COME HOME Non-Hodgkin Lymphoma pathway development worksheet, v6 September 2014 1. Please review the following table, make any changes you think are necessary and highlight those changes. Feel free to put notes on the next page Test Name (CT, MRI, KRAS, etc.) H&P Performance Status B symptoms CBC, differential, platelets LDH Comprehensive metabolic panel Hepatitis B testing Evaluation of ejection fraction Pregnancy test Quantitative immunoglobulins Reticulocyte count Diagnostic Chest/ abdominal/pelvic CT Beta-2-microglobulin Uric Acid Bone Marrow Biopsy CLL/SLL Follicular Lymphoma Mantle Cell Lymphoma Diffuse Large B-Cell Lymphoma All pts. All pts. All pts. All pts. Burkitt Lymphoma All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. All pts. If using CD20 antibody All pts. If considering rituximab If considering rituximab All pts. All pts. If anthracycline- or anthracenedione-based regimen is indicated Women of child bearing age Optional Optional Optional Optional All pts. Optional Optional Optional All pts. Optional Stage I-II PET-CT Optional Optional FISH Pts with good PS Optional Neck CT Marginal Zone Lymphomas Optional All pts. Gastric: Optional Nongastric: Optional Nodal: Required Splenic: Required Nongastric: Optional Nodal: Optional Splenic: Optional Optional All pts. All pts. Optional Optional All pts. All pts. All pts. All pts. (> 1.6 cm biopsy) Optional All pts. Optional Optional Optional Optional Optional Optional Optional 1 All pts. All pts. All pts. Test Name (CT, MRI, KRAS, etc.) CLL/SLL Follicular Lymphoma SPEP Optional Hepatitis C Testing Optional H.pylori testing Endoscopy MRI Cryoglobulins Direct Coombs testing Colonoscopy Lumbar puncture Marginal Zone Lymphomas Gastric: Optional Nongastric: Optional Nodal: Optional Splenic: Required Gastric: Optional Nongastric: Optional Nodal: Optional Splenic: Required Gastric Gastric: Required Nongastric: Optional Nongastric: Optional Mantle Cell Lymphoma Diffuse Large B-Cell Lymphoma Burkitt Lymphoma Optional Brain MRI Optional Optional All pts. Optional Splenic: Optional Splenic: Optional Optional Blastic variant/CNS symptoms IPI calculation Head CT HIV test Flow cytometry of cerebrospinal fluid All pts. Optional Optional 2 All pts. All pts. A new group of lymphomas starts below: Test Name (CT, MRI, KRAS, etc.) H&P Performance Status B symptoms CBC, differential, platelets LDH Comprehensive metabolic panel Hepatitis B testing Evaluation of ejection fraction Pregnancy test Quantitative immunoglobulins Reticulocyte count Diagnostic Chest/ abdominal/pelvic CT Beta-2-microglobulin Uric Acid Bone Marrow Biopsy PET-CT FISH Peripheral blood flow cytometry SPEP Calculation of IPI Primary Cutaneous BCell All pts.: incl. skin exam All pts. All pts. All pts. Peripheral T-Cell Lymphoma All pts.: incl. skin exam All pts. All pts. All pts. Adult T-Cell Leukemia/ Lymphoma All pts.: incl. skin exam All pts. All pts. All pts. All pts. T-Cell Prolymphocytic Leukemia All pts.: incl. skin exam All pts. Hairy Cell Leukemia All pts. All pts. All pts. All pts. All pts. All pts. All pts. If rituximab If rituximab considered considered If anthracycline- or anthracenedione-based regimen is indicated Women of child bearing age Optional PCMZL All pts. And/or PETCT, All pts All pts. Required if All pts. PC-DLBCL, Leg type, Optional otherwise Optional And/or Dx CT, All pts. Optional Optional If CBC demonstrates lymphocytosis Optional PCMZL All pts. All pts. All pts. Optional Optional All pts. Optional Optional Optional Optional 3 Optional Test Name (CT, MRI, KRAS, etc.) Neck CT Head CT Head MRI Skin biopsy HIV Test Electrolytes, BUN, creatinine, serum calcium Upper GI endoscopy Skeletal Survey Stool examination for parasites CNS evaluation by CT, MRI or LP HTLV-1 serology Screen for active infections and CMV serology Peripheral blood examination Primary Cutaneous BCell Peripheral T-Cell Lymphoma Optional Optional Optional Optional Optional Adult T-Cell Leukemia/ Lymphoma T-Cell Prolymphocytic Leukemia All pts. All pts., calcium not required Hairy Cell Leukemia Optional Optional Optional Optional Optional If alemtuzumab is considered Optional 4 Mantle Cell Lymphoma Stage I-II 5 Mantle Cell Lymphoma Stage IIx, III, IV Yes RT and or any of the regimens below Complete Response High-dose therapy with autologous stem cell rescue Candidate for HDT/ASCR? Yes No Treated with RCHOP R-HyperCVAD Rituximab maintenance Follow Up Relapse No NORDIC CALGB RT Sequential RCHOP/RICE Mantle Cell Stage Iix, III, IV Bortezomib +/- rituximab Bendamustine +/- rituximab Bendamustine + rituximab Bortezomib +/- rituximab Cladribine + rituximab Cladribine + rituximab CVP + rituximab Dose-adjusted EPOCH + rituximab Bendamustine +/- rituximab RT Alternating RCHOP/RDHAP Partial Response CR/ Improved PR RCHOP FMR Lenalidomide +/- rituximab PCR PEPC +/- rituximab Progression 6 FC FCMR FC FCMR Cladribine + rituximab No further response FMR Lenalidomide +/- rituximab PCR PEPC +/- rituximab Ibrutinib Diffuse Large B-Cell Lymphoma Stage I-II Note: These guidelines may also be used for AIDS related B Cell Lymphoma, in conjunction with HART. 7 Diffuse Large B-Cell Lymphoma Stage III-IV 8 Diffuse Large B-Cell Lymphoma Relapse/refractory Disease 9 Burkitt Lymphoma 10 Chronic Lymphocytic Leukemia - CLL/ Small Lymphocytic Lymphoma - SLL Part 1 11 Chronic Lymphocytic Leukemia CLL/ Small Lymphocytic Lymphoma SLL Part 2 12 Follicular Lymphoma Stage I, II (initial therapy) 13 Follicular Lymphoma Stage II, III, IV (initial therapy) 14 Follicular Transformation Histologic transformation to diffuse B-cell lymphoma Clinical Trial Radioimmunotherapy RCHOP Dose-dense RCHOP 14 Multiple prior therapies Dose-adjusted EPOCH Responsive Disease RCEPP Consider high dose therapy with autologous stem cell rescue or allogeneic stem cell transplant RCDOP RCNOP RCEOP IFRT Best Supportive Care Histologic transformatoin to diffuse large B-cell lymphoma Clinical Trial Observe CR Consider high dose therapy with autologous stem cell rescue or allogeneic stem cell transplant RCHOP Dose-dense RCHOP 14 Minimal or no prior chemotherapy Dose-adjusted EPOCH Clinical Trial RCEPP RCDOP Consider radioimmunotherapy PR RCNOP Consider high dose therapy with autologous stem cell rescue or allogeneic stem cell transplant RCEOP Clinical Trial Radioimmunotherapy NR Best supportive care 15 Non-gastric MALT 16 Splenic MALT Lymphoma If Hepatitis C positive, and no contraindications to treatment, treat Hepatitis C as appropriate If lymphoma progresses, treat per guidelines for Follicular Lymphoma 17 Primary Cutaneous B Cell Lymphoma Marginal zone or follicle type 18 Primary Cutaneous Diffuse Large B Cell Lymphoma leg type 19 Peripheral T-Cell Lymphoma Initial Therapy Multi-agent Chemotherapy Options: CHOP-14 CHOP-21 CHOEP-21 CHOP followed by ICE CHOP followed by IVE alternating with intermediate-dose methotrexate Dose-adjusted EPOCH HyperCVAD alternating with high-dose methotrexate and cytarabine 20 Peripheral T-Cell Lymphoma Relapse/Refractory 21 Adult T-Cell Leukemia/Lymphoma 22 T-Cell Prolymphocytic Leukemia Hairy Cell Leukemia 23
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