NH Lymphoma Flashcards
Treatment - Stage I NHL - SWOG 8736
CHOP x3 followed by involved field XRT better OS than CHOP x8
done quicker, less cardiotox probably
Why CHOP in NHL - SWOG 8516 (1993)
CHOP vs (MACOP-B, m-BACOD, ProMACE-CytaBOM)
3yr OS same 50-54%
more deaths in other 3
IPI negative prognostic variables
Age >60yo, LDH >1x ULN, PS EGOG 2-4, Stage III or IV, >1 extranodal sit of involvement* (*not prognostic in pts <60)
R-CHOP 2002 study- 1st study (GELA 98.5) (french)
60-80yo; 2yr OS 70 vs 57% (early f/u but good signal); -> 5yr OS ~60 vs ~45%
IPI by CR and 5yr OS -3
0-1 87% CR, 5 yr OS 73%
2-3 55-67% CR, 5yr OS 43-51%
4-5 44% CR, 5yr OS 26%
Rituximab induction vs maintanence in NHL - ECOG 4494
Does not matter when you get just that you do so we give R-CHOP for convinence
R-CHOP =CHOP+MR =R-CHOP+MR >CHOP
rituximab maintenance post-SCT
maintenance vs none; no benefit 4yr OS 61-65%
DHAP (=ESHAP, =ICE) vs autoSCT in NHL
Use autoSCT if prove chemosensitivity first with DHAP=ESHAP=ICE. then auto 53% 5 yr OS vs DHAP 32%
Treatment - Indolent NHL - oral cyclophosphamide vs CHOP-B (bleomycin)
OS 8.7yrs vs 9.7; CR 66 vs 60%, TTF 4.2yrs vs 3.6
Treament - Indolent NHL - rituximab only
RR 48%, TTP 13mo; THEN retreatment RR 40%, TTP 17.8mo
Treament - Indolent NHL - R-CVP (vs CVP, R-CHOP)
CR 41%, 10%, 55%; TTP 32mo, 15mo, NOT reached (really looking at R-CVP here, NOT R-CHOP)
Consensus Role of autoSCT in NHL
- chemosensitive relapse (yes) 2. untested relapse (No) 3. chemorefractory relapse (No) 4. Pts slow responders to CHOP or PR to front line chemo (unknown) 5. front line (unknown)
indolent NHL pathophysiology
median 55 yo, survival 11 years, time until tx 3 yrs, spontaneous regression 19%, Richter’s transformation 20%
PRIMA trial - assesment of maintenance R in indolent NHL
maintenance R (q8wks x2yrs) improves 3yr PFS 75% vs 58%, TTP not reached vs 48.3mo; discontinue rate 4 vs 2% (AE=infusion related events which get better with each infusion)
when to tx indolent - more advanced
pleural/cardiac effusions, ascites, CNS involvement, marrow infiltration (cytopenias), severe B sx, symptomatic dz not amenable to XRT
indolent - observation vs chemotherapy (ProMACE-MOPP)
5yr OS - >75% for both
rituximab
murine/human; CD20 on normal and malignant cells; induces apoptosis and activates complement rxn
bendamustine vs R-bendamustine indolent NHL
alkylating agent + antimetabolite activity; CR 15 vs 14%; TTP 7.1 vs 9.3mo (lean toward adding R given TTP result)
R-bendamustine vs R-CHOP (std of care) indolent NHL
PFS 69.5 vs 31.2, need for salvage tx decreased, death and secondary malignancies same (moving this toward std of care) (NOT ON EXAM)
radioimmunotherapy rituximab - ibritumomab tiuxetan –2nd line post R treatment
CR 30 vs 16%, TTP 11.2 vs 10.1mo (not used much– cost, inc pt visits
ibritumomab tiuxetan –1st line - phase II only
CR 75%, PFS 6.1yr, not std of care, long term secondary malignancies not known
Richter’s Syndrome - pathophysiology
1 in 5 pts, median time from dx to transformation 66mo, median survival after transformation 22mo, DLBCL most common, 40%CR, SAVE doxorubicin for this!! (it does not inc OS 1st or 2nd line) if possible
Richter’s Syndrome - good progrnostic factors
limited extent of dz, prior CR with tx, no prior chemo
Mantle cell - treatment
1st line: R-hyperCVAD
2nd line: bortezomib
Role of SCT?? allo vs auto
MALT lymphoma - treatment
lining of stomach; H. pylori tx (clarithromycin, omeprazole, amoxicillin)
cutaneous T cell - treatment - denileukin diftitox
MOA CD25 fusion protein, RR 30%, toxicity: capillary leak, lymphopenia, fever; NOT AVAILABLE IN US
cutaneous T cell - treatment - bexarotene
MOA retinoid (RAR-X receptor), RR 50%, toxicity: rash, inc lipids, lymphopenia
cutaneous T cell - treatment - vorinostat
MOA HDAC inhibitor, RR 30%, TOX: inc glucose, dec platelets, diarrhea
cutaneous T cell - treatment - romidepsin
MOA HDAC inhibitor, RR 30%, TOX: arrhythmias, rash, hypotension, myelosuppresion
cutaneous T cell - treatment - goals
shedding too much skin, avoid open ulcers, avoid staph aureus bacteremias
peripheral T cell - treatment - 1st line
CHOP
peripheral T cell - treatment - 1st line –more aggressive than indolent
pralatrexate, MOA: antifolate, RR 31%, TOX: edema, fatigue, fever, rash, hypokalemia, N/V, mucositis, myelosuppression, hepatotox; (competes for tubular secretion with NSAIDs, probenecid, PCN’s) (supplement vit b12, folate)
anaplastic large cell lymphoma - treatment - relapsed, refractory dz after CHOP (T cell)
phase II - brentuximab vedotin 1.8mg/m2 q21d up to 16 doses- RR 86%, CR 57%, duration of response 13 mo, 12 mo OS 70%
