Lymphoma

Question 1

Types of Lymphoma

Answer 1

Hodgkin’s lymphoma
Non-Hodgkin’s Lymphoma
- Diffuse large B-cell lymphoma
- follicular lymphoma

Question 2

NHL grading

Answer 2

indolent
aggressive
very aggressive

Question 3

Signs and Symptoms

Answer 3

Lymphadenopathy
B-symptoms:
- fevers
- night sweats
- weight loss
may mimic other cancers sx/imaging
laboratory abnormalities: SCr, LFTs, Uric acid

Question 4

NHL stage 1

Answer 4

single lymph nide or group of adjacent lymph nodes

Question 5

NHL stage 2

Answer 5

two or more groups of lymph nodes on same side of diaphragm

Question 6

NHL stage 3

Answer 6

Lymph nodes on both sides of the diaphragm

lymph nodes above the diaphragm with spleen involvement

Question 7

NHL sage 4

Answer 7

widespread disease in lymph nodes and organ involvement

Question 8

Diffuse Large B-cell lymphoma (DLBCL) Cytogenetics

Answer 8

BCL2 -> resistance to chemo

BCL6

MYC: rearrangement within an IgG gene
- double/triple hit: MYC + BCL2 +/- BCL6 (high grade lymphoma)

TP53

Question 9

R-CHOP

Answer 9

Gold standard in fit patients
- R: Rituximab 375 mg/m2 IV day 0
- C: Cyclophosphamide 750 mg/m2 IV day 1
- H: Doxorubicin 50 mg/m2 IV day 1
- O: Vincristine 1.4 mg/m2 IV day 1
- P: Prednisone 100 mg PO daily days 1-5

Given every 21 days x6 cycles

Question 10

Rituximab

Answer 10

MOA: chimeric monoclonal antibody binds to CD20
Admin: IV or SQ
ADE:
- TLS
- infusion reactions
- GI perforation
- hepatitis reactivation
- progressive multifocal leukoencephalopathy: JK virus, rare but fatal
- vaccinations less effective

Pearls:
- test for HBV and HCV prior to initiation
- infusion rxn risk highest cycle 1
- hold first cycle if disease in GI tract

Question 11

Cyclophosphamide pearls

Answer 11

contributes to alopecia
N/V: high risk antiemesis reg
Hemorrhagic cystitis: HYDRATE OR DIE-DRATE

Question 12

Doxorubicin pearls

Answer 12

• Lifetime cap dose 450 mg/m2
• monitor for cardiac dysfunction
• ejection fraction < 50% consider risk v benefit
• N/V and mucositis

Question 13

Vincristine pearls

Answer 13

• Dose/cycle capped at 2mg
• Fatal if given intrathecally
• Neuropathy
• sensory neuropathy: taste, smell, touch
• constipation

Question 14

Prednisone pearls

Answer 14

100mg daily
Hyperglycemia
Steroid induced psychosis
Insomnia

Question 15

CHOP: Supportive Care

Answer 15

Emetogenic Risk: high
- NK1 antagonist or olanzapine
- additional prednisone not necessary
Febrile neutropenic risk 11%
- growth factors routinely given
Viral reactivation (rituximab)
- give antiviral therapy for any patients who have had HBV (entecavir)
Tumor lysis syndrome
- aggressive hydration
- allopurinol 1st cycle
- hold rituximab?

Question 16

R-CHOP alternatives:

Answer 16

Poor LVEF and other CI to doxorubicin therapy:
- R-CEOP (rituximab, cyclophosphamide, etoposide, vincristine, prednisone)
- R CEPP (rituximab, cyclophosphamide, etoposide, procarbazine, prednisone)
- R CDOP (rituximab, liposomal doxorubicin, cyclophosphamide, vincristine, prednisone)
- R GCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, prednisone)
- R DA EPOCH (continuous infusion of doxorubicin)

NB: Anthracycline intensity tied to benefit
- can always consider using dexrazoxane

Question 17

Pola-R-CHP

Answer 17

Frontline option for DLBCL
Add Polatuzumab Vedotin and subtract vincristine from R-CHOP

ADE:
- higher FN

Question 18

Polatuzumab Vedotin

Answer 18

Antibody drug conjugate
ADE:
- peripheral sensory neuropathy
- neutropenia
- infusion related reactions

Question 19

DA-R-EPOCH

Answer 19

preferred over R-CHOP for:
- Double/Triple Hit Lymphoma
- Primary Mediastinal Lymphoma
- HIV-associated DLBCL

basically R-CHOP with continuous infusion of doxorubicin

Question 20

R-DHA

Answer 20

• R-DHAP (dexamethasone, high dose Ara C, CISplatin)
• R-DHAC (dexamethasone, high dose Ara C, CARBOplatin)
• R-DHOX (dexamethasone, High dose Ara C, Oxaliplatin)

Question 21

DLBCL Consolidation therapy

Answer 21

Preferred:
- R DHA
- R GDP (Gemcitabine, Dexamethasone, CISplatin)
- R ICE (Ifosfamide, CARBOplatin, Etoposide)

Can be used for CAR T-cell therapy
- R GemOX (Gemcitabine, Oxaliplatin)
- Pola BR (Polatuzumab, Bendamustine, Rituximab)

Question 22

CAR T-cell therapy

Answer 22

Indication: relapsed after 2 prior therapies, refractory to frontline regimen
sorta like a “vaccine”
ADE:
- infections
- neutropenia
- cytokine release syndrome (Hypotension, fevers, CIRS)
- neurotoxicity (HA, delirium, seizures, edema)

Question 23

Follicular lymphoma 1st line treatment: Stage I, II