The 2012 Oncology Nurse Hematology Conference

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Downloadable slide decks are a great tool for self study and teaching purposes. They are non-certified resources available to enhance your knowledge.Review a downloadable slide deck by Sandra E. Kurtin, MS, RN, ANP, AOCN, covering the most clinically relevant new data reported from The 2012 Oncology Nurse Hematology Conference. Target AudienceThis activity has been designed to meet the educational needs of medical oncologists, radiation oncologists, surgical oncologists, APNs, RNs, pharmacists, managed care pharmacy directors, pathologists, medical directors, allied health professionals, and other physicians affiliated with medical facilities treating patients with head and neck cancers (HNC).Format: Microsoft PowerPoint (.ppt) | File size: 10.1 MB | Date posted: 4/19/2012Slide Deck DisclaimerThis slide deck in its original and unaltered format is for educational purposes and is current as of April 2012. All materials contained herein reflect the views of the faculty, and not those of IMER, the CE provider, or the commercial supporter. These materials may discuss therapeutic products that have not been approved by the US Food and Drug Administration and off-label uses of approved products. Readers should not rely on this information as a substitute for professional medical advice, diagnosis, or treatment. The use of any information provided is solely at your own risk, and readers should verify the prescribing information and all data before treating patients or employing any therapeutic products described in this educational activity.Usage RightsThis slide deck is provided for educational purposes and individual slides may be used for personal, non-commercial presentations only if the content and references remain unchanged. No part of this slide deck may be published in print or electronically as a promotional or certified educational activity without prior written permission from IMER. Additional terms may apply. See Terms of Service on for details.


<ul><li>1.DISCLAIMERParticipants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. Theinformation presented in this activity is not meant to serve as a guideline forpatient management. Any procedures, medications, or other courses of diagnosisor treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patients conditions and possible contraindications on dangers in use, review of any applicable manufacturers product information, and comparison with recommendations of other authorities. DISCLOSURE OF UNLABELED USEThis activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. IMER does not recommend the use of any agent outside of the labeled indications.The opinions expressed in the activity are those of the faculty and do not necessarily represent the views of IMER. Please refer to the official prescribinginformation for each product for discussion of approved indications,contraindications, and warnings.</li></ul><p>2. Disclosure of Conflicts of InterestSandra E. Kurtin, MS, RN, ANP, AOCNReported a financial interest/relationship or affiliation inthe form of: Consultant, Celgene Corporation, MillenniumPharmaceuticals, Inc., Novartis PharmaceuticalsCorporation. 3. Activity OverviewSandra E. Kurtin, MS, RN, ANP, AOCN Arizona Cancer Center 4. Learning ObjectivesUpon completion of this activity, participantsshould be better able to: Evaluate recent research highlights for patients with DLBCL, CLL, CML, TCL,FL, MCL, MDS, and MM Describe the diagnostic work-up and various stages of hematologicmalignancies and their prognostic significance Explain how prognostic indicators are used to determine treatment options forpatients with DLBCL, CLL, CML, TCL, FL, MCL, MDS, and MM Identify the current and ongoing treatment regimens available for patients withnewly diagnosed, relapsed, and refractory DLBCL, CLL, CML, TCL, FL, MCL,MDS, and MM Describe the optimal administration and schedule of current and novel agentsused in the treatment of DLBCL, CLL, CML, TCL, FL, MCL, MDS, and MM Apply effective oncology nursing toxicity assessment and monitoringstrategies to help patients achieve positive clinical outcomes Develop individualized patient and family education strategies for patientsreceiving therapies for hematologic malignancies 5. Activity Agenda 8:00 8:30 AM Registration and Breakfast 8:30 8:35 AM Welcome and Activity Overview 8:35 8:55 AM Introduction to Lymphoma 8:55 9:25 AM Diffuse Large B-Cell Lymphoma 9:25 9:55 AM T-Cell Lymphoma 9:55 10:05 AMBREAK 10:05 10:35 AM Follicular Lymphoma 10:35 11:05 AM Mantle Cell Lymphoma 11:05 11:25 AM Supportive Care Case Study Breakout Session 1 11:25 11:35 AM Panel Discussion / Q&amp;A 11:35 12:35 PM LUNCH 12:35 1:05 PMChronic Lymphocytic Leukemia 1:05 1:35 PM Chronic Myeloid Leukemia 1:35 2:05 PM Multiple Myeloma 2:05 2:15 PM BREAK 2:15 2:45 PM Myelodysplastic Syndrome 2:45 3:05 PM Supportive Care Case Study Breakout Session 2 3:05 3:15 PM Panel Discussion / Q&amp;A 3:15 3:25 PM Survivorship 3:25 3:30 PM Closing Remarks and Evaluations 6. Introduction to LymphomaSandra E. Kurtin, MS, RN, NP, AOCNThe University of Arizona Cancer Center 7. Incidence NHL A heterogeneous group of neoplasms with differing patterns ofgrowth and response to treatment Cases ~ 70,130 estimated new cases for 2012 There were ~ 66,360 new cases in 2011 NHL ranks 7th among men and women as the most frequentlynewly diagnosed cancer in the US Deaths NHL accounted for ~ 19,320 deaths in 2011 (~ 3% of all cancerdeaths) NHL is the 9th leading cause of cancer deaths in men and the7th leading cause of cancer deaths in womenNHL = non-Hodgkin lymphoma.Siegel et al, 2012; ACS, 2012, 2011. 8. Risk Factors Associated With NHL Age Immunodeficiency AIDS, organ transplants, autoimmune disorders Infectious agents HTLV-1: Adult T-cell lymphoma EBV: Burkitts lymphoma (Africa) Helicobacter pylori (MALT lymphomas) Environmental exposure Drugs, chemicals, occupational exposureAIDS = acquired immune deficiency syndrome; HTLV-1 = human T-lymphotropic virus type I; EBV = Epstein-Barr virus.Lister, 2004. 9. Common Sites of Disease in Lymphoma Lymphatic vessels, nodes,Waldeyers ringand organs Primary organs BM, thymus Secondary organs LNs Spleen MALT Waldeyers ringBM = bone marrow; LNs = lymph nodes; MALT = mucosa-associated lymphoid tissue.Lister, 2004. 10. Lymphoma: A Blood-Related CancerYarbro et al, 2000; Canellos et al, 2006. 11. B-Cell Development Malignancies occur at all stages Specific disease depends upon when malignancy occursYarbro et al, 2000; Canellos et al, 2006. 12. Where Do B-Cell Lymphomas Originate?CLL = chronic lymphocytic leukemia; SLL = small lymphocytic lymphoma; MALT = mucosa-associated lymphoid tissue.Jaffe et al, 2008. 13. Normal LN OrganizationAdapted from Willard-Mack, 2006. 14. Ann Arbor Staging System Stage I Single LN group Stage II Multiple LNs on same side ofdiaphragm Stage III Multiple LNs on both sides of thediaphragm Stage IV Multiple extranodal sites or LNsand extranodal disease Substaging Extranodal extension (E) Systemic symptoms (A/B) Bulk &gt; 10 cm (X)Lister, 2004; NCCN, 2012a. 15. NHL Subtypes N = 1,403REAL = Revised European American Lymphoma; DLBCL = diffuse large B-cell lymphoma; FL = follicular lymphoma;MCL = mantle cell lymphoma; PTCL = peripheral T-cell lymphoma; SLL = small lymphocytic lymphoma.Armitage et al, 1998; Lichtman, 2006. 16. Clinical Behavior of NHL SubtypesIndolent Aggressive Very Aggressive CLL/SLL MCL PrecursorB-lymphoblasticLymphoplasmacytic/WMFollicle center lymphoma, lymphoma/leukemia follicular, grade 3 MZLB-cell acute leukemia DLBCL Follicle center lymphoma,Therapy undertakenfollicular, grade 1/2 Primary mediastinal largewith curative intentB-cell lymphoma Most are incurable Cure rates varyRequire immediate therapyGoal is control andminimize symptomsVariable treatment goals Cure rates varyWM = Waldenstrms macroglobulinemia.Ansell et al, 2005; Goroll et al, 2009. 17. General Diagnostic Workupfor LymphomaHistory and Physical Physical exam Particular attention to node-bearing areas, including Waldeyers ring, hepatomegaly, splenomegaly, abdominal masses, skin nodules Presence of distal swelling or lymphedema Performance status B symptomsLaboratory analysisTissue biopsyBone marrow biopsy and aspirateImaging studies for completion of stagingNCCN, 2012b. 18. Diagnostic Evaluation: Tissue Biopsy Diagnostic Study Clinical Significance Morphology Review of cytology using low-power microscope to define basicarchitecture of the lymphatic tissue Immunohistochemistry Excisional biopsy is the standard for initial diagnosis of NHL(fine needle aspirates are inadequate) Used to isolate cellular proteins which correlate with phases ofB-cell differentiation Flow cytometry Immunophenotyping used to describe antigen expression onB-cells using peripheral blood and bone marrow Used to correlate with the tissue biopsy for WHO classificationof subtype Molecular profiling Newer molecular profiling has identified key prognostic markersas well as potential targets for new therapiesWHO = World Health Organization.Kurtin, 2008; Morice et al, 2008; LeBien et al, 2008; NCCN, 2012b. 19. Diagnostic Evaluation: Peripheral Blood Diagnostic StudyClinical Significance CBC + differential + platelets Evaluate presence of cytopenias, lymphocytosis, reticulocyte countmorphological abnormalities, and bone marrow response to anemia LDH, haptoglobin, coombs, and Evaluate for underlying hemolysis - particularly important reticulocyte countin CLL LDH Necessary for risk stratification Evaluate for aggressive disease, risk for TLS, and hemolysis Serum 2m Prognostic relevance Reflects WBC membrane turnover Levels are affected by renal function Hepatic profile Treatments have potential renal and hepatic toxicities or may be affected by renal or hepatic insufficiencies Dose modification may be required for elevated bilirubin levels Serum albumin reflects nutritional status and is used to estimate prognosisCBC = complete blood count; LDH = lactate dehydrogenase; 2m = beta-2-microglobulin; IPI = International Prognostic Index;TLS = tumor lysis syndrome; WBC = white blood cell.Federico et al, 2007; NCCN, 2012b; Kurtin, 2009; WebMD, 2010; MedlinePlus, 2012. 20. Diagnostic Evaluation: Bone Marrow Diagnostic Study Clinical Significance Aspirate Evaluation of morphological abnormalities of hematopoietic Should include spicules and be precursors to allow WHO classification cellular enough to assess at least Used for flow cytometry, FISH analysis, and cytogenetics 500 cells Biopsy Evaluate cellularity, topography, presence of lymphocytic infiltrates, Should be of adequate size for exclusion of other bone marrow disorders or infiltration by solid evaluation (12 cm)tumors Cytogenetics Evaluate for possible non-random chromosomal abnormalities t(11;14) is the hallmark for MCL Based on evaluation of 20 metaphases Greater than 2 metaphases is considered non-random Molecular TestingNewer molecular profiling has identified key prognostic markers aswell as potential targets for new therapiesFISH = fluorescent in situ hybridization.Kurtin, 2008; Jaffe et al, 2008; NCCN, 2012b. 21. Flow Cytometry: The Zip Code forPrimary Cell Type of B-Cell NeoplasmsCML-LBC = chronic myeloid leukemia-lymphoid blast crisis; HL = Hodgkin lymphoma.LeBien et al, 2008. 22. Immunohistochemistry: Unraveling the Patchwork of B-Cell Malignancies Normal LN With Germinal Center and Surrounding MZL (C) Normal Germinal Center (F)MCL (D) ALL PeripheralGrowth PatternBlood (A) andMay Be Diffuse, BM (B) Nodular, orBlastoid FL (G)CLL inPeripheral Blood (E)DLBCL (H) HodgkinDisease (J) HCL in Peripheral Blood (L) and BM (K) BL (I)MZL (M) PL (P) WM (N)MM (O)ALL = acute lymphoblastic leukemia; HCL = hairy cell leukemia; PL = plasmablastic lymphoma; MM = multiple myeloma.LeBien et al, 2008. 23. Diagnostic Evaluation: Imaging Diagnostic Study Clinical Significance MUGA scan or Baseline evaluation for patients receiving anthracycline therapy echocardiogram CT chest, abdomen, and Current standard of care for initial staging on NHL pelvis Estimation of anatomic extent of disease and areas of abnormalLNs (&gt; 1 cm) 18 FDG-PET PET with FDG shows functional metabolic status reported as SUV Useful in evaluation of LNs &lt; 1 cm Not useful in all subtypes of NHL Scanning after a few cycles of therapy have been shown to predicttreatment outcomes in MCL CXR Baseline evaluation for any underlying disease and as a source ofcomparisonMUGA = multi-gated acquisition scan; CT = computed tomography; 18FDG-PET = 18-fluorodeoxyglucose-positron emission tomography;CXR = chest X-ray; LNs = lymph nodes; SUV = standardized uptake value.NCCN, 2012b; Kurtin, 2009; Dupuis et al, 2007; Podolofff et al, 2007. 24. The Role of PET PET is most useful for aggressive lymphomas More susceptible to false positives Rituximab Myeloid growth factors If used for restaging, wait 8 wks after completion of chemotherapy/radiotherapy PET/CT notable radiation risk NCCN: optional Cost and conveniencePfreundschuh, 2010; Friedberg et al, 2003. 25. Recommendations for PET Scans in Lymphoma Therapy and Trials Histology Pre-TxMid-Tx Post-Tx F/U DLBCL Yesa Trial Only YesNo HLYesa Trial Only YesNo FL Nob Trial Only NobNo MCLNob Trial Only NobNo Other Aggressive NHL Nob Trial Only Nob,cNo Other Indolent NHL Nob Trial Only Nob,cNoaStrongly recommended but not mandated.bOnly if response is a primary study end point.cOnly if PET+ pretreatment. HL = Hodgkin lymphoma; MCL = mantle cell lymphoma; Tx = treatment; F/U = follow-up. Seam et al, 2007. 26. Risk Stratification in NHL:IPI, FLIPI, MIPI, and BeyondRisk stratification systems IPI:Diffuse Large B-Cell Lymphoma FLIPI: Follicular Lymphoma MIPI: Mantle Cell LymphomaCytogenetic and molecular factors Hallmark translocations for common subtypes with associated molecular abnormalitiesNCCN, 2012b. 27. IPI Stratifies Risk by ClinicalFactors in Aggressive NHL Prognostic factors (APLES) 100 OS (all) Age &gt; 60 yrs PS &gt; 1Patients50 L(%) LI LDH &gt; 1 x normalHI Extranodal sites &gt; 1 H 0 Stage III or stage IV0 2 46 8 10 Risk category100 OS (age 60) Factors LPatientsLow (L)0 or 1(%)50 LILow-Intermediate (LI)2HIHigh-Intermediate (HI) 3HHigh (H) 4 or 50 0 2 4 68 10Extranodal sites of disease are excluded from the AAIPI.aPS = performance status; AAIPI = age-adjusted IPI.Sehn et al, 2007. 28. Revised IPI Criteria Proposes 3 risk groups based on thenumber of IPI risk factors withrecommendations for treatmentstrategies Very good = no risk factors90% chance of long-term PFSLarge trials will be necessary to propose treatment approaches other than CHOP-R Good = 12 risk factors80% chance of long-term PFSTreatment strategies without excessive toxicity will be necessary due to favorable survival Poor = 35 risk factors A = PFS in 365 patients treated with CHOP-R50% chance of long-term PFSClinical trials are recommended to evaluate disease characteristics and novel treatment approachesCHOP-R = cyclophosphamide, doxorubicin, vincristine, prednisone, rituximab; PFS = progression-free survival.Sehn et al, 2007. 29. Follicular Lymphoma IPI Survival as defined by FLIPI FLIPI Risk Factors1.0Low Risk (01) (1 patient each)Survival Probability (%) 0.8 Age &gt; 60 yrsIntermediate Risk (2) LDH &gt; ULN 0.6 Hgb &lt; 12 g/dL High Risk ( 3) 0.4 Ann Arbor stage III/IV &gt; 4 involved node 0.2 regions N = 1,795 0.012 24 36 48 60 72 84 96 Time (mos)ULN = upper limt of normal; Hgb = hemoglobin.Solal-Cligny, 2006. 30. Gene Profiling and Survival Rates inDifferent DLBCL Genetic GroupsActivated B-celllike diffuse Germinal center B-celllike Primary mediastinal large B-cell lymphoma (ABC) (GCB)B-cell lymphoma (PMBL)GenesLymphoma Biopsies 1.0 0.8 5-Yr Survival Probability (%) 0.6 PMBL 64% GCB59% 0.4 0.2ABC30%0 02 4 6810OS (Yrs)Dave et al, 2006; Rosenwald et al, 2003; Lenz et al, 2008. 31. Mantle Cell Lymphoma IPI Established in 2008 to identifyOS According to MIPIprognostic factors relevant to MCL Multivariate analysis of 455 patients 1.00.9from 3 randomized clinical trialsProbability of OS (%)0.8 4 independent prognostic factors for0.7survival (age, PS, LDH, leukocyte 0.60.5counts) 0.4 LR: 03 points0.3 IR: 45 points0.2 HR: 611 points 0.1p = .1080 Ann Arbor stage, BM involvement,0 12 24 36 48 60 72 84 96number of extranodal sites used in Time (mos since registration)the IPI were not prognosticallyrelevant in MCLLR: Median not reached More recent studies have added theIR: Median 51proliferation index (Ki67 &gt; 30)HR: Median 29 PS = performance score; LR = low risk; IR = intermediate risk; HR = high risk.Hoster et al, 2008; Smith, 2008; Schaffel et al, 2010. 32. Molecular Indices inLymphocytic Malignancies LymphomaMorphologyImmunophenotypingCommonMolecular Testing Subtype Favorable = fCytogenetic Unfavorable = uAbnormalities...</p>