Lymphomas

Question 1

Lymphomas

Answer 1

• Group of hematological malignancies that develop from lymphoid tissues
• 2 Subtypes: Non-Hodgkin and Hodgkin’s Lymphoma
• NHL: B or T cell derived
• HL: Reed-Sternberg cells

Question 2

NHL Clinical Presentation

Answer 2

• Variety of symptoms depends on site of involvement
• Fever, night sweats, weight loss (B symptoms), fatigue, malaise, pruritis
• 2/3 of patients present with peripheral adenopathy

Question 3

NHL Labs/Diagnostic

Answer 3

Labs

• CBC
• Serum electrolytes (SCr and LFTs)
• LDH may be helpful for prognosis/response to therapy

Diagnosis

• Biopsy
• PET/CT scan

Question 4

NHL Staging

Answer 4

• Stage I: Single nodal region
• Stage II: Two or more nodal region on same side of diaphragm
• Stage III: Nodal regions on both sides of diaphragm
• Stage IV: Diffuse extra-nodal disease

Question 5

FLIP-2

Answer 5

Follicular Lymphoma International Prognostic Index

• Age > 60
• B-2 microglobulin > ULN
• Hemoglobin < 12
• Bone marrow + for disease
• Largest lymph node > 6 cm

Question 6

IPI

Answer 6

International Prognostic Index for NHL

• Age > 60
• ECOG performance status > 2
• Serum LDH > 1x ULN
• > 1 extranodal site of disease
• Stage III or IV

Question 7

Follicular Lymphoma

Answer 7

• Indolent lymphoma in older adults
• Most patient have advanced disease at diagnosis
• Initial dramatic response to therapy, many relapses
• High conversion rate to DLBCL

Question 8

DLBCL

Answer 8

• Diffuse Large B Cell Lymphoma
• Most common lymphoma (30% of NHLs)
• Treated by Stage I/II non-bulky, Stage I/II bulky, and Stage III/IV

Question 9

DLBCL Treatment

Answer 9

• R-CHOP
• Given every 21 days
• Number of cycles and inclusion of radiotherapy depends on stage/bulkiness

Question 10

R-CHOP Toxicities

Answer 10

• Rituximab: infusion related rxns, Hep B reactivation
• Cyclophosphamide: myelosuppression. hemorrhagic cystitis, N/V, secondary malignancies
• Doxorubicin: cardiac toxicity, myelosuppression, mucositis
• Vincristine: constipation, peripheral neuropathy, jaw pain
• Prednisone: hyperglycemia, hypertension, weight gain, insomnia

Question 11

Relapsed/Refractory DLBCL

Answer 11

• 10-20% don’t get complete remission, and 20-30% of those who do relapse
• Give second line chemo with intent to get to high dose chemo and autologous stem cell transplant
• High dose chemo with autologous HSCT is preferred in young patient with chemosensitive relapse

Question 12

HL

Answer 12

• Hodgkin Lymphoma
• Malignant transformation of lymphocytes
• Presence of Reed-Sternberg Cells
• R-S Cells express CD30 and CD15

Question 13

HL Etiology

Answer 13

• Infectious exposure is a potential cause but no firm cause is known
• Increased risk of HL if infected with EBV
• Immunosuppressed also more likely to develop HL
• 25x greater in HIV patients

Question 14

HL Work-Up

Answer 14

• Labs
• Physical exam
• PET/CT (Staging)
• Bone marrow biopsy (disease extent)
• ECHO: doxorubicin cardiotoxicity
• Pulmonary function test: bleomycin

Question 15

Classifications of HL

Answer 15

1. Classical HL (CHL)

2. Nodular Lymphocyte Predominant HL (NLPHL)

Question 16

CHL

Answer 16

• Nodular Sclerosis
• Mixed cellularity
• Lymphocyte-rich
• Lymphocyte-depleted

Question 17

Ann Arbor Staging for HL

Answer 17

1. Early stage favorable: Stages I/II with no factors
2. Early stage unfavorable with non-bulky disease: Stages I/II
3. Early stage unfavorable with bulky disease: Stages I/II
4. Advanced stage disease: Stages III/IV

Question 18

Unfavorable HL Factors

Answer 18

• ESR > 50
• B symptoms
• Mediastinal mass ratio > 0.33
• > 3 nodal sites of involvement
• Bulky disease (any node > 10 cm)

Question 19

HL Treatment

Answer 19

• Radiation Alone: early stage predominant
• Chemo/Radiation
• Salvage Chemo: choose by response to initial therapy
• Hematopoietic stem cell transplantation

Question 20

BPT

Answer 20

• Bleomycin pulmonary toxicity
• Supportive care issue of ABVD
• Need baseline pulmonary fxn tests and follow-up through treatment
• More common with older age, pulmonary irradiation, and total doses > 400 units

Question 21

ABVD + Neutropenia

Answer 21

• Supportive care issue of ABVD
• Not an indication for dose reduction
• Can give safely without growth factors
• Bleomycin toxicities can also be exacerbated with the use of growth factors

Question 22

Extravasation Treatments

Answer 22

• Anthracyclines: cold and dexrazoxane

- Vinca alkaloids: heat and hyaluronidase

Question 23

HL Relapse/Refractory

Answer 23

• Majority occurs within 3 years of completing therapy
• Second line chemo with intent to initiate high dose chemo followed by autologous HSCT
• Radiotherapy to non previously treated sites

Question 24

Brentuximab

Answer 24

• Anti-CD30 antibody that binds to R-S cells and releases anti-microtubule agent once inside (MMAE)
• Use in advanced, untreated HL, relapsed/refractory HL, failure after autologous HSCT, or maintenance therapy after autologous HSCT for 1 year if high risk for relapse
• AE: myelosuppression, peripheral neuropathy

Question 25

Nivolumab HL Indications

Answer 25

• Progressed after autologous HSCT and brentuximab

- After 3 or more lines of systemic therapy that includes autologous HSCT

Question 26

Pembrolizumab HL Indications

Answer 26

-Relapses or refractory disease in those with 3 or more lines of chemo

Question 27

HL Survivorship

Answer 27

• Increased risk of developing many therapy related complications
• Detect early through screenings

Screen for following

• Secondary cancers (lung and breast)
• CV disease: mediastinal XRT and anthracyclines
• Hypothyroidism
• Fertility issues