NHL

Question 1

Epidemiology

Answer 1

8th most common new cancer diagnosis in the US

Median age of diagnosis: 68

Question 2

Pathophysiology

Answer 2

Malignant B or T lymphocytes and precursors

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

B-cell 85%–>precursor B-cell–>peripheral B-cell

Question 3

Risk factors

Answer 3

EBV
Burtkitt lymphoma
AIDS
H.pylori

Environmental exposures/physical agents

Question 4

Presentation

Answer 4

B-cell: lymph nodes, spleen, bone marrow

T-cell: extra nodal sites (skin and lungs)

B SYMPTOMS

Lymphadenopathy

Question 5

Diagnosis

Answer 5

Excisional biopsy

CT or PET imagining

Bone marrow biopsy

Lumbar puncture in patients with symptoms or high-risk disease

Question 6

Indolent B-cell lymphoma

Answer 6

25-40%

Relatively long survival

Usually incurable

Question 7

Aggressive B-cell lymphoma

Answer 7

60-75%

Rapid growth

Short survival if untreated

Usually curable

DLBCL

Question 8

Highly aggressive

Answer 8

Doubling time=18 hours

Usually curable

Burkitts

Lymphoblastic

AIDS related

Question 9

Staging and Prognosis

Answer 9

DLBCL and IPI

All patients:
Age> 60
Abnormal LDH
Performance status > 2
Ann Arbor III or IV
Extra nodal involvement > 2 sites

Less than 60 years old
Abnormal LDH
Performance status > 2
Ann Arbor stage III or IV

Question 10

Follicular lymphoma

Answer 10

2nd most common type of NHL

Indolent: Grade 1 or 2

Median age: 60

Treated if symptomatic or patient preference

Question 11

Richter’s transformation

Answer 11

Follicular lymphoma can transform into an aggressive NHL!

Chemotherapy yields 40% CR (of the DLBCL) but: Still have underlying follicular lymphoma

Treatment options include doxorubicin-based chemo with rituximab

Question 12

Diffuse Large B-cell Lymphoma (DLBCL)

Answer 12

30% of NHL

30-40% present with extra nodal disease

Genetic abnormalities to identify: double-hit/triple hit (MYC, BCL2, BCL6 translocations)

Therapy based on:
Ann Arbor stage
IPI score
Bulky mass
Localized vs advanced stage

R-CHOP x 6 cycles

Question 13

R-CHOP

Answer 13

Rituximab
Cyclophosphamide
Doxorubicin
Vincristine
Prednisone

Toxicities:
Neurotoxicities
Neutropenia
Anemia
Thrombocytopenia
Peripheral neuropathies

Question 14

Rituximab and Hepatitis B

Answer 14

Hepatitis B surface antigen and hepatitis B core antibody prior to anti-CD20 directed therapy

Treatment with pre-emptive therapy: entecavir 0.5 mg daily

Question 15

Relapsed DLBCL/Aggressive NHL

Answer 15

Salvage chemotherapy followed by autologous stem cell rescue

CAR-T cell therapy

Question 16

CAR-T cell process

Answer 16

1. Take the patients cells through leukapheresis
2. activate the patients T cells outside of the body
3. allow T cells to grow and multiple outside the patient
4. chemotherapy to get rid of the patients T cells that are not activated in the body
5. T-cell infusion - add the active cells back into the patient so they will attack the cancer

Question 17

BiTE

Answer 17

Third line option

after at least 2 lines of systemic therapy

Epcoritamab and glofitamab: receptor for CD3 on T-cell and CD20 on B-cells

Question 18

BiTE and CAR-T cell toxicities

Answer 18

Cytokine storm: fever, tachycardia, hypotension

Immune Effector Cell-Associated Neurotoxicity (ICANS)–> CAR-T: tremors, confusion, seizures, cerebral edema/coma