Hodgkin lymphoma, nodular lymphocyte-predominant

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ABVD

ABVD: Adriamycin, Bleomycin, Vinblastine, Dacarbazine

Regimen

Q28days x 2-6 cycles based on stage, response, and whether radiation therapy is used.

References

  1. See additional references above
  2. Savage KJ, Skinnider B, Al-Mansour M, Sehn LH, Gascoyne RD, Connors JM. Treating limited-stage nodular lymphocyte predominant Hodgkin lymphoma similarly to classical Hodgkin lymphoma with ABVD may improve outcome. Blood. 2011 Oct 27;118(17):4585-90. link to original articlePubMed

CHOP

CHOP: Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone

Regimen

Q21days x 6-8 cycles (number of cycles for CHOP in LPHL is not well-established)

References

  1. Feugier P, Van Hoof A, Sebban C, Solal-Celigny P, Bouabdallah R, Fermé C, Christian B, Lepage E, Tilly H, Morschhauser F, Gaulard P, Salles G, Bosly A, Gisselbrecht C, Reyes F, Coiffier B. Long-term results of the R-CHOP study in the treatment of elderly patients with diffuse large B-cell lymphoma: a study by the Groupe d'Etude des Lymphomes de l'Adulte. J Clin Oncol. 2005 Jun 20;23(18):4117-26. link to original article contains protocol--this was for diffuse large B-cell lymphomas; no primary reference available for use of CHOP in LPHL PubMed

R-CHOP

R-CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone

Regimen

Q21days x 6-8 cycles (number of cycles for R-CHOP in LPHL is not well-established)

References

See references for CHOP

CVP

CVP: Cyclophosphamide, Vincristine, Prednisone

Regimen

Q21days x up to 8 cycles (number of cycles for CVP in LPHL is not well-established)

References

  1. Marcus R, Imrie K, Belch A, Cunningham D, Flores E, Catalano J, Solal-Celigny P, Offner F, Walewski J, Raposo J, Jack A, Smith P. CVP chemotherapy plus rituximab compared with CVP as first-line treatment for advanced follicular lymphoma. Blood. 2005 Feb 15;105(4):1417-23. link to original article contains protocol--this was for follicular lymphoma; no primary reference available for use of CVP in LPHL PubMed

R-CVP

R-CVP: Rituximab, Cyclophosphamide, Vincristine, Prednisone

Regimen

Q21days x up to 8 cycles (number of cycles for R-CVP in LPHL is not well-established)

References

See references for CVP

EPOCH

EPOCH: Etoposide, Prednisone, Oncovin, Cyclophosphamide, Hydroxydaunorubicin

Regimen, original EPOCH protocol (Wilson, et al. 1993)

  • Etoposide (Vepesid) 50 mg/m2/day (200 mg/m2 total) IV continuous infusion on days 1-4
  • Prednisone (Sterapred) 60 mg/m2/day PO on days 1-5 (regimen originally was days 1-6, but now is just days 1-5)
  • Vincristine (Oncovin) 0.4 mg/m2/day (1.6 mg/m2 total) (sometimes capped at maximum total dose of 2mg per cycle) IV continuous infusion on days 1-4
  • Doxorubicin (Adriamycin) 10 mg/m2/day (40 mg/m2 total) IV continuous infusion on days 1-4
  • Cyclophosphamide (Cytoxan) 750 mg/m2 IV over 15 minutes on day 5 (regimen originally was day 6, but now is day 5)
  • PCP prophylaxis (choose one)
    • Trimethoprim/Sulfamethoxazole (Bactrim DS) (160/800 mg) PO BID 3 days per week
    • Atovaquone (Mepron) 1500mg PO daily
    • Pentamidine (Nebupent) 300 mg nebulized Q28days
  • Filgrastim (Neupogen) 5 mcg/kg SQ daily start day 6 and continue until ANC >5,000/uL past nadir

Q21days x 6-8 cycles

Alternate regimen, as listed for the dose-adjusted EPOCH protocol (Wilson, et al. 2002)

  • PCP prophylaxis (choose one)
    • Trimethoprim/Sulfamethoxazole (Bactrim DS) (160/800 mg) PO BID 3 days per week
    • Atovaquone (Mepron) 1500mg PO daily
    • Pentamidine (Nebupent) 300 mg nebulized Q28days
  • Filgrastim (Neupogen) 5 mcg/kg SQ daily start day 6 and continue until ANC >5,000/uL past nadir

Q21days x 6-8 cycles

Dose-adjustments for EPOCH protocol:

  • Start cycle 1 as described above
  • Obtain twice per week CBCs for nadir measurements
  • If nadir ANC >500, increase etoposide, doxorubicin, and cyclophosphamide by 20% compared to previous cycle.
  • If nadir ANC <500 on 1 or 2 measurements, use same doses as last cycle
  • If nadir ANC <500 on at least 3 measurements, decrease etoposide, doxorubicin, and cyclophosphamide by 20% compared to previous cycle.
  • And/or if nadir platelet count <25 on at least 1 measurement, decrease etoposide, doxorubicin, and cyclophosphamide by 20% compared to previous cycle.
  • Dose adjustments below the cycle 1 starting dose only applies to cyclophosphamide. The lowest etoposide and doxorubicin would be dosed at is the original cycle 1 dose.
  • Can start new cycle Q21days if ANC >1,000 and platelets >100. If counts are below those levels, check daily CBC and continue growth factor support until counts are adequate and next cycle can start.

Historic dose adjustments for hematologic toxicity: These adjustments were in the original paper for standard EPOCH, which are much less relevant due to growth factor support.
If ANC on day 1 is:

  • >1,500, full dose cyclophosphamide
  • 1,000-1,500, reduce cyclophosphamide by 187 mg/m2 (equal to 25% dose reduction)
  • <1,000, hold EPOCH
  • If ANC nadir is <500, reduce cyclophosphamide an additional 187 mg/m2
  • If ANC nadir is >500 and patient had previously been dose-reduced, increase cyclophosphamide dose by 187 mg/m2

References

  1. Wilson WH, Bryant G, Bates S, Fojo A, Wittes RE, Steinberg SM, Kohler DR, Jaffe ES, Herdt J, Cheson BD, et al. EPOCH chemotherapy: toxicity and efficacy in relapsed and refractory non-Hodgkin's lymphoma. J Clin Oncol. 1993 Aug;11(8):1573-82 link to original article contains protocol PubMed
  2. Wilson WH, Grossbard ML, Pittaluga S, Cole D, Pearson D, Drbohlav N, Steinberg SM, Little RF, Janik J, Gutierrez M, Raffeld M, Staudt L, Cheson BD, Longo DL, Harris N, Jaffe ES, Chabner BA, Wittes R, Balis F. Dose-adjusted EPOCH chemotherapy for untreated large B-cell lymphomas: a pharmacodynamic approach with high efficacy. Blood. 2002 Apr 15;99(8):2685-93. link to original article contains protocol PubMed
  3. Wilson WH, Dunleavy K, Pittaluga S, Hegde U, Grant N, Steinberg SM, Raffeld M, Gutierrez M, Chabner BA, Staudt L, Jaffe ES, Janik JE. Phase II study of dose-adjusted EPOCH and rituximab in untreated diffuse large B-cell lymphoma with analysis of germinal center and post-germinal center biomarkers. J Clin Oncol. 2008 Jun 1;26(16):2717-24. link to original article PubMed

R-EPOCH

R-EPOCH: Rituximab, Etoposide, Prednisone, Oncovin, Cyclophosphamide, Hydroxydaunorubicin

Regimen, based on original EPOCH protocol (Wilson, et al. 1993)

  • Rituximab (Rituxan) 375mg/m2 IV once per cycle (usually given as outpatient due to reimbursement issues)
  • Etoposide (Vepesid) 50 mg/m2/day (200 mg/m2 total) IV continuous infusion on days 1-4
  • Prednisone (Sterapred) 60 mg/m2/day PO on days 1-5 (regimen originally was days 1-6, but now is just days 1-5)
  • Vincristine (Oncovin) 0.4 mg/m2/day (1.6 mg/m2 total) (sometimes capped at maximum total dose of 2mg per cycle) IV continuous infusion on days 1-4
  • Doxorubicin (Adriamycin) 10 mg/m2/day (40 mg/m2 total) IV continuous infusion on days 1-4
  • Cyclophosphamide (Cytoxan) 750 mg/m2 IV over 15 minutes on day 5 (regimen originally was day 6, but now is day 5)
  • PCP prophylaxis (choose one)
    • Trimethoprim/Sulfamethoxazole (Bactrim DS) (160/800 mg) PO BID 3 days per week
    • Atovaquone (Mepron) 1500mg PO daily
    • Pentamidine (Nebupent) 300 mg nebulized Q28days
  • Filgrastim (Neupogen) 5 mcg/kg SQ daily start day 6 and continue until ANC >5,000/uL past nadir

Q21days x 6-8 cycles

Alternate regimen, as listed for the dose-adjusted EPOCH protocol (Wilson, et al. 2002)

  • PCP prophylaxis (choose one)
    • Trimethoprim/Sulfamethoxazole (Bactrim DS) (160/800 mg) PO BID 3 days per week
    • Atovaquone (Mepron) 1500mg PO daily
    • Pentamidine (Nebupent) 300 mg nebulized Q28days
  • Filgrastim (Neupogen) 5 mcg/kg SQ daily start day 6 and continue until ANC >5,000/uL past nadir

Q21days x 6-8 cycles

Dose-adjusted R-EPOCH protocol

  • Start cycle 1 as described above
  • Obtain twice per week CBCs for nadir measurements
  • If nadir ANC >500, increase etoposide, doxorubicin, and cyclophosphamide by 20% compared to previous cycle.
  • If nadir ANC <500 on 1 or 2 measurements, use same doses as last cycle
  • If nadir ANC <500 on at least 3 measurements, decrease etoposide, doxorubicin, and cyclophosphamide by 20% compared to previous cycle.
  • And/or if nadir platelet count <25 on at least 1 measurement, decrease etoposide, doxorubicin, and cyclophosphamide by 20% compared to previous cycle.
  • Dose adjustments below the cycle 1 starting dose only applies to cyclophosphamide. The lowest etoposide and doxorubicin would be dosed at is the original cycle 1 dose.
  • Can start new cycle Q21days if ANC >1,000 and platelets >100. If counts are below those levels, check daily CBC and continue growth factor support until counts are adequate and next cycle can start.

Historic dose adjustments for hematologic toxicity

These adjustments were in the original paper for standard EPOCH, which are much less relevant due to growth factor support.
If ANC on day 1 is:

  • >1,500, full dose cyclophosphamide
  • 1,000-1,500, reduce cyclophosphamide by 187 mg/m2 (equal to 25% dose reduction)
  • <1,000, hold EPOCH
  • If ANC nadir is <500, reduce cyclophosphamide an additional 187 mg/m2
  • If ANC nadir is >500 and patient had previously been dose-reduced, increase cyclophosphamide dose by 187 mg/m2

References

See references for EPOCH

Single agent Rituximab (Rituxan)

Regimen

One course of 4 week therapy

Supportive medications

  • Acetaminophen 650 mg PO 30 minutes prior to each dose of rituximab
  • Diphenhydramine (Benadryl) 25 mg PO 30 minutes prior to each dose of rituximab

References

  1. Ekstrand BC, Lucas JB, Horwitz SM, Fan Z, Breslin S, Hoppe RT, Natkunam Y, Bartlett NL, Horning SJ. Rituximab in lymphocyte-predominant Hodgkin disease: results of a phase 2 trial. Blood. 2003 Jun 1;101(11):4285-9. link to original article contains protocol PubMed
  2. Ibom VK, Prosnitz RG, Gong JZ, Moore JO, DeCastro CM, Prosnitz LR, Rizzieri DA, Gockerman JP. Rituximab in lymphocyte predominance Hodgkin's disease: a case series. Blood. 2003 Jun 1;101(11):4285-9. link to original article contains protocol PubMed
  3. Schulz H, Rehwald U, Morschhauser F, Elter T, Driessen C, Rüdiger T, Borchmann P, Schnell R, Diehl V, Engert A, Reiser M. Rituximab in relapsed lymphocyte-predominant Hodgkin lymphoma: long-term results of a phase 2 trial by the German Hodgkin Lymphoma Study Group (GHSG). Blood. 2008 Jan 1;111(1):109-11. link to original article contains protocol PubMed
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