Aggressive: 55-60% most common-survival measured in weeks-months
Highly Aggressive: 5% medical emergency measured in days.
What are the involved sites for B-cell NHL?
C.
What are the involved sites for T-cell NHL?
D.
What are the invoved sites for lymphadenophathy? a. skin and lungs
b. lymph system, spleen, bone marrow,
c. GI tract (nausea pain vomiting), bone marrow
d. localized pain, swollen painless lymph nodes, extremity edema?
D.
What are the invoved sites for extranodal involvement?
C.
Note, NHL will originate outside the bone marrow but can move to this site.
What are NHL B symptoms? (3)
Weight loss: >10% in 6 months
Drenching Night Sweats
Fevers of unknown origin.
Noted seen in 40-50%, more common in aggressive or highly aggressive diseases.
When are bone marrow biopsies used in diagnosis?
When WBC are off, bone marrow is rarely involved--signifies a poor prognosis.
What is the Ann Harbor Staging Classification system (four stages and 2 designations).
Stage Criteria Designation
(Applicable to all Stages)
I Single nodal region or single
extranodal site
II ≥2 lymph regions on the same side
of the diaphragm
III Lymph nodes on both sides of the
diaphragm
IV
Lymph node involvement and
extensive involvement of liver,
lung, or bone marrow
*If localized (stage III), bulky disease, then treat like advanced (stage IIIIV)
A. No "B" symptoms
B. "B" symptoms--fever, night sweats, weight loss
What are the most common types of NHL (3 kinds and what %)?
DLBCL: 30% diffuse large b-cell lymphoma--Aggressive
Follicular: 22% indolent
MALT: 7.6%
Which of these three cell stages are potentially curable with chemotherapy and why?
A. indolent/low grade
B. Aggressive/intermediate grade
C. Highly Agressive/High Grade?
B and C.
A is not because the cells are not dividing rapidly enough for the chemo to work, has a pallative goal instead.
What are some good prognosis factors for Follicular Lymphoma?
How many adverse factors does one need low risk class, intermediate, or high?
What are the critera for localized FL disease? Looking for stage, % affected, size, and treatment type/duration.
Stages: 1 and 2
%: <30
Size: non bulky=<10 cm diameter
Treatment: Radiation, CHOP for 3 cycles +radiation
What are the criteria for advanced FL disease? Looking for stage, size, when to treat.
Stage: 3 or 4, or bluky 1 or 2
Size: bulky=>10 cm
Treat: when recurrent infections, symptomatic, end organ failure, cytopenia, massive bulk, steady progression over six months, and pt pref.
What are FL treatment options? (6)
WObservation
Single agent rituximab
Combination therapy: CHOP, CVP
Combo therapy and rituximab
Chemo followed by 2 yrs or rituximab
Radioimmunotherapy
CVP is the most common therapy in FL
What is CVP? (Drug, Dose, frequency)
Cyclophosphamide Iv 750mg/m2 over 1 hr Day 1
Vincristine IV push 1.4mg/m2 Day 1 (max 2 mg)
Prednisone PO 40 mg/m2/day Days 1-5
Every 21 days for max of 8 cycles
What is CHOP? (drug, dose, frequency) What about R-CHOP
CHOP
Cyclophosphamide
IV 750mg/m2 over 1 hr day 1 C
Doxorubicin IV push 50mg/m2 day 1H (first drug used was hydroxyrubicin)
Vincristine IV push 1.4mg/m2 day 1 (max 2 mg) O (brand name)
Prednisone PO 40 mg/m2 day 1-5 P
Given every 21 days.
R-CHOP: chop with addition ofRituximab=375 mg/m2 day 1
1.pre med: APAP PO 625, and
diphenhydramine PO 25 mg
2. Start infusion rate= 50
-100mg/hr
3. Max infusion rate of 400 mg/hr
Criteria for aggressive NHL (DLBCL)? (Age, performance status, LDH, extranodal sites, stage)
Age: >60 years
PS: > 2 (score b/w 0-3)
LDH: > 1x normal
extranodal: > 2 (GI, bone marrow, sinus, lung, liver)
stage: III-IV
low=1 low intermediate=2 high intermediate=3 and high=4+
~Treatment for stage I-II no "b" symptoms non bulky DLBCL?
R-CHOP (where R=rituximab) for 3 cycles followed by radiation
*curative in ~50% of patients. Addition of R increases relapse free survival and overall survival..
Treament for stage I-II bulky or III/IV DLBCL?
R-CHOP for 6-8 cycles
*NO RADIATION= increase SE and no benefit
Rituximab AE and concerns
Infusion Rxns 50-75%: Fevers, Chills, N/V pruritis, HA, dizziness, anaphylaxis
risk highest with first dose
start low and go slow
Hyper or hypotension 20%: (low bp more common, tell pt hold their antihypertension morning of, if goes ok dont have to next time).
Doxorubicin concerns and AE
Concerns:
LVEF < 30%=DONT USE
Lifetime accumulative dose should not exceed 550mg/m2 to decrease CHF toxiicity
Adjust dose for hepatic dysfunction
AEs
Cardiotoxicity
leukopenia
mucositis
alopecia
n/v
Vincristine concerns and AEs
Concerns:
dose adjust hepatic dysfunction
closely follow neurologic function (tingling numbness)
AEs
peripheral neuropathy
constipation (treat with a laxative up front)
SIADH (syndrom of inappropriate antidiuretic hormone secretion
Cyclophosphamide AEs
hemorrhagic cystitis--increase h2o flush bladder to remove metabolite
infertility
leukopenia
n/v
alopecia
Prednisone AEs
hyperglycemia-watch blood sugar v.closely with high dose steriods
anxiety
insomnia (take in the morning to decrease)
*irratating to gi tract-take with food-add ppi for protection
What to do if relapse/refractory dlbcl?
D.
take pt own blood stem cells, give them med/chemo, then give the blood stem cells back
standard for chemosensitve disease
40% achieve rfs
if fail-chance for cure nonexistance
What is pancytopenia
D.
Hodgkins lymphoma: cure rate, cause, age distributio?
cure rate=80-90%
cause=unknown
age=bimodal distribution, 1st peak ot 15-40 years, 2nd peak after age 55
Hodgkins pathophysiology, what happens, how to identify
destruction of lymph node artitecture
Reed-Sternberg (RS) cell- how you can tell if hodkins or nonhodgkins, dervived from b-cells.
Hodgkins Lymphoma risk factors
postive family history of lymphoma or hematologic malignancy--same sex sibling increase risk by 10 fold
higher socioeconomic status-single home family, people who dont have siblings