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71 Cards in this Set
- Front
- Back
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GHSG Favorable Criteria
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Must meet ALL: 1) 1-2 sites 2) No bulky disease (<1/3 thorax, <10 cm) 3) No extranodal involvement 4) ESR: <50 if no B symptoms <30 if B symptoms |
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Pertinent History in Hodgkin's |
B symptoms
Alcohol intolerance Pruritus Performance status Fatigue |
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Pertinent Exam in Hodgkins
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All lymphoid regions, including Waldeyer's ring Spleen Liver |
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Essential NCCN Workup for Hodgkins |
Complete H&P CBC with differential CMP LFTs ESR LDH Pregnancy test CT with contrast PET Counseling re: smoking cessation and fertility |
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Extra Workup for Hodgkins |
1) Fertility preservation, if desired 2) Chemo preparation: - PFTs - EF evaluation 3) If splenic RT: vaccines against pneumococcus, H-flu and meningococcus 4) Testing for Hep B and HIV 5) Bone marrow biopsy IF cytopenias and PET is negative in the marrow |
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IHC for classical Hodgkins |
POSITIVE: CD15, CD30 NEGATIVE: CD45, CD20 |
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IHC for Nodular Sclerosing Hodgkins |
Positive: CD20, CD45 Negative: CD15, CD30 |
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Which lymph node regions are grouped? |
1) Cervical/occipital/supraclavicular 2) Pectoral and axillary 3) Inguinal and femoral *Infraclavicular and supraclavicular are SEPARATE * Bilateral disease = 2 sites |
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Define stage IV Hodgkin's |
Diffuse or disseminated extranodal involvement Includes: any involvement of the liver, bone marrow, lungs or CSF |
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Types of classical Hodgkins |
Nodular sclerosing Mixed cellularity Lymphocyte rich Lymphocyte depleted |
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Treatment for stage IA and IIA Hodgkins |
1) Does the patient meet the strict GHSG criteria? If yes, proceed. If no, use more aggressive regimen 2) ABVD x 2 cycles 3) Restage with PET 4) For anything less than Deauville 5 --> 20 Gy ISRT 5) If Deauville 5, biopsy. ISRT if negative, treat as refractory if positive |
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Deauville 1 |
No uptake |
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Deauville 2 |
Uptake greater than background but no more than mediastinal blood pool |
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Deauville 3 |
Uptake greater than mediastinum but no greater than liver |
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Deauville 4 |
Uptake moderately higher than liver |
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Deauville 5 |
Uptake markedly higher than liver AND/OR |
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What is the probability that a solitary plasmacytoma will progress to MM within 10 years? |
60-70% |
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Burkitt's translocation |
t(8;14) |
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Most common histology of primary CNS lymphoma |
Large B cell |
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Bcl-2 is what kind of gene? |
Proto-oncogene that affects apoptosis |
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Typical phenotype for nodular sclerosing HL |
Young Female Above the diaphragm |
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Typical phenotype for mixed cellularity HL |
Older OR children in the developing world Male Below the diaphragm EBV-related |
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Which leukemia is MOST associated with the Philadelphia chromosome? |
CML (chronic myelogenous leukemia) |
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Name 3 T cell markers (IHC) |
CD2 CD3 CD7 |
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What should be included in ISRT planning? |
GTV: PRE-chemotherapy tumor volume CTV: Above with -
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When should you suspect splenic involvement in HL? |
Paraaortic nodes Bone marrow involvement Liver involvement |
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Do patients with HL need a bone marrow biopsy? |
Generally no. Can usually evaluate BM involvement on PET |
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When should you consider doing a BM biopsy in HL? |
PET is negative in the marrow BUT there are cytopenias |
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What is one way to reduce heart and/or lung dose in HL? |
Deep inspiration breath hold Consider when treating the mediastinum, lung, paraaortics and/or spleen |
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Ways to address respiratory motion in HL |
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What is the general tx paradigm in pediatric HL? |
Usually on protocol Chemo --> assess response Chemo --> assess response No RT if the patient was a rapid early responder and had a CR 21 Gy if the patient had a slow response or a bulky mediastinal mass |
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Dose for early stage favorable HL meeting GHSG criteria |
20 Gy |
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Dose for early stage HL (do not meet GHSG) |
30-36 Gy |
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Dose for patients with Deauville 4-5 disease after chemo |
39.6-45 Gy |
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Dose for NLPHL |
30-36 Gy |
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Rough PTV margins for Hodgkins ISRT |
Head and neck with mask: 0.5 cm Thorax: 0.5-0.8 cm No IGRT: 1-1.5 cm |
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How far sup/inf should you go when contouring NLPHL? |
Up to 4 cm sup/inf from the involved disease |
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Lung constraint in HL |
MEAN lung <14-17 Gy |
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Heart Constraint in HL |
Mean heart <15-20 Gy |
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Parotid Constraint in HL |
MEAN <20-26 Gy |
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Spinal cord constraint in HL |
<45 Gy (like always) |
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High priority OAR in HL |
Based on risk of second malignancies: Heart Lung Breast Stomach Thyroid *Doses as low as 5 Gy have been associated with higher risk of cardiac mortality and 2nd cancers |
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What is the purpose of the IPS? |
Prognostic system in advanced HL which predicts 5 yr freedom from progression and OS |
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Which factors are included in the International Prognostic Score for HL? |
All of these are BAD: 1. Age ≥45 2. Male 3. Albumin 4. Hgb < 10.5 5. Stage IV 6. Leukocytosis >15k 7. Lymphocytopenia <8% or 600 |
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Which is better: ECOG 0 or 4? |
0 - Means fully functional without restriction *Like golf, you want the lower number |
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ECOG 2 is equivalent to approximately what KPS score(s)? |
60-70 |
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ECOG 3 is equivalent to what KPS score(s)? |
40-50 |
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ECOG 4 is equivalent to what KPS score(s)? |
30 and below |
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What is the IPI? |
International Prognostic Index For use with aggressive NHL patients |
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Which factors are important in the IPI score? |
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How is IPI calculated? |
Give 1 point for each risk factor:
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How is the age-adjusted IPI calculated? |
1 point for each risk factor:
*Age and extranodal sites are irrelevant |
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What are the IPI risk groups? |
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How many risk factors do you need for each IPI risk group? |
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What is FLIPI? |
Follicular Lymphoma International Prognostic Index |
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What risk factors are used to calculate FLIPI? |
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What is the prognostic age cutoff for HL vs NHL? |
Hodgkins IPS: 45 yo IPI and FLIPI: 60 yo |
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Which prognostic scores use Hgb? |
Hodgkin's IPS (<10.5) FLIPI (<12) *NOT IPI |
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What are the differences between calculating IPI and FLIPI? |
IPI: Uses ECOG performance status ≥2 and >1 extranodal site FLIPI: Uses Hgb <12 and >4 nodal sites |
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Tx paradigm for advanced HL |
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Duke dose for advanced HL ISRT |
18-20 Gy |
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a |
a |
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a |
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Does NLPHL present early or late? |
Early. (80% with early stage disease) |
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Does NLPHL present early or late? |
Early. (80% with early stage disease) |
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What is the relapse pattern for NLPHL? |
Tend to progress slowly, relapse late and may transform into a NHL
*Are more easily salvaged than relapses in classical HD |
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Tx for relapsed Hodgkins |
Salvage chemo (ICE)
If CR --> high dose chemo with BEAM conditioning and then auto transplant |
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Tx for relapsed Hodgkins |
Salvage chemo (ICE)
If CR --> high dose chemo with BEAM conditioning and then auto transplant |
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About what fraction of relapsed Hodgkins disease pts can be salvaged? |
~1/3 |
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How does the GHSG nodal grouping differ from Ann Arbor? |
Group the following into a single region:
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Reach goal for heart dose constraint with all the fancy techniques |
Mean < 5 Gy |
