy of an area or mass within a body
• The degree of uptake can be altered due to various factors including treatment
• Positive result when compared with initial finding may be very different
• Deauville criteria takes into account the findings at diagnosis and possible reaction to treatment.

Question 11

Will RT be used as primary treatment for HL?

Answer 11

• in early stage lymphocyte-predominant HL
• CTV increased to fight microscopic disease

Question 12

What is RT dose for early HL?

Answer 12

• 20Gy in 10#
• 30Gy in 15# (unfavourable characteristics)

Question 13

How is intermediate HL treated?

Answer 13

• Stage 1 + 2 with risk factors
  -Standard chemotherapy: 4 cycles of ABVD,
  -Standard radiotherapy IFRT, 30.6Gy 17#

Question 14

How is advanced stage HL treated?

Answer 14

• chemo alone
• combined with RT if there is a large residual mass
• ABVD- 4 cycles
  BEACOPP- Dose escalated, up to 8 cycles
  (a more intensive course of chemotherapy involving; bleomycin,etoposide,doxorubicin cyclophosphamide,vincristine(Oncovin®),
  procarbazineand prednisolone)
• consolodative RT: ESMO (European society for medical oncology) recommend localised RT with 30Gy to residual lymphoma greater than 1.5cm

Question 15

How is progressive or relapsed HL treated?

Answer 15

• chemo with bentuximab, if response seen, HDT with autologous stem cell transplant
• RT alone (localised late relapse)
• allogenic stem cell transplant

Question 16

How is follow up managed in HL?

Answer 16

• every 2 months for 2 years
• every 3 months for 2 years
• every 6 months there after

Question 17

How is NHL managed?

Answer 17

• RT utilised if localised and agressive lymphomas
• RT can be delivered as consolidation
• Many patients cured with shorter chemo and consolidation RT
• RT important in treating patients not suitable for systemic treatment

Question 18

How are fields determined for NHL?

Answer 18

• CTV is determined from original scans
• Involvced nodal groups closer than 5 cm will be in one field
• Further than 5cm they will be treated in separate fields

Question 19

What is a typical RT dose for NHL?

Answer 19

• 30-55Gy in fractionations of 1.8-2.0Gy in approx 30#
• Agressive can be around 40-55Gy
• recent trials have found no significant difference between doses

Question 20

How do monoclonal antibodies work in Lymphoma?

Answer 20

• take advantage of tumour-related-targets
• e.g CD20
• bare antibody covalently links to cytotoxic compound
  -deliver cytotoxic compound to target antigens
• Useful in B-cell NHL
• Use of retuximab has reduced mortality rate (CD20)
• Brentuximab (CD30)
• Nivolumab (replapse classical HL, following auto SCT and brentuximab)
• Ibritumomab CD20+ve and rituximab has failed

Question 21

How is follicular NHL managed?

Answer 21

• Indolent (most common)
• Does patient have symptoms?
• Watch and wait
• Retuximab induced therapy
• Retuximab with additional drugs
• If relapse, retuximab and chemo, perhaps stemp cell transplant if multiple relapse

Question 22

How is diffuse Large B-cell lymphoma managed?

Answer 22

• Most common and agressive NHL
• Grows rapidle, short time e.g few weeks
• Always express CD20
• R-CHOP x 8 cycles, no response then salvage chemo, then consolidation HDT and stem cell transplant
• No response = palliative RT
• RT may be used as first treatment if bulky disease, after response to immunochemo and consolidated with stem cell transplant