Non-Hodgkin's Lymphoma

Question 1

What is the difference in staging/prognosis between HL and NHL?

Answer 1

HL

• Ann Arbor focuses on distribution of lymph node sites, as HL tends to have contiguous lymph node spread and has little or no extranodal involvement

NHL

• NHL does not spread contiguously and frequently involves extranodal sites
• Many NHL patients stage III or IV at diagnosis

Therefore, Ann Arbor stage correlates poorly with outcomes/prognosis in NHL.

Question 2

treatment options for stage I/II indolent NHL (25%)

Answer 2

• Radiation alone can be curable
• Can do chemotherapy + radiation

Question 3

general treatment options for stage III/IV indolent NHL (75%)

Answer 3

• Conservative strategy (preferred in patients who are older, have co-morbidities, asymptomatic, or minimal tumor burden)
  
  • Observation (“watch and wait”)
  • Radiation OR biologic therapy OR single agent-chemotherapy
• Aggressive strategy:
  
  • Combination chemotherapy + biologic therapy +/- radiation
  • Radioimmunotherapy

Question 4

chemotherapy options for indolent lymphomas

Answer 4

• CHOP or CVP
• Bendamustine

Question 5

biologic options for indolent lymphomas

Answer 5

• Rituximab (Rituxan®, Rituxan Hycela®)
• Obinutuzumab (Gazyva®)

Question 6

rituximab MOA

Answer 6

Rituximab is a monoclonal antibody directed against CD20, and has multiple MOAs that coordinate the immune system.

Question 7

rituximab side effects

Answer 7

• Infusion-related reactions (hives, rash, SOB, fevers, flushing)
  
  • Pre-medicate prior to each infusion with acetaminophen, diphenhydramine +/- a corticosteroid
  • Titrate infusion based on patient’s tolerability
• Delayed neutropenia
• Tumor lysis syndrome

Question 8

obinutuzumab pros/cons

Answer 8

PROS

• Can use in patients resistant to rituximab
• More potent at inducing ADCC and complement-mediated cytotoxicity than rituximab

CONS

• More neutropenia than rituximab

Question 9

bendamustine MOA

Answer 9

• Alkylator: rapid production of DNA crosslinks and DNA strand breaks
• Novel mechanisms: possible inhibition of mitotic checkpoints and purine antagonist
  
  • Novel mechanism may explain why it is active in patients with disease refractory to other alkylators (typically use in relapsed/refractory setting) and in combination with rituximab

Question 10

bendamustine side effects

Answer 10

• Myelosuppression (but really not that bad)
• Infusion-related reactions (common with subsequent infusions)
• Rash and skin reactions
• Patients don’t lose their hair!

Question 11

Diffuse Large B-Cell (DLBCL) is the most common subtype of NHL, and is considered aggressive.

Describe general treatment options for DLBCL.

Answer 11

• Localized Disease (Stage I and II)
  
  • Chemotherapy +/- radiation
• Advanced Disease (Stage IIB, III, IV)
  
  • Chemotherapy

Question 12

first-line chemotherapy and biologic therapy for DLCBCL

Answer 12

• Chemotherapy: CHOP repeated every 21 days
  
  • Rituximab 375 mg/m2 IV, day 1
  • Cyclophosphamide 750 mg/m2 IV, day 1
  • Doxorubicin 50 mg/m2 IV, day 1
  • Vincristine 1.4 mg/m2 (cap at 2 mg) IV, day 1
  • Prednisone 100 mg PO, days 1-5
• Biologic therapy: rituximab

Question 13

cyclophosphamide side effects

Answer 13

• Nausea/vomiting (acute and delayed)
• Myelosuppression
• Hemorrhagic cystitis (generally not seen with doses ≤ 1250 mg/m2, supportive mesna not routinely used)

Question 14

vincristine side effects

Answer 14

• Peripheral neuropathy
• Constipation
  
  • May need OTC laxatives
  • Senokot-S 1-2 tabs PO QHS

Question 15

N/V patient education (R-CHOP)

Answer 15

• Considered moderately emetogenic
• Prednisone included in regimen, only need 5HT3 antagonist
• See ABVD Patient Counseling

Question 16

FN patient education (R-CHOP)

Answer 16

• Nadir around day 7-10, recover by day 14
• Most institutions will use G-CSF on day 2, (not required unless doing every 14-day regimen)