Lymphoma & Leukemia
What is the purpose of CSI (CNS technique)?
CSI treats leukemic cells in the CSF or used for palliation of bone pain
Chronic leukemia may lead to what?
Enlarged organs and decreases BM function
What are the 7 risk factors associated with NHL?
Exposure to particular infectious agents, reduced immune function, viral, H. Pylori, transplants, genetic alteration of B or T- lymphocyte cells, exposure to ionizing radiation
T/F- MOPP, and ABVD are common chemotherapy regimens used for non-Hodgkin's lymphoma.
False
T/F-An autologous bone marrow transplant is one in which the patient receives bone marrow from a donor.
False
T/F-Non-Hodgkin's lymphoma most commonly occurs in younger people (under 40).
False
T/F- Non- Hodgkin's diseases' spread is predictable.
False; Hodgkins diseases spread is predictable
T/F- Acute side effects from TBI could be sterility and cataracts.
False; chronic
T/F- There is a 50% chance of finding a matching relative for bone marrow.
False; less than 50%
T/F- TBI is given with a high dose rate so that the treatment is quicker.
False; low dose rate to spare late-responding tissues
T/F- More females than males get leukemia
False; opposite
T/F- NHL is more curable than HD.
False; opposite
T/F- For HD histologic type has the most effect for prognosis.
False; stage
What are the signs/symptoms of a patient with anemia?
Flue like malaise, fatigue pallor
What is the name of the immunotherapy agent used for CML; it has bad side effects and is a MAB?
Gleevec
What does GVHD stand for?
Graft vs host disease (aka: rejection)
For NHL, what is the most important indication of survival?
Histology (opposite from HD)
The bone marrow registry is based on which type of marker?
Human Leukocyte Antigen (HLA) marker
What is the purpose of TBI before BMT?
Immunosuppress the patient so that they won't reject the donor marrow AND kill any remaining leukemic cells
What happens when acute leukemic cells accumulate in the BM?
Impairs the bodies normal production of RBC, WBC and platelets
What is the problem with treating a mantle field on a young patient?
Increased risk of breast cancer or other cancers
What are the signs/symptoms of a patient with neutropenia?
Increases susceptibility to respiratory, dental, sinus, perirectal, and urinary tract infections.
The mantle field is considered an ___________ field because of the contour of the patient.
Irregular
For treating a patient with TBI for leukemia, where is the gantry located?
Lateral
What is the most common pediatric malignancy overall?
Leukemia
What are the OAR's for the inverted "Y" field?
Liver, kidney, reproductive organs
Indolent (NHL) is B-cell origin, usually ________ grade and _________.
Low, chronic
What are the OAR's for the mantle field?
Lung, humeral head, larynx, spinal cord, heart (apex & pericardium)
For treating a patient with TBI for leukemia, the arms can be placed over the __________ as compensators.
Lungs
Which type of Hodgkin's disease carries the worst prognosis?
Lymphocyte- depleted (Classic Hodgkin's)
What are the 2 type of combination chemotherapy used for HD?
MOPP and ABVD
If a patient had recurrence after chemo or radiation therapy for HD, what may be done next?
Monoclonal antibodies (mabs)
What are the "B" symptoms?
Night sweats, unexplained fever, weight loss (10% in 6 months), pruritis (itching), alcohol induced pain
Which type of Hodgkin's disease is the most favorable?
Nodular lymphocyte predominant HL
The two most common pathological types of Hodgkin's disease is _________________________ and ________________________.
Nodular sclerosing HL & Mixed cellularity (Classic Hodgkin's)
Reed-Sternberg cells are sometimes called "______________" because of the 2 large nuclei.
Owl eyes
What is the presenting sign and symptom for Hodgkin's disease?
Painless mass in cervical, supraclavicular or mediastinal nodes (most common sites- can occur anywhere)
Name the lymph node groups included in the inverted "Y" field (hint: 3)
Paraaortic, iliac, inguinal
Why may a patient with HD not be able to receive ABVD for chemo?
Patient has a heart condition; Adriamycin is cardiotoxic
What are the advantages of cord blood vs bone marrow?
Quicker than BMT, less chance of GVHD, does not need a 100% match
The presence of _______________ distinguishes Hodgkin's disease from non-Hodgkin's lymphoma.
Reed-Sternberg cells
Describe 3 similarities and 3 differences between HD and NHL:
Similarities Both are radiosensitive and can be treated with a low dose Both have EBV as a viral risk factor Both can have the "B" symptoms Differences NHL is more common than HD NHD does not have the presence of the Reed-Sternberg cells NDHs spread is not predictable like HD
For Non-Hodgkin's Disease, a patients symptoms will depend on what?
Site of involvement
What is the main difference when treating acute leukemias vs chronic?
You will need to treat the symptoms (ex; splenomegaly) fir the chronics while treating for cute for the acutes
What are the signs/symptoms of a patient diagnosed with AML?
-Non specific flulike symptoms, fatigue, pallor, dyspnea, anemia -Petechiae, purpura, epistaxis, gum bleeding, GI or urinary tract bleeding are symptoms of thrombocytopenia -Fevers, chills, susceptibility to infection'
What are the risk factors for CML?
-Prior radiation exposure -Males
What are the risk factors for AML?
-Similar to ALL- prior radiation exposure, benzene, chemotherapy agents -Tobacco smoke
Which chemo combination is considered the gold standard for stage 1 &2 HD?
ABVD= Adriamycin, bleomycin, vincristine, dacarbazine
A BM biopsy is a necessary diagnostic test for which type of leukemia?
ALL
For which type of leukemia can the majority of patients expect a remission after treatment?
ALL
What is the most common type of pediatric malignancy?
ALL
Which type of leukemia requires over 25% leukoblasts for diagnosis?
ALL
Which types of leukemia includes monoclonal antibody treatments?
ALL, CLL, CML
Also known as acute non-lymphocytic leukemia:
AML
Auer rods is essential for diagnosis of which type of leukemia?
AML
Increased myeloblasts (30% or more) needed to be considered for which type of leukemia?
AML
Which type of leukemia required a CBC with differential and platelet count for diagnosis?
AML
(Acute or chronic) leukemia involves the rapid proliferation of undifferentiated (immature) stem cells.
Acute
For treating a patient with TBI for leukemia, where are the TLD's placed in order to check midline dose?
Ankles, knees and thighs
What are the 3 risk factors associated with HD?
EBV, family history and HIV
What is the difference between allogenic BMT and autologous BMT?
-Allogenic= BM taken from a compatible sibling or other non-related matching donor from registry -Autologous= patients own marrow harvested while in remission, leukemic cells removed with the help on monoclonal antibodies, then frozen and stored for reinfusion later
What are the risk factors for CLL
-Family hx -Agent orange
What are the risk factors for ALL?
-Ionizing radiation -Chemicals such as benzene (cigarettes, cleaning supplies, detergents) -Hydrocarbons -Alkylating chemo agents -HTLV-1 virus
What are some prognostic indicators for HD (hint: 7)?
-Age (youth is more favorable- 45 & older= worse) -More sites involved= worse -Advanced stage= worse -"B" symptoms= worse -Males -Marked abnormal labs -Presence of disease below diaphragm= worse
For HD, how many patients will have the "B" symptoms?
1/3
Normal cells begin to produce in how many weeks after a BMT transfusion?
2-4
What is the radiation tolerance of the kidney?
2000 cGy
For the bone marrow registry, how many out of the 6 markers is required for a relative match?
3/6
What is the radiation tolerance of the liver?
3000 cGy
What is the optimal dose for the mantle and paraaortic fields in the treatment of Hodgkin's Disease?
3500-4400 cGy
For treating a patient with TBI for leukemia, what field size is typically used?
40 x 40 (largest size)
For treating a patient with TBI for leukemia, a SSD of _____ft or more will be used to encompass the whole body.
5
For the bone marrow registry, how many out of the 6 markers is required for a non-relative match?
5/6
Aggressive NHL has an overall 5-years survival rate of ______%.
60
Where and when was Total Marrow Irradiation (TMI) started?
At U of M in 2006
What are the signs/symptoms of a patient with thrombocytopenia?
Bleeding gums, epistaxis (nosebleed), petechiae (small spots under skin due to bleeding), ecchymosis (discoloration of skin due to bleeding underneath), menorrhagia (heavy periods), excessing bleeding after dental procedures
What type of diagnostic tests are done to determine CLL?
Blood test and BM biopsy
Where do acute leukemic cells accumulate in?
Bone marrow
Where do chronic leukemic cells accumulate in?
Bone marrow, lymph nodes, liver, spleen
What are the signs/symptoms of a patient diagnosed with CML?
Bone pain, splenomegaly
Exposure to agent orange is a factor for which type of leukemia?
CLL
What is the most common type of adult leukemia?
CLL
Which type of leukemia the the only one not linked to previous radiation exposure?
CLL
Which types of leukemia are likely to require treatment of the spleen?
CLL,CML
Which type of leukemia is hard to diagnose and is typically found incidentally?
CML
Which type of leukemia required the presence of the Philadelphia chromosome for diagnosis?
CML
What is the most common treatment for NHL?
Combination chemotherapy (CHOP) with or without RT
The first dose of chemo for ALL before BMT is _______________________ alone or with __________.
Cyclophosphamide, busulfan
What does CHOP stand for? And which type of cancer is it used for?
Cyclophosphamide, doxorubicin, vincristine, prednisone; NHL
The presence of the "B" symptom increase or decreases the prognosis for HD and NHL?
Decreases
What are the signs/symptoms of a patient diagnosed with ALL?
Depends on the cells suppressed -Low RBC=Anemia -Low platelets= Thrombocytopenia -Low WBC= Neutropenia
Name some viral risk factors for NHL.
EBV, HTLV-1, HIV, Hep-C
What are the signs/symptoms of a patient diagnosed with CLL?
Spread to liver, nodes or spleen; splenomegaly
For HD, what is the most important indication of survival?
Stage
What is the chemo regimens for the different stages of HD?
Stage 1 & 2 chemo is used; involved area RT may be added Stage 3&4 chemo + RT is always used
Name the lymph node groups included in a mantle field (hint: 8)
Submandibular Occipital Cervical Infraclavicular Supraclavicular Hilar Axillary Mediastinal
Describe the borders of an anterior mantle field:
Sup border= At inferior mandible OR tips of mastoid process Inf border= At level of diaphragm (T9-T10 interspace) Laterals= Wide enough (flash) to include axillary nodes
Why do youth have a favorable outcome for HD?
They have the ability to tolerate aggressive treatments compared to older patients with co-morbidities.
For TBI treatment for a patient with leukemia, the compensators are placed where on the body?
Thinnest parts of the body
Total Marrow Irradiation can only be delivered by what?
Tomotherapy
What is the name of the treatment when both the mantle and inverted "Y" fields are bot being treated?
Total Nodal Irradiation
T/F- B-cell NHL are more common than T-cell NHL.
True
T/F- Both Hodgkin and non-hodgkins' lymphoma patients can display "B" symptoms.
True
T/F- Fifty percent of BMT patients will get some degree of graft vs. host disease.
True
T/F- For treating a patient with TBI for leukemia, half of the dose is given to each side of the body.
True
T/F- Previous exposure to radiation is a risk factor for most types of leukemia.
True
List 5 chemotherapy drugs used to treat leukemia:
Vincristine Daunorubicin Cytarabine Gleevac Methotrexate
What are the disadvantages of cord blood vs bone marrow?
Weight restriction of 50ml/cord- a larger person would need more
Staging for Hodgkin's disease includes an A-B grouping. Which symptom is NOT one of the classical B symptoms? a. profuse night sweats b. petechiae c. unexplained fever above 38˚ C d. weight loss greater than 10% of body weight in 6 months
b
Which of the following is the most frequent presentation for Hodgkin's disease? a. abdominal mass b. painless supraclavicular node enlargement c. painful cervical node enlargement d. lung mass
b
Name the 4 sub categories that fall under the classic Hodgkin's.
•Lymphocyte-rich HL •Nodular sclerosing HL* •Mixed cellularity* •Lymphocyte -depleted