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29 Cards in this Set
- Front
- Back
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What factors are included in the IPI?
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APLES
- Age > 60 - Performance status 2 or higher - LDH elevated - Extranodal dz (1 or more) - Stages III-IV |
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What is low risk NHL?
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0-1 IPI risk factor (age >60, poor performance status, elevated LDH, extranodal diseaes, stage III-IV)
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What is low-intermediate risk NHL?
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2 IPI risk factors (age >60, poor performance status, elevated LDH, extranodal diseaes, stage III-IV)
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What is high-intermediate risk NHL?
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3 IPI risk factors (age >60, poor performance status, elevated LDH, extranodal diseaes, stage III-IV)
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What is high risk NHL
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4-5 IPI risk factors (age >60, poor performance status, elevated LDH, extranodal diseaes, stage III-IV)
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What is the revised IPI (R-IPI) for intermediate risk NHL incorporating the use of rituxan?
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the R-IPI incorporates the same 5 factors as the standard IPI but with substantial changes in the prognosis.
Very good = 0 factors = 94% 5 yr OS Good = 1-2 factors = 79% 5 yr OS Poor = 3-5 factors = 55% 5 yr OS |
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What factors are included in the FLIPI? (follicular lymphoma international prognostic index)
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HASSL
Hgb < 12 age >60 stages III-IV sites. 5 or more extranodal sites LDH elevated |
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with FLIPI, what are the expected stratified survivals?
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low risk = 0-1 factor = 71% 10 yr OS
intermediate risk = 2 factors = 51% 10 yr OS high risk = 3-5 factors = 36% 10 yr OS |
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What remains the treatment standard for localized, low grade, FL?
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per NCCN (2010), locoregional RT to 30-36Gy remains standard. However, observation and combined modality treatment are considered viable options depending on patient and disease characteristics.
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What are the basic treatment principles for stage III-IV, low grade FL?
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No tx is curative.
Several RCTs have indicated that therapy can be deferred without reducing survival. Tx is reserved for the following: 1. symptomatic disease 2. threatened end organ dysfunction 3. cytopenias 4. bulky diseaes 5. steady disease progression 6. clinical trial 7. patient preference |
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What is the role of RT for stage III-IV, low grade FL?
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in advanced stage, indolent lymphomas, RT is reserved for palliation
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What is SLL?
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SLL is the same disease entity as CLL but with a predominant manifestation in the spleen, liver, or nodes as opposed to peripheral blood or BM.
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What is the role of RT in the Tx of SLL?
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RT is used for the palliation of symptomatic lesions in SLL. consider 2 Gy x 2 Gy.
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What is the role of RT in treating nodal marginal zone lymphomas?
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RT is used for the palliation of symptomatic lesions in advanced stage nodal marginal zone lymphomas
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What is the most common multi-agent chemo used in the management of intermediate/high grade NHL?
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R-CHOP
1. rituximab 2. cyclophosphamide 3. adriamycin (hydroxydaunorubicin) 4. oncovin (vincristine) 5. prednisone |
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what are the current indications for RT in early stage, intermediate-/high grade NHL?
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institution dependent. It may be included as consolidation after 3-4 cycles of R-CHOP in favorable disease, in patients with a PR to chemo, or in patients with bulky disease.
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what are the low grade (i.e. indolent) NHLs?
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follicular (grade 1-2)
chronic lymphocytic leukemia (CLL) MALT Mycosis fungoides |
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what are the intermediate grade (i.e. aggressive) NHLs?
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follicular (grade 3)
mantle cell DLBCL NK/T cell peripheral T cell anaplastic large cell |
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what are the high grade (i.e. very aggressive) NHLs?
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burkitt
lymphoblastic |
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What is the present treatment paradigm for advanced stage, intermediate/high grade NHL?
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R-CHOP x 6-8 cycles. IFRT may be considered for initially bulky sites.
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Estimate the prognosis of limited-stage aggressive B cell lymphoma treated with R-CHOP and IFRT?
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limited long term outcome data. SWOG 0014 enrolled 60 patients with limited-stage aggressive NHL and at least 1 risk factor. treated with R-CHOP x 3 +IFRT.
- 4 year PFS 88% - 4 year OS 92 % (Persky DO et al. JCO 2008) |
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What is the long term DFS for patients with localized DLBCL treated with RT alone? what were the typical doses used in clinical trials?
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Using 45-50 Gy to maximize LC, only 40% of pts with DLBCL had long term DFS based on historical RT-alone data.
(Chen MG et al, Cancer 1979; Kamiski MS et al. ann int med 1986; Sweet DL et al. Blood 1981). |
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What was demonstrated in the initial publication of the SWOG 8736 study comparing chemo alone to abbreviated CRT in localized intermediate grade NHL?
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in SWOG 8736, 401 patients with stage I or IE (including bulky) and stage II or IIE (nonbulky) intermediate grade NHL were randomized to CHOP x 8 vs. CHOP x 3 + IFRT.
RT doses of 45-55 Gy were used. At 5 yr follow up: PFS and OS favored the combined therapy group. (OS 82% vs. 72%) (Miller TP et al. NEJM 1998) |
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What was demonstrated in the updated analysis of SWOG 8736 at median follow up of 8.5 years (published in abstract form in 2001)?
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PFS curves overlapped at 7 years and OS curves overlapped at 9 years. there were excess late relapses and deaths from advanced lymphoma in the combined arm seen in years 5-10. Results are stratified by IPI:
- stage I, no risk factors: 94% OS at 5 years - stage II (nonbulky) and/or 1+ adverse risk factor: 71% OS at 5 years - 3 risk factors (Stage II may by 1 of them): 50% OS at 5 years. (Miller TP et al. ASH abstract 3024, 2001) |
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What was demonstrated in ECOG E1484 study randomizing postchemo complete responders to obs vs. IFRT?
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352 pts with intermediate grade, bulky stage I-IE or nonbulky stage II-IIE Dz were given CHOP x 8. Complete responders (215) were randomized to IFRT vs. observation.
At 6 years: - DFS favored IFRT (73% vs. 56%), but OS was equivalent. - FFS was equivalent in partial responders administered IFRT and in CR patients. - Failure at initial sites was greater in patients not given IFRT (Horning SJ et al. JCO 2004). |
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What was demonstrated in the GELA LNH 93-1 study comparing aggressive chemo vs. standard chemo and RT in patients 60 or younger?
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647 pts with low risk (IPI 0), stage I or II, intermediate risk NHL (extranodal or bulky) were randomized to ACVBP x 3 then methotrexate/etoposide/ifosfamide/cyarabine vs. CHOP x 3 then IFRT to 30-40Gy.
ACVBO improved EFS and OS regardless of the presence of bulky disease (Reyes F et al. NEJM 2005). |
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What was demonstrated in the GELA LNH 93-4 study evaluating pts age >60 with low risk, localized, intermediate grade NHL?
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576 pts age >60 with low risk (age-adjusted IPI 0), stage I or II NHL (bulky [8%] or extranodal [56%] disease allowed) were randomized to CHOP x 4 vs. CHOP x 4 +IFRT to 40Gy. the 5 yr EFS and OS were equivalent in both Tx arms.
(Bonnet C et al. JCO 2007) |
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What is the current treatment paradigm for relapsed, intermediate/high grade NHL?
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high dose chemo + stem cell transplant
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What are expected RT toxicities associated with treatment of NHL?
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important ones to think about
- coronary artery disesae - hypothyroidism - 2nd malignancies |
