NH Lymphoma

Question 1

Treatment - Stage I NHL - SWOG 8736

Answer 1

CHOP x3 followed by involved field XRT better OS than CHOP x8
done quicker, less cardiotox probably

Question 2

Why CHOP in NHL - SWOG 8516 (1993)

Answer 2

CHOP vs (MACOP-B, m-BACOD, ProMACE-CytaBOM)
3yr OS same 50-54%
more deaths in other 3

Question 3

IPI negative prognostic variables

Answer 3

Age >60yo, LDH >1x ULN, PS EGOG 2-4, Stage III or IV, >1 extranodal sit of involvement* (*not prognostic in pts <60)

Question 4

R-CHOP 2002 study- 1st study (GELA 98.5) (french)

Answer 4

60-80yo; 2yr OS 70 vs 57% (early f/u but good signal); -> 5yr OS ~60 vs ~45%

Question 5

IPI by CR and 5yr OS -3

Answer 5

0-1 87% CR, 5 yr OS 73%
2-3 55-67% CR, 5yr OS 43-51%
4-5 44% CR, 5yr OS 26%

Question 6

Rituximab induction vs maintanence in NHL - ECOG 4494

Answer 6

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

Question 7

rituximab maintenance post-SCT

Answer 7

maintenance vs none; no benefit 4yr OS 61-65%

Question 8

DHAP (=ESHAP, =ICE) vs autoSCT in NHL

Answer 8

Use autoSCT if prove chemosensitivity first with DHAP=ESHAP=ICE. then auto 53% 5 yr OS vs DHAP 32%

Question 9

Treatment - Indolent NHL - oral cyclophosphamide vs CHOP-B (bleomycin)

Answer 9

OS 8.7yrs vs 9.7; CR 66 vs 60%, TTF 4.2yrs vs 3.6

Question 10

Treament - Indolent NHL - rituximab only

Answer 10

RR 48%, TTP 13mo; THEN retreatment RR 40%, TTP 17.8mo

Question 11

Treament - Indolent NHL - R-CVP (vs CVP, R-CHOP)

Answer 11

CR 41%, 10%, 55%; TTP 32mo, 15mo, NOT reached (really looking at R-CVP here, NOT R-CHOP)

Question 12

Consensus Role of autoSCT in NHL

Answer 12

1. 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)

Question 13

indolent NHL pathophysiology

Answer 13

median 55 yo, survival 11 years, time until tx 3 yrs, spontaneous regression 19%, Richter’s transformation 20%

Question 14

PRIMA trial - assesment of maintenance R in indolent NHL

Answer 14

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)

Question 15

when to tx indolent - more advanced

Answer 15

pleural/cardiac effusions, ascites, CNS involvement, marrow infiltration (cytopenias), severe B sx, symptomatic dz not amenable to XRT

Question 16

indolent - observation vs chemotherapy (ProMACE-MOPP)

Answer 16

5yr OS - >75% for both

Question 17

rituximab

Answer 17

murine/human; CD20 on normal and malignant cells; induces apoptosis and activates complement rxn

Question 18

bendamustine vs R-bendamustine indolent NHL

Answer 18

alkylating agent + antimetabolite activity; CR 15 vs 14%; TTP 7.1 vs 9.3mo (lean toward adding R given TTP result)

Question 19

R-bendamustine vs R-CHOP (std of care) indolent NHL

Answer 19

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)

Question 20

radioimmunotherapy rituximab - ibritumomab tiuxetan –2nd line post R treatment

Answer 20

CR 30 vs 16%, TTP 11.2 vs 10.1mo (not used much– cost, inc pt visits

Question 21

ibritumomab tiuxetan –1st line - phase II only

Answer 21

CR 75%, PFS 6.1yr, not std of care, long term secondary malignancies not known

Question 22

Richter’s Syndrome - pathophysiology

Answer 22

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

Question 23

Richter’s Syndrome - good progrnostic factors

Answer 23

limited extent of dz, prior CR with tx, no prior chemo

Question 24

Mantle cell - treatment

Answer 24

1st line: R-hyperCVAD
2nd line: bortezomib
Role of SCT?? allo vs auto

Question 25

MALT lymphoma - treatment

Answer 25

lining of stomach; H. pylori tx (clarithromycin, omeprazole, amoxicillin)

Question 26

cutaneous T cell - treatment - denileukin diftitox

Answer 26

MOA CD25 fusion protein, RR 30%, toxicity: capillary leak, lymphopenia, fever; NOT AVAILABLE IN US

Question 27

cutaneous T cell - treatment - bexarotene

Answer 27

MOA retinoid (RAR-X receptor), RR 50%, toxicity: rash, inc lipids, lymphopenia

Question 28

cutaneous T cell - treatment - vorinostat

Answer 28

MOA HDAC inhibitor, RR 30%, TOX: inc glucose, dec platelets, diarrhea

Question 29

cutaneous T cell - treatment - romidepsin

Answer 29

MOA HDAC inhibitor, RR 30%, TOX: arrhythmias, rash, hypotension, myelosuppresion

Question 30

cutaneous T cell - treatment - goals

Answer 30

shedding too much skin, avoid open ulcers, avoid staph aureus bacteremias

Question 31

peripheral T cell - treatment - 1st line

Answer 31

CHOP

Question 32

peripheral T cell - treatment - 1st line –more aggressive than indolent

Answer 32

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)

Question 33

anaplastic large cell lymphoma - treatment - relapsed, refractory dz after CHOP (T cell)

Answer 33

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%