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Challenges and Opportunities in Hodgkin Lymphoma: Clinician's Resource Guide

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i3 Health is pleased to make the clinician's resource guide available for use as a nonaccredited self-study or teaching resource.

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Challenges and Opportunities in Hodgkin Lymphoma: Clinician's Resource Guide

  1. 1. www.i3Health.com Clinical Tools and Resources for Self-Study and Patient Education HODGKIN LYMPHOMA REFERENCE GUIDE The clinical tools and resources contained herein are provided as educational adjuncts to the CME/CE-certified online activity Challenges and Opportunities in Hodgkin Lymphoma. To access the activity and earn CME/CE credit, visit: https://www.i3Health.com/Hodgkin-Lymphoma CONTENTS I: Types of Classical Hodgkin Lymphoma (cHL)............................................................... 2 II: Hodgkin Lymphoma Staging ....................................................................................... 3 III: International Prognostic Score.................................................................................... 4 IV: Deauville Criteria ........................................................................................................ 5 V: cHL: Refractory Disease (Second-Line Therapy).......................................................... 6 VI: cHL: Suspected Relapse ............................................................................................. 7 VII: Generic and Brand Names of HL Agents .................................................................. 8 VIII: Systemic Therapy Options: Relapsed/Refractory cHL ............................................ 10 IX: Therapeutic Options Depending on Treatment Outcome....................................... 11 X: Checkpoint Inhibitors and Guidelines for Use........................................................... 12 XI: Patient Education on Adverse Events....................................................................... 13
  2. 2. 086HL Reference Guide | Page 2 of 14 www.i3Health.com I: TYPES OF CLASSICAL HODGKIN LYMPHOMA (CHL) Type Description Nodular sclerosing • Most common type of Hodgkin lymphoma • Usually found in early stage when lymph nodes in neck become enlarged Mixed cellularity • Often affects a few groups of lymph nodes • Contains a mixture of different types of lymphocytes and other blood cells Lymphocyte rich • Very small • Many lymphocytes but very few Reed-Sternberg cells seen under microscope Lymphocyte depleted • Very rare • Lymph nodes contain a lot of fibrous tissue with few Reed-Sternberg cells • Alternately, fibrous tissue could contain a lymphocyte called reticular lymphocyte and many Reed-Sternberg cells Cancer Research UK (2018). Hodgkin lymphoma. Available at: https://www.cancerresearchuk.org/about-cancer/hodgkin- lymphoma/types
  3. 3. 086HL Reference Guide | Page 3 of 14 www.i3Health.com II: HODGKIN LYMPHOMA STAGING Stage Criteria Stage I • Involvement of a single lymph node region or • Localized involvement of a single extralymphatic organ or site Stage II • Involvement of ≥2 lymph node regions on the same side of the diaphragm or • Localized involvement of a single associated extralymphatic organ or site and its regional lymph node(s) • May or may not include involvement of other lymph node regions on the same side of the diaphragm Stage III • Involvement of lymph node regions on both sides of the diaphragm, possibly also accompanied by localized involvement of an associated extralymphatic organ or site via involvement of the spleen or by both Stage IV • Disseminated (multifocal) involvement of one or more extralymphatic organs, with or without associated lymph node involvement, or • Isolated extralymphatic organ involvement with distant (nonregional) nodal involvement National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: https://www.nccn.org
  4. 4. 086HL Reference Guide | Page 4 of 14 www.i3Health.com III: INTERNATIONAL PROGNOSTIC SCORE International Prognostic Score: 1 Point per Factor (Advanced Disease) • Albumin <4 g/dL • Hemoglobin <10.5 g/dL • Male • Age ≥45 years • Stage IV disease • Leukocytosis (white blood cell count ≥15,000/mm3 ) • Lymphocytopenia (lymphocyte count <8% of white blood cell count and/or lymphocyte count <600/mm3 ) National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: https://www.nccn.org
  5. 5. 086HL Reference Guide | Page 5 of 14 www.i3Health.com IV: DEAUVILLE CRITERIA Deauville Criteria: PET 5-Point Scale Score PET/CT scan result 1 No uptake 2 Uptake not higher than mediastinum 3 Uptake higher than mediastinum but not higher than liver 4 Uptake moderately higher than liver 5 Uptake markedly higher than liver and/or new lesions X New areas of uptake unlikely to be related to lymphoma PET = positron emission tomography; CT = computed tomography. National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Version Available at: https://www.nccn.org
  6. 6. 086HL Reference Guide | Page 6 of 14 www.i3Health.com V: CHL: REFRACTORY DISEASE (SECOND-LINE THERAPY) Deauville Score Additional Therapy Maintenance Therapy 1-3 • High-dose therapy and autologous stem cell rescue (HDT/ASCR) ± RT (category 1) • If HDT/ASCR is contraindicated: observe ± RT • Observe • Brentuximab vedotin for 1 year for patients at high risk of relapse 4 • HDT/ASCR ± RT • RT • Subsequent systemic therapy ± RT • Brentuximab vedotin for 1 year for patients at high risk of relapse 5 • RT • Subsequent systemic therapy ± RT • Autologous or allogeneic stem cell transplant if patient responds to secondary therapy RT = radiotherapy. National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: https://www.nccn.org
  7. 7. 086HL Reference Guide | Page 7 of 14 www.i3Health.com VI: CHL: SUSPECTED RELAPSE ISRT = involved site radiation therapy. National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: https://www.nccn.org
  8. 8. 086HL Reference Guide | Page 8 of 14 www.i3Health.com VII: GENERIC AND BRAND NAMES OF HL AGENTS Generic Name Brand Name(s) Bendamustine BendekaÒ Bleomycin BlenoxaneÒ Brentuximab vedotin AdcectrisÒ Carboplatin ParaplatinÒ Carmustine BiCNUÒ Cisplatin PlatinolÒ Cyclophosphamide CytoxanÒ Cytarabine Cytosar-UÒ , DepoCytÒ Dexamethasone DecadronÒ Doxorubicin AdriamycinÒ , RubexÒ Etoposide EtopophosÒ , VePesidÒ ToposarÒ Everolimus AfinitorÒ , Afinitor DisperzÒ , ZortressÒ Gemcitabine GemzarÒ Ifosfamide IfexÒ Lenalidomide RevlimidÒ Liposomal doxorubicin DoxilÒ Mechlorethamine MustargenÒ Melphalan AlkeranÒ Mesna MesnexÒ Methylprednisolone Depo-MedrolÒ , Solu-MedrolÒ Mitoxantrone NovantroneÒ Nivolumab OpdivoÒ Pembrolizumab KeytrudaÒ Prednisone DeltasoneÒ , RayosÒ , Prednisone IntensolÒ
  9. 9. 086HL Reference Guide | Page 9 of 14 www.i3Health.com Generic Name Brand Name(s) Procarbazine MatulaneÒ Rituximab RituxanÒ Vinblastine VelbanÒ Vincristine MarqiboÒ , Vincasar PFSÒ Vinorelbine NavelbineÒ
  10. 10. 086HL Reference Guide | Page 10 of 14 www.i3Health.com VIII: SYSTEMIC THERAPY OPTIONS: RELAPSED/REFRACTORY CHL Treatments Subsequent Systemic Therapy Options • Brentuximab vedotin, alone or in combination with one of the second-line regimens below: o DHAP (dexamethasone/high-dose cytarabine/ cisplatin) o ESHAP (etoposide/ methylprednisolone/ high-dose cytarabine/ cisplatin) o Bendamustine/ gemcitabine/vinorelbine o GVD (gemcitabine/ vinorelbine/liposomal doxorubicin) o ICE (ifosfamide/ carboplatin/etoposide) o IGEV (ifosfamide/ gemcitabine/vinorelbine) • Bendamustine • C-MOPP (cyclophosphamide/vincristine/procarbazine /prednisone) • Everolimus • GCD (gemcitabine/ carboplatin/ dexamethasone) • Lenalidomide • MINE (mesna/ifosfamide/ mitoxantrone/etoposide) • Mini-BEAM (carmustine/etoposide/ cytarabine/melphalan) • Nivolumab • Pembrolizumab National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: https://www.nccn.org
  11. 11. 086HL Reference Guide | Page 11 of 14 www.i3Health.com IX: THERAPEUTIC OPTIONS DEPENDING ON TREATMENT OUTCOME Protocol After Second-Line Treatment Treatment working well • Stem cell transplant • Radiotherapy if unable to have stem cell transplant • Observation: “watch and wait” Treatment working less than desired • Stem cell transplant • Radiotherapy if unable to have stem cell transplant • Chemo regimen not used previously, possibly with added radiotherapy Treatment working poorly • Radiotherapy • Chemo regimen not used previously, possibly with added radiotherapy *Patients receiving a transplant should not be administered chemotherapy with mechlorethamine, procarbazine, carmustine, or melphalan, as these drugs may result in a poor collection of stem cells. Radiation therapy may be administered with the transplant. TLI (total lymphoid irradiation) is radiation given to all lymphatic tissue. National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: http://www.nccn.org
  12. 12. 086HL Reference Guide | Page 12 of 14 www.i3Health.com X: CHECKPOINT INHIBITORS AND GUIDELINES FOR USE Checkpoint Inhibitors (CPI) Nivolumab Indicated for the treatment of adult patients with cHL that has relapsed or progressed after • Autologous HSCT and brentuximab vedotin or • ≥3 lines of systemic therapy, one of which is autologous HSCT Pembrolizumab Indicated for the treatment of adult and pediatric patients with • Refractory cHL or • Relapse after ≥3 prior lines of therapy Guidelines for CPI Use General Indications for Use • Patients with refractory cHL who are transplant-ineligible based on comorbidity or failure of first salvage chemotherapy • Patients who have relapsed after autologous HSCT ± brentuximab vedotin Recommendations Following Allogeneic Transplant • Patients can receive either nivolumab or pembrolizumab • Caution is advised due to increased risk of GVHD and other immunological complications HSCT = hematopoietic stem cell transplantation; GVHD = graft-versus-host disease. National Comprehensive Cancer Network (2018). Clinical Practice Guidelines in Oncology: Hodgkin lymphoma. Version 3.2018. Available at: https://www.nccn.org
  13. 13. 086HL Reference Guide | Page 13 of 14 www.i3Health.com XI: PATIENT EDUCATION ON ADVERSE EVENTS Neutropenia Scale Mild ANC <1,500 cells/mm3 Moderate ANC <1,000 cells/mm3 Severe ANC <500 cells/mm3 ANC = absolute neutrophil count. Neutropenia Signs/symptoms • Fever ³100.5°F • Chills or sweating • Sore throat, sores in the mouth, or toothache • Abdominal pain • Pain near the anus • Frequent, painful, or burning urination • Diarrhea or sores around the anus • Cough or shortness of breath • Any redness, swelling, or pain (especially around a cut, wound, or catheter) • Unusual vaginal discharge or itching Causes • Some types of chemotherapy • Cancers that directly affect bone marrow • Cancer that has spread • Radiation therapy to several parts of the body or to bones in the pelvis, legs, chest, or abdomen • Factors increasing neutropenia risk: o Age ≥70 o Lowered immune system from other causes, such as HIV infection or organ transplant Treatment • Antibiotics • Hospitalization Lustberg M (2012). Management of neutropenia in cancer patients. Clin Adv Hematol Oncol, 10(12):825-826. American Society of Clinical Oncology (2018). Neutropenia. Available at: https://www.cancer.net/navigating-cancer- care/side-effects/neutropenia
  14. 14. 086HL Reference Guide | Page 14 of 14 www.i3Health.com Thrombocytopenia Signs/symptoms • Prolonged bleeding, especially from minor cuts • Bleeding from mouth or nose, especially nosebleeds or bleeding when brushing teeth • Purpura (bruising of the skin) • Petechiae (small red or purple dots on skin) • Blood in urine or stool • Headaches/neurological symptoms (rare) Causes • Cancer types, such as lymphoma, which destroy blood stem cells and damage bone marrow • Chemotherapy Treatment • Corticosteroids • Immunoglobulins/rituximab • Splenectomy National Heart, Lung, and Blood Institute (2018). Thrombocytopenia. Available at: https://www.nhlbi.nih.gov/health- topics/thrombocytopenia

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