Primary Mediastinal Large B-Cell Lymphoma

Disclaimer: This algorithm has been


OF USE IN CERTAIN CIRCUMSTANCES:
• EBER in situ hybridization, LMP-1, HHV-8, CD138, TdT, ALK1 • FISH studies to detect gene rearrangements involving: MYC, BCL2 and/or BCL6 • Molecular studies to detect clonality of the IGH STRONGLY RECOMMENDED: • FNA or core biopsy for tissue array/banking by protocol  Primary Mediastinal Large B-Cell Lymphoma Page 3 of 10 Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson's specific patient population, services and structure, and clinical information.This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.This algorithm should not be used to treat pregnant women.
Copyright 2024 The University of Texas MD Anderson Cancer Center Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson's specific patient population, services and structure, and clinical information.This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.This algorithm should not be used to treat pregnant women.Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson's specific patient population, services and structure, and clinical information.This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.This algorithm should not be used to treat pregnant women.
Copyright 2024 The University of Texas MD Anderson Cancer Center APPENDIX C: 5-Point Scale (5PS) • Score 1: no uptake • Score 2: uptake less than or equal to mediastinum • Score 3: uptake greater than mediastinum but less than or equal to liver • Score 4: uptake moderately greater than liver • Score 5: uptake markedly greater than liver and new sites of disease • Score X: new areas of uptake unlikely to be related to lymphoma Disclaimer: This algorithm has been developed for MD Anderson using a multidisciplinary approach considering circumstances particular to MD Anderson's specific patient population, services and structure, and clinical information.This is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient's care.This algorithm should not be used to treat pregnant women.

1
Typical immunophenotype: diffuse positivity for CD20 or another pan B-cell marker 2 See Appendix A: International Prognostic Index (IPI) 3 MUGA scan may be omitted for young patients receiving limited anthracycline 4 See Physical Activity, Nutrition, and Tobacco Cessation Treatment algorithms; ongoing reassessment of lifestyle risks should be a part of routine clinical practice ESSENTIAL: • Physical exam: attention to node-bearing areas, including Waldeyer's ring, and to size of liver and spleen • ECOG performance status • B symptoms (unexplained fever > 38°C during the previous month; recurrent drenching night sweats during the previous month; weight loss > 10% of body weight ≤ 6 months of diagnosis) • CBC with differential, LDH, BUN, creatinine, albumin, AST, ALT, total bilirubin, alkaline phosphatase, calcium, uric acid • Beta 2 microglobulin • Screening for HIV 1 and 2, hepatitis B and C (HBcAb, HBsAg, HCV Ab) (refer to Hepatitis B Virus (HBV) Screening and Management and Hepatitis C Virus (HCV) Screening algorithms) • PET/CT preferably with contrast • Calculation of IPI 2 • MUGA scan 3 or echocardiogram • Discuss fertility issues and sperm banking for patients of child bearing potential (refer to Fertility Preservation Prior to Cancer Treatment algorithm) , carboplatin, etoposide ESHAP = etoposide, methylprednisolone, high-dose cytarabine, cisplatin MINE = mesna, ifosfamide, mitoxantrone, etoposide DHAP = dexamethasone, cytarabine, cisplatin BV-Nivo = brentuximab vedotin, nivolumab 1 GCC should be initiated by the Primary Oncologist.If Primary Oncologist is unavailable, Primary Team/Attending Physician to initiate GCC discussion and notify Primary Oncologist.Patients, or if clinically indicated, the Patient Representative should be informed of therapeutic and/or palliative options.GCC discussion should be consistent, timely, and re-evaluated as clinically indicated.The Advance Care Planning (ACP) note should be used to document GCC discussion.Refer to GCC home page (for internal use only). 2 For response assessment, refer to: Cheson, B. D., Fisher, R. I., Barrington, S. F., Lister, T. A., Cavalli, F., Zucca, E., & Schwartz, L. H. (2014).Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: The Lugano classification.Journal of Clinical Oncology, 32(27), 3059-3067.doi:10.1200/JCO.2013.54.8800 3 Clinical trials or individual regimens: except for patients with disease-free interval, those who progress after three successive regimens are unlikely to derive additional benefit from currently utilized combination chemotherapy regimens • Clinical trial • Standard of care chimeric antigen receptor (CAR) T-cell therapy • New non cross-resistant regimen chemotherapy (e.g., rituximab with one of the following regimens: ICE, ESHAP, MINE, DHAP) or immunotherapy (e.g., BV-Nivo, pembrolizumab) • Consider radiation therapy for consolidation with involved site approach • Discuss Goal Concordant Care (GCC) with patient or if clinically indicated, with Patient Representative 1 • Standard of care CAR T-cell therapy • High dose therapy plus autologous or allogeneic stem cell transplant if eligible (in the context of a clinical trial) Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 02/20/2024 Note: Consider Clinical Trials as treatment options for eligible patients.Primary Mediastinal Large B-Cell Lymphoma Page 4 of 10 Measurements of ANC and platelet nadir are based on twice weekly CBC only Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 02/20/2024 Primary Mediastinal Large B-Cell Lymphoma Page 6 of 10

A
score of 1-3 is regarded as negative and 4 or 5 as positive Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 02/20/2024 Primary Mediastinal Large B-Cell Lymphoma Page 7 of 10

risk assessment 4
Consider Clinical Trials as treatment options for eligible patients.
• Lifestyle • Biopsy of residual mass is not possible due to location/patient refusal with high clinical/radiographic suspicion Multidisciplinary conference and/or follow-up evaluation if previous bulky mass 3 or large residual nonfluorodeoxyglucose (FDG) avid mass Multidisciplinary conference and/or consider Radiation Oncology evaluation if previous bulky mass 2 or large residual non-FDG avid mass No Department of Clinical Effectiveness V6 Approved by the Executive Committee of the Medical Staff on 02/20/2024 Yes PA = posterior anterior Note: Consider Clinical Trials as treatment options for eligible patients.

Table 2 .
EPOCH dose-adjustment paradigm Dose adjustments above starting dose level apply to etoposide, doxorubicin and cyclophosphamide.Dose adjustments below starting dose level apply to cyclophosphamide only.

Table 1 .
EPOCH-R starting dose level