3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Panel Members • Lauren Maeda, MD – Clinical Assistant Professor, Hematology/Oncology, Stanford Lymphoma Tumor Board • David Miklos, MD, PhD – Associate Professor of Medicine, Blood and Marrow 2017 Transplant, Stanford • Richard Hoppe, MD – Henry. S Kaplan ‐ Harry Lebeson Professor of Cancer Biology, Radiation Oncology, Stanford • Ronald Levy, MD – Robert K. and Helen K. Summy Professor, Hematology/Oncology, Chair: Joseph Tuscano, MD Stanford • Charalambos Andreadis, MD – Associate Professor of Clinical Medicine, Hematology deLeuze Endowed Professor of Medicine and Blood and Marrow Transplant, UCSF UC Davis Cancer Center • Lawrence Kaplan, MD – Clinical Professor of Medicine, Hematology/Oncology; Director, Adult Lymphoma Program, UCSF • Raj Krishnan, MD – Clinical Fellow, Hematology/Oncology, UC Davis 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1 Case 1 65 yo male with Bicuspid Aortic Valve s/p AVR presented with cervical and Excisional Bx of the L cervical LAP was completed, showing CD20+, CD10 ‐ , MUM1+ • • mediastinal LAP and weight loss DLBCL (high Ki67) with FISH revealing rearrangement of BCL6 and gain of BCL2 with no MYC rearrangement Examination revealed palpable L cervical LAP; otherwise unremarkable • BMBx was completed and did not reveal evidence of disease • Labs showed a WBC of 7.1 K/mm 3 with normal differential, Hgb of 15.5 g/dL and • Plt of 234 K/mm 3 ; CMP was unremarkable; LDH 462 U/L Patient is diagnosed with Stage IVA, ABC ‐ subtype DLBCL • PET/CT revealed a 6 cm L cervical LAP, 7 cm mediastinal LAP, L pleural mass, para ‐ • aortic LAP and 4 cm L renal mass; SUV ranging between 20 ‐ 24 for all lesions except the kidney mass (mild uptake) 1
3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1 Case 1 Considering an ECOG of 0, what treatment options should be considered for this Does his disease warrant referral to transplant at this time? patient? A. Yes A. R ‐ CHOP B. No B. DA ‐ R ‐ EPOCH C. R 2 ‐ CHOP (Lenalidomide) D. R ‐ GCVP E. R ‐ CHOP/Ibrutinib 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1 Case 1 Patient was started on R 2 ‐ CHOP on a clinical trial, tolerating it well and having a At this point, what next steps should be taken? • clinical response A. Salvage chemotherapy PET/CT completed after C3, showed a near CR • B. Salvage chemotherapy followed by Auto ‐ HCT Patient completed 6 cycles of R 2 ‐ CHOP, with only complication being Afib with RVR • C. Salvage chemotherapy followed by Allo ‐ HCT PET/CT completed 1 month after C6 showed widespread progression with increase • in size/number/FDG ‐ activity of supraclavicular, mediastinal, L internal mammary, retroperitoneal, retrocrural LN as well as involvement of the L Lung, Liver, subcutaneous tissue and osseous structures 2
3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1 Case 1 What salvage chemotherapy regimens would be considered at this time? Patient was then started on R ‐ ICE with plans to proceed to Allo ‐ HCT • A. R ‐ ICE After C2 of R ‐ ICE, repeat PET/CT was completed showing a mixed response overall; • C3 was then given with another PET/CT completed after showing continued B. Rituximab/Bendamustine progression C. R ‐ DHAP Patient was then switched to R ‐ ESHAP, again progressing after one cycle • D. Rituximab/Lenalidomide E. R ‐ GDP 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1 Case 1 Considering his disease progression, what approach should be taken next? Patient was then placed on clinical trial while search for URD allo ‐ HCT was • completed as well as work up for Haplo ‐ HCT A. Hospice Patient continued to progress and eventually went home on Hospice • B. Blinatumumab C. Auto ‐ HCT D. Ablative Allo ‐ HCT, if donor found E. Clinical Trial 3
3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 1 ABC ‐ subtype DLBCL are associated with a worse 5 ‐ year PFS and OS relative to GCB ‐ • DLBCL (Blood. 2005;105(5):1851.) As such, preferred frontline options include clinical trial, with the following options • showing activity. END OF CASE 1 R 2 ‐ CHOP (J Clin Oncol. 2015;33(3):251, Lancet omcol 2014;15:730 ‐ 37)) • R ‐ CHOP/Ibrutinib (Lancet Oncol. 2014 Aug;15(9):1019 ‐ 26.) • R ‐ CHOP/Bortezomib (J Clin Oncol. 2011;29(6):690) • The role of DA ‐ EPOCH remains unclear (Blood 2016;128:Ab# 469) • With persisent/agressive disease, allo ‐ HCT may be the only curative option • 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 2 Case 2 50 yo female with no significant PMH presents with enlargement of the R Excisional Bx was taken from the R supraclavicular LN, revealing Classical Hodgkin • • supraclavicular LN and no other symptoms Lymphoma, Nodular Sclerosing Subtype (CD15+, CD30+, PAX5 ‐ , CD20 ‐ ) Exam was remarkable for enlarged (2x2 cm) supraclavicular LN on the R with no BMBx was completed and did not reveal evidence of disease • • other significant findings Patient was diagnosed with Stage IIA Nodular Sclerosing Hodgkin Lymphoma • Labs showed a WBC of 7.2 K/mm 3 with normal differential, Hgb of 12.8 g/dL and • Plt of 350 K/mm 3 ; CMP was unremarkable; ESR 60 mm/hr She was started on ABVD • PET/CT completed showing FDG ‐ avid lesions including bilateral supraclavicular and • mediastinal regions; 0.7x0.8 cm R lower neck LN (SUV 11.9), 1.9x1.8 cm L supraclavicular LN (SUV 6.6) and R lower paratracheal mass 3.0x2.2 cm (SUV 9.7) 4
3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 2 Case 2 Based on her disease characteristics, would the patient be considered favorable or What treatment strategy would be appropriate for this patient? unfavorable risk (based on ECOG/NCIC criteria)? A. Two cycles of ABVD followed by PET/CT A. Favorable B. Three cycles of ABVD followed by PET/CT B. Unfavorable C. Four cycles of ABVD followed by PET/CT D. Six cycles of ABVD followed by PET/CT 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 2 Case 2 Patient received 2 cycles of ABVD and repeat PET/CT showed a Deauville of 3 What would be the next course of treatment? • A. IFRT B. ABVD for two further cycles (4 total) C. ABVD for two further cycles (4 total) plus IFRT D. ABVD for one further cycle (3 total) A. ABVD for one further cycle (3 total) plus IFRT 5
3/7/2017 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 2 Case 2 Patient was offered IFRT but decided to complete two further courses of ABVD If the patient relapsed in 20 months with disease only found in the mediastinum, what • regimen would be considered next? Patient did not undergo further imaging and is now following with exam and H&P • every 6 months A. ABVD for 4 ‐ 6 cycles She was advised of relapse, secondary malignancies and cardiovascular toxicity B. IFRT alone • C. Escalated BEACOPP or Stanford V for 4 ‐ 6 cycles D. ICE followed by Auto ‐ HCT E. ABVD + IFRT 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach 17 th Multidisciplinary Management of Cancers: A Case ‐ based Approach Case 2 The choice for initial therapy for favorable ‐ risk Hodgkin Lymphoma is tailored to • the individual, based on age, gender and tumor location(s) Combined modality has higher disease ‐ free survival compared to chemotherapy alone, • however OS is similar EORTC H10 and UK RAPID trials are addressing PET/CT after 2 ‐ 3 cycles of ABVD to • END OF CASE 2 help determine the next steps in treatment Must counsel patients on potential secondary malignancies and heart disease • related to chemotherapy/radiation 6
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