Lymphoma – ClinCaseQuest https://clincasequest.hospital Medical education in clinical cases Wed, 07 Jun 2023 15:07:22 +0000 en-US hourly 1 https://wordpress.org/?v=6.2.11 https://clincasequest.hospital/wp-content/uploads/sites/7/2020/02/logo-ru-project-90x90.png Lymphoma – ClinCaseQuest https://clincasequest.hospital 32 32 Charlson Comorbidity Index (CCI) Online Calculator https://clincasequest.hospital/charlson-comorbidity-index/ Wed, 10 May 2023 13:55:51 +0000 https://clincasequest.hospital/?p=35025 Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities. Variable Points Age   <50 years 0 50–59 years +1 60–69 years +2 70–79…

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]]> Charlson Comorbidity Index predicts 10-year survival in patients with multiple comorbidities.

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History of definite or probable MI (EKG changes and/or enzyme changes)

Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents

Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)

History of a cerebrovascular accident with minor or no residua and transient ischemic attacks

Chronic cognitive deficit

Any history of treatment for ulcer disease or history of ulcer bleeding

Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)

Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)

* Required


VariablePoints
Age 
<50 years0
50–59 years+1
60–69 years+2
70–79 years+3
≥80 years+4
Myocardial infarction
History of definite or probable MI (EСG changes and/or enzyme changes)		+1
Congestive heart failure
Exertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents		+1
Peripheral vascular disease
Intermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)		+1
Cerebrovascular accident  or Transient ischemic attack
History of a cerebrovascular accident with minor or no residua and transient ischemic attacks		+1
Dementia
Chronic cognitive deficit		+1
Chronic obstructive pulmonary disease+1
Connective tissue disease+1
Peptic ulcer disease
Any history of treatment for ulcer disease or history of ulcer bleeding		+1
Liver disease
Severe = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history, mild = chronic hepatitis (or cirrhosis without portal hypertension)		None 0
 Mild +1
 Moderate to severe +3
Diabetes mellitusNone or diet-controlled 0
 Uncomplicated +1
 End-organ damage +2
Hemiplegia+2
Moderate to severe chronic kidney disease
Severe = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)		+2
  
Solid tumorNone 0
 Localized +2
 Metastatic +6
Leukemia+2
Lymphoma+2
AIDS+6

Charlson Comorbidity Index assess by addition of the selected points:

VariableDefinitionPoints
Myocardial infarctionHistory of definite or probable MI (EKG changes and/or enzyme changes)1
Congestive heart failureExertional or paroxysmal nocturnal dyspnea and has responded to digitalis, diuretics, or afterload reducing agents1
Peripheral vascular diseaseIntermittent claudication or past bypass for chronic arterial insufficiency, history of gangrene or acute arterial insufficiency, or untreated thoracic or abdominal aneurysm (≥6 cm)1
Cerebrovascular accident or transient ischemic attackHistory of a cerebrovascular accident with minor or no residua and transient ischemic attacks1
DementiaChronic cognitive deficit1
Chronic obstructive pulmonary disease–1
Connective tissue disease–1
Peptic ulcer diseaseAny history of treatment for ulcer disease or history of ulcer bleeding1
Mild liver diseaseMild = chronic hepatitis (or cirrhosis without portal hypertension)1
Uncomplicated diabetes–1
Hemiplegia–2
Moderate to severe chronic kidney diseaseSevere = on dialysis, status post kidney transplant, uremia, moderate = creatinine >3 mg/dL (0.27 mmol/L)2
Diabetes with end-organ damage–2
Localized solid tumor–2
Leukemia–2
Lymphoma–2
Moderate to severe liver diseaseSevere = cirrhosis and portal hypertension with variceal bleeding history, moderate = cirrhosis and portal hypertension but no variceal bleeding history3
Metastatic solid tumor–6
AIDS*–6

Plus 1 point for every decade age 50 years and over, maximum 4 points.

Note: liver disease and diabetes inputs are mutually exclusive (e.g. do not give points for both “mild liver disease” and “moderate or severe liver disease”).

*This data is from the original Charlson study in 1987, before the widespread availability of effective antiretroviral therapy. Currently, there are no any re-evaluations of the CCI using more recent data.

10-year survival = 0.983^(e CCI × 0.9), where CCI = Charlson Comorbidity Index.


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Literature:

  1. Charlson ME, Pompei P, Ales KL, MacKenzie CR: A New Method of Classifying Prognostic Comorbidity in Longitudinal Studies: Development and Validation. Journal of Chronic Diseases 40:373-383, 1987
  2. Quan H, Li B, Couris CM, Fushimi K, Graham P, Hider P, Januel JM, Sundararajan V. Updating and Validating the Charlson Comorbidity Index and Score for Risk Adjustment in Hospital Discharge Abstracts Using Data From 6 Countries. Am. J. Epidemiol. (2011)doi: 10.1093/aje/kwq433
  3. Radovanovic D, Seifert B, Urban P, Eberli FR, Rickli H, Bertel O, Puhan MA, Erne P; AMIS Plus Investigators. Validity of Charlson Comorbidity Index in patients hospitalised with acute coronary syndrome. Insights from the nationwide AMIS Plus registry 2002-2012. Heart. 2014 Feb;100(4):288-94. doi: 10.1136/heartjnl-2013-304588. Epub 2013 Nov 1.
  4. Zavascki AP, Fuchs SC. The need for reappraisal of AIDS score weight of Charlson comorbidity index. J Clin Epidemiol. 2007;60(9):867-8.

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]]> Follicular Lymphoma International Prognostic Index (FLIPI). Online calculator https://clincasequest.hospital/flipi/ Mon, 10 Jan 2022 09:27:11 +0000 https://clincasequest.hospital/?p=32403 Follicular Lymphoma International Prognostic Index (FLIPI) estimates overall survival based on clinical information. FLIPI is designed to be used in patients with follicular lymphoma and…

Сообщение Follicular Lymphoma International Prognostic Index (FLIPI). Online calculator появились сначала на ClinCaseQuest.

]]> Follicular Lymphoma International Prognostic Index (FLIPI) estimates overall survival based on clinical information.

FLIPI is designed to be used in patients with follicular lymphoma and to risk stratify patients based on prognosis. This can help guide when and how to treat such patients.

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(See Evidence for nodal diagram)

Stage III-IV Stage I: disease is located in a single region, usually one lymph node and the surrounding area. Stage II: disease is located in two separate regions, an affected lymph node or organ and a second affected area. Both affected areas are confined to one side of the diaphragm. Stage III: disease involves both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen. Stage IV: diffuse or disseminated involvement of one or more extranodal organs, with or without associated lymph node involvement. (See Evidence for stage diagram)

Points 0
* Required

The FLIPI score was developed based on 4,167 patients with follicular lymphoma providing characteristics at diagnosis. Univariate and multivariate analyses were then used to develop a prognostic index. This was then validated in a cohort of 919 patients. Age, Ann Arbor stage, hemoglobin level, number of nodal areas, and serum LDH level were identified as adverse prognostic factors. The FLIPI was validated in a subsequent study and the performance improved by further stratifying age and including the presence of cerebrovascular disease.

The FLIPI, while a useful general prognostic tool, does not reliably predict those at diagnosis who will have an extremely rapid decline. Rather it assists with providing prognostic information. Ultimately, clinical judgement and comprehensive review of the patient’s previous workup are critical to make this assessment.

The GELF Criteria can help identify those patients with follicular lymphoma at higher risk for rapid disease progression and in whom immediate therapy may be needed.

The FLIPI score is easy to use with information most providers will already have available. Clinical evaluation, laboratory testing, and imaging are all that is needed to risk stratify patients and estimate prognosis.

Age > 60 yearsNo0
 Yes+1
>4 nodal sites
See Nodal Sites diagram		No0
 Yes+1
LDH elevatedNo0
 Yes+1
Hemoglobin <120 g/L or 12 g/dLNo0
 Yes+1
Stage III-IV
Stage I: disease is located in a single region, usually one lymph node and the surrounding area.
Stage II: disease is located in two separate regions, an affected lymph node or organ and a second affected area. Both affected areas are confined to one side of the diaphragm.
Stage III: disease involves both sides of the diaphragm, including one organ or area near the lymph nodes or the spleen.
Stage IV: diffuse or disseminated involvement of one or more extranodal organs, with or without associated lymph node involvement.
See Staging Diagram		No0
 Yes+1

Score Interpetation

ScoreRisk Group10-year Overall Survival
≤1Low70%
2Intermediate50%
≥3High35%

Useful Mnemonic – NoLash

  • Nodal areas
  • LDH
  • Age
  • Stage
  • Hemoglobin level

Nodal Sites

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Staging Diagram

  • Follicular Lymphoma International Prognostic Index, FLIPI, follicular lymphoma, follicular lymphoma therapy, tumor, follicular lymphoma detection, follicular lymphoma treatment, lymphoma treatment, lymphoma, nodal site, node, nodal sites, calculator, medical calculators, medcalk, calculate online, estimate, online calculator, severity estimate, criteria, Prognostic Index, Index

A FLIPI score of 0 to 1 is considered “low risk” with a 10 year overall survival of 70%. A score of 2 is considered “intermediate risk” with a 10 year overall survival of 50%. Finally, a score of ≥ 3 is considered “high risk” with a 10 year overall survival of 35%. Patients with an initial remission duration less than the median progression free survival for a particular treatment regimen and/or with a high FLIPI score are more likely to have a shorter remission duration.

Treatment is varied depending on the stage and tumor burden.

Stages I-II

  • Treatment options include:
    • Involved field radiotherapy (IFRT)
    • Clinical trials
    • Active surveillance

Stages III-IV or Bulky stage II – asymptomatic

  • Treatment options include:
    • Clinical trials
    • Active surveillance

Stages III-IV or Bulky Stage II – with GELF/BNLI risk factors or high-risk FLIPI score

  • Treatment options include:
    • Rituximab + cyclophosphamide, vincristine, doxorubicin, prednisone
    • Rituximab alone
    • Bendamustine + rituximab
    • Rituximab + cyclophosphamide, vincristine, prednisone
    • Clinical trials

There is continued controversy around when and how to treat follicular lymphoma, including in patients with relapsed/refractory disease. Questions to consider when making treatment decisions:

  • When to initiate therapy versus active surveillance
    • Deciding amongst various treatment options
    • Balancing efficacy and toxicities of treatment options
    • Determining what constitutes a complete response/endpoint of treatment
  • Finally, with follicular lymphoma, a provider should be aware of transformation to diffuse large B-cell lymphoma, which is a more aggressive disease and would require prompt treatment.

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Literature:

  1. Solal-Celigny et al. Follicular Lymphoma International Prognostic Index. Blood 104:1258-1265. (2004) https://pubmed.ncbi.nlm.nih.gov/15126323/
  2. van de Schans SAM, et. al. Validation, revision and extension of the Follicular Lymphoma International Prognostic Index (FLIPI) in a population-based settingAnn Oncol (2009) 20 (10): 1697-1702 first published online June 23, 2009 doi:10.1093/annonc/mdp053 https://www.journals.elsevier.com/annals-of-oncology

See also:

Groupe d’Etude des Lymphomes Folliculaires (GELF) Criteria. Online calculator

Сообщение Follicular Lymphoma International Prognostic Index (FLIPI). Online calculator появились сначала на ClinCaseQuest.

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