Onco 2: Lymphohohohoma Flashcards
risk factors for lympohma
- male
- older age (and younger agen in hodgkiins)
- immunosuppression
- enovironmental
- radiaiton
- infections (Epstein and HIV)
numbered for footnote, not in order
- 3, 4, 5 esp in DLBCL
- 6 esp in Hodgkin’s
B symptoms
seen in 30% of all B cell lympohomas
- fever
- wt loss (10% over 6 months)
- nigh sweats
Diffuse large B cell (DLBCL) relapse
- even though it’s curable, it’s so aggressive, high chance of relapse
- CAR-T
- BsAb (bispecifc Ab)
- autologous stem cell transplant
- salvage chemo
- R-ICE
- GDP
R-ICE
- Rituximab
- Ifosfamide
- Carboplatin
- Etoposide
GDP
- Gemcitabine
- Dexamethasonne
- carboPlatin
refractory - salvage chemo
DLBCL presentaiton
- B symptoms
- nodal mass
- elevated lactate dehydrogease
- bone marrow involvement
- AMS
- laboratory abnoralities: SCr, uric acid, LFTs, electolytes
ympoh nodes lysing (can lead to TLS) -> the dehydrogenase and alb abnormalities
DLBCL dx
lympoh node bioposy
- IHC panel to look for ccertain mutations: for non-Hodgkin’s, CD20 is important
- imaging (PET scan) to fiure out what to biopsy
DLBCL prognosis
use the IPI (international prognosis index)
- low score = high risk -> poorer outcomes
DLBCL treatment
standard treatment (does not include the ifs: EF, CNS, frail)
- preferred: R-CHOP or pola-R-CHP
- other: DA-R-EPOCH
- no difference between pola-R-CHP and R-CHOP except that pola may be better for pts with subtype ABC
- DA-R-EPOCH preferred in more aggressive lympohomas: CMAC, BCL2 and BCL6
DLBCL treatment in pts with EF < 40%
canNOT receive doxorubucin at regular dose/infusion/formulation
- DA-R-EPOCH: slower infusion -> less cardiotox
- R-CDOP: liposomal doxorubicin instead of regular
- R-CEOP
DLBCL treatment in frail pts or pts > 80
- R-mini-CHOP
- R-CDOP
- R-CEOP
DLBCL treatment in pts with parenchymal presnetiaton
R-CHOP + high dose MTX
DLBCL treatment in pts iwth leptomenigeal presentaiton
intrathecal MTX/cytarabine
OR R-CHOP with high dose MTX
R-CHOP
- Rituxima
- Cyclophosphamide
- Hdryoxydaunorubicin (doxorubicin)
- Ocovin (vincristine)
- Prednisone
Pola-R-CHP
- Polatuzumab vedotin
- Rituximab
- Cyclophosphamide
- Hdryoxydaunorubicin (doxorubicin)
- Prednisone
NO vincrisitne dt severe neuropathy risk
DA-R-EPOCH
- Dose Adjusted
- Rrituximab
- Etoposide
- Cyclosphosphamide
- Hdryoxydaunorubicin (doxorubicin)
- Ocovin (vincristine)
- Prednisone
give G-CSF ppx dt febrile neutorpenia risk
R-CDOP
- Rituxima
- Cyclophosphamide
- Doxorubicin (liposomal)
- Ocovin (vincristine)
- Prednisone
R-CEOP
- Rituxima
- Cyclophosphamide
- Etoposide
- Ocovin (vincristine)
- Prednisone
R-CEPP
- Rituxima
- Cyclophosphamide
- Etoposide
- Prednisone
- Procarbazine
what makes DA-R-EPOCH “dose adjusted”
twice weekly labs
- ANC and plts too high icrease dose
- ANC and plts too low, decrease dose
why did R-CHOP become the mainstay isntad of CHOP
MiNT trial: rituxuimab improves surival vs CHOP wihtout increasing tox
R-CHOP overall ADR
- high emetic risk
- moderate febrile neutropenia risk (consdier G-CSF)
- infections
- fattigue
- anemia, neutropenia, thromboctyopenia
- alopecia
doxorubicin ADR
cardiotox -> max lifetime dose
vincristine ADR
- peripheral neuropathy: max dose 2mg
- constipation
cyclosphosphamdie ADR
hemorrhagic cystitis (though this is unlikely at CHOP dose)
rituximab MOA
anti-CD20
rituximab ADR
- infusion relataed rxn -> premiedicae and give first dose over 6 hrs (if well tolerated can give susbequent doses in like 60-90min)
- HepB reactivation
- hypergammaglobinuemia (B cell depletion) - consider holdign for first cycle if lyphoma in GI tract dt perforation
- progressive multifocal leukoencephalopathy
when to give entavacir in pts receiving rituximab
if pt has chronic HepB
- HBsAg (+) and antiHBC (+)
polatuzmab MOA
antiCD79B antibody-drug (vedotin) complex
- mab directly delivers drug to tumor
polatuzumab ADR
- constsipation
- skeletomuscular pain
- peripheral neuropathy
- infusion reaction
- anemia, neutropenia, thrombocytopenia
CLL/SLL
accumulation of immunologically dysfunctional mature B lympohcytes
- up to 50% pts do NOT need treatment
CLL/SLL sympotms
only 30% of pts symptomatic
- enlarged lympoh nodes
- enlarged spleen or liver
- B symptoms
- autoimmune cytopenia; hemolytic anemia or ITP
- hypergamaglobinemia -> frequent infeciotsn
CLL/SLL prognosis factors
unfavorable outcomes if
- del(17p)
- Tp53 mutation
who gets treatment in CLL/SLL
- sympotomatic: B sympoms
- end organ damage
- progression of bulky disease: splenomegaly or lypohadenopathy
- bone marrow failure: anemia, thrombocytopenia
- disease outside of lymph ndes
CLL/SLL treatment: of pts who are getting treatment, who gets fixed duration adn who gets indefinite and what’s the treatment
- indefiite: elderly, poor performing, pt preference
- (acalabrutinib +/- obinutuzumab) OR (zanubrutinib) - fixd duraiton: younger, good performing (no comorbidites, no renal impairment
- venetoclax + obinutuzumab
Obinutuzumab MOA
2nd gen antiCD-20 (lil more potent than rituximab)
- Ab dependent cellular cytotox
- complement dependent cytotox
- Ab dependent phagocytosis
- activation of lysosomes -> cell death
Obinutuzumab ADR
- infusion reaction -> titration schedule for first cucle and pre-medicate
- Hep B reactivation - chekc panel prior to start
- incrased risk of viral infectionN: acyclovir ppx
BTKi MOA
bruton tyrosine kinase inhibitors
- bind to BTK enzyme -> prevent BCR sgnaling
- prevent proliferation and surivval of malignant nad normal cells
on initiation may have transient increase in lympohcyte count -> does NOT mean disease progression
BTKi ADR
by agent
- ibrutinib: neutropenia, afib, HTN, bleed, diarrhea
- acalabrutinib: HA and musculosketela pain (self resolving, APAP and NSAIDs prn)
- zanubrutinib: neutropenia (and least likely to cause afib)
classical Hodgkin’s presentaiton
presence of mature B cells with 2 nuclei (Reed-Sternberg cells)
- B sympotoms
- lymphadenopathy - lympoh node biopsy (+) for CD30+
- gneralize malaise: cough, SOB, decreased appetite
classical Hodgkin’s treatment
cHL
goal is cure
- stage I/II (whether or not favorable or bulky: ABVD
- stage III/IV: ABVD or BV+AVD
ABVD
- Adriamycin (doxorubicin)
- Bleomycin
- Vinblastine
- Dacarbazine
BV-AVD
- Brentuximab Vedotin
- Adriamycin (doxorubicin)
- Vinblastine
- Dacarbazine
no bleomycin dt pulm tox
ABVD general ADR
- high emetic risk -> high anti-emetic ppx
- infection
- fatigue
- anemia, neutropenia, thrombocytopenia
- alopecia
bleomycin ADR
pulm tox
- avoid G-CSF despite some febrile neutropenia risk for ABVD; if pt at high risk for recurrence, can dc bleomycin and do G-CSF
can also dc bleomycin if pt doing well? we want to use lowest dose
dacarbizine ADR
cytopenias
brentuximab vedotin MOA
antiCD30 Ab-drug conjugate
brentuximab vedotin ADR
- peripheral neuroapthy
- infusion rxn
- anemia, neutropenia, thrombocytopenia
- pulm tox
- constipation
MUST give with G-CSF (febrile neutropenia risk?)
non-Hodgkin’s relapse/refractory treatment
DLBCL
typically occurs within 3 yrs
- salvage chemo: R-ICE OR GVD
- autologous stem cell transplant
- immunotherapy (can add to salvage therapy): nivolumbab or pembrolizumab
GVD
- Gemcitabine
- Vinorelbine
- Doxorubicin (lipsomal)
