1. NHL origin in what cell types? Which are more common in adults? Children?
    • Majority of adult NHL: originates in B-lymphocytes (85%). Median age: 48 year
    • Children more commonly: T-lymphocytes (70-75%).
  2. What are common risk factors for NHL (7)?
    • Chronic inflammatory diseases
    • Chronic infections--h. pylori (MALT lymphomas), EBV (Burkitt's lymphomas).
    • Immune Suppression: HIV for Burkitts, DLBCL
    • Herbicides
    • Phenytoin
    • Chemotherapy
    • Radiation
  3. What does MALT stand for?
    • mucosal associated lymphoid tissue (MALT).
    • It is here or lymph nodes that NHL arises.
  4. NHL Grades (3)?
    • Indolent: 35-40%-survival measured in years
    • Aggressive: 55-60% most common-survival measured in weeks-months
    • Highly Aggressive: 5% medical emergency measured in days.
  5. What are the involved sites for B-cell NHL?

  6. What are the involved sites for T-cell NHL?

  7. 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?
  8. What are the invoved sites for extranodal involvement?

    • C.
    • Note, NHL will originate outside the bone marrow but can move to this site.
  9. 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.
  10. When are bone marrow biopsies used in diagnosis?
    When WBC are off, bone marrow is rarely involved--signifies a poor prognosis.
  11. 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
  12. 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%
  13. 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.
  14. What are some good prognosis factors for Follicular Lymphoma?
    How many adverse factors does one need low risk class, intermediate, or high?
    Image Upload 1
  15. 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
  16. 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.
  17. 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
  18. 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
  19. 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 of
    • Rituximab=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
  20. 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+
  21. ~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..
  22. Treament for stage I-II bulky or III/IV DLBCL?
    • R-CHOP for 6-8 cycles
    • *NO RADIATION= increase SE and no benefit
  23. 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).
  24. 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
  25. 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
  26. Cyclophosphamide AEs
    • hemorrhagic cystitis--increase h2o flush bladder to remove metabolite
    • infertility
    • leukopenia
    • n/v
    • alopecia
  27. 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
  28. 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
  29. What is pancytopenia

  30. 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
  31. 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.
  32. 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
    • chronic infection (ebv, hiv) highest birth order, fewer playmates
  33. Clinical presentation of Hodgkins Lymphoma
    • peripheral llymphadenopathy-80%
    • b symptoms 40%
    • generalize pruritus
    • lymph node pain after alcohol ingestion
    • anterior mediastinal mass (large mass middle of chest)
  34. Cotswolds-Ann Arbor Staging Classification (four stages and 5 designations) for hodgkins lymphoma?
    • cotswolds
    • Image Upload 2
  35. What are the poor prognostic factors for hodgkins lymphoma?

    don't have to memorize stage iii/iv
    maybe have to memorize i/ii????
    Image Upload 3
  36. What is the treatment plan for Hodgkin lymphoma (4 dependent of stage and favorbility)
    Image Upload 4
  37. What is ABVD? (drugs, dose, frequency)
    Image Upload 5
  38. Bleomycin considerations an AEs
    • Considerations:
    • Renal impairment: <60 reduce dose, <30 not recommended
    • Pumlonary function tests: give @ baseline and @ every 2 cycles (not for testicular cancer)
    • give a test dose of 1-2 units to reduce allergic reaction
    • AEs
    • Pulmonary fibrosis
    • Erythema
    • hyperpigmentation
  39. Vinblastin considerations and AEs
    • Considerations:
    • reduce dose for hepatic dysfunction

    • AEs:
    • leukopenia
    • thrombocytopenia
    • alopecia
    • SIADH
    • neurophathy
  40. Dacarbazine considerations and AEs
    • Considerations:
    • <60 cr/cl reduce dose
    • leukopenia
    • thrombocytopenia
    • nausea/vomiting
  41. What is BEACOPP? (what used for, drugs, treatment facts)
    • Image Upload 6
    • Used in Hodgkins Lymphoma
  42. What is Stanford V (what used for, drugs, treatment facts)?
    • Image Upload 7
    • Used in hodgkins lymphoma
    • pfs=progression survival
  43. When is Hodgkins response to therapy considered refractory?
    • reduction <50% after 4-6 cycles
    • progression during treatment

    *15-30% refractory response rate
  44. How to treat hodgkins lymphoma when relapse occurs?
    • > 12 months, initial therapy may be repeated
    • <12 months, alternative therapy
  45. What are Hodgkins lymphoma relapsed/refractory regimens?
    • Salvage chemotherapy (if need to switch regimens)
    • ICE (ifosfamide, carboplatin, etoposide
    • DHAP( dexamthasone, cytarabine, cisplatin)
    • ESHAP (etoposide, methylprednisolone, cytarabine, cisplatin)
    • Autologous stem cell transplant (ASCT) is becoming more of a standard of care.
Card Set
Non-Hodgkin's and Hodgkin's Lymphoma Diagnosis, Classification, and Treatments.