Hematology Oncology TB
A UNC Lineberger Cancer Network Monitored Tumor Board.
Parker Hematologic Malignancies Multidisciplinary Tumor Conference
University of North Carolina, Lineberger Comprehensive Cancer Center
The Parker Hematologic Malignancies Multidisciplinary Tumor Board meets weekly to review new inpatient and outpatient hematologic malignancy cases at the University of North Carolina. The participants of this weekly meeting include oncologists specializing in the management of leukemia, lymphoma, and multiple myeloma as well as bone marrow transplantation. Further, advanced practitioners, nurse navigators, nurses, hematology/oncology fellows, and occasionally internal medicine residents are present for this meeting. Hematopathologists are present at the meeting to review pathology cases including but not limited to bone marrow aspirates, biopsies, lymph node biopsies, skin biopsies, and other diagnostic methodologies. When reviewing specific radiologic imaging, radiologists may present the data to the group. There is also a virtual meeting option to allow colleagues at participating facilities including Rex and Sanford to participate with cases at their own institution. The patient’s presentation is presented in a HIPAA compliant forum in which the diagnostic hematopathology is presented by the Hematopathologist while the oncologist will provide the clinical details of each case. This facilitates a discussion amongst the group to ascertain a consensus in the diagnosis and evidence-based discussion about the optimal treatment regimen for the individual patient being presented. At the end of each case, a summary is given regarding the diagnosis and management plan based on an evidence-based discussion from the group.
Examples of cases presented:
- A 66-year-old male with worsening abdominal pain for several months and enlarging abdominal masses by serial imaging underwent an abdominal resection of the masses and associated lymph nodes. Pathology revealed classical Hodgkin Lymphoma but the patient was recovering from his abdominal surgery with multiple abdominal wounds. He was diagnosed with Stage IV Hodgkin Lymphoma. We discussed the first-line management of Hodgkin Lymphoma being ABVD multi-agent chemotherapy of curative intent. However, recent data suggests that substituting Brentuximab vedotin for Bleomycin improves progression-free survival based on the ECHELON-1 trial. Therefore, the committee recommended treating this patient with first-line AVD as opposed to ABVD (Straus et al. Blood 2020).
- An 18-year-old male presented with increasing shortness of breath and fatigue and was found to have an elevated white blood cell count to 100,000 with pancytopenia. He had no signs of leukostasis. We reviewed the blood smear that revealed many immature blasts suspicious for acute leukemia. We reviewed the flow cytometry results which confirmed acute myeloid leukemia. We then reviewed the bone marrow aspirate revealing a confluence of immature myeloblasts in the marrow consistent with AML. The pathology group noted that FLT3-ITD mutation was present in the bone marrow leukemia cells. Given this mutation, we discussed a clinical trial that is available at our institution comparing standard-of-care 7+3 + midostaurin (given the FLT3 mutation) versus 7+3 + crenolanib- a new, potent FLT3 inhibitor. Based on promising findings from phase 1 and 2 studies, crenolanib may provide therapeutic benefit over midostaurin. Based on the findings from early phase studies, the group recommended consideration of this clinical trial for this patient. Moreover, given his young age and lack of comorbidities with FLT3-ITD mutation, the bone marrow transplant group recommended a bone marrow transplant in first remission to improve his chance of overall long-term survival and cure.
The second half of this conference (4:30-5 PM) includes an evidence-based lecture/presentation on a hematologic malignancy topic. The oncologist will present an overview about a specific problem or disease state and provide case-based evidence-based discussion about management and diagnostic methodologies. Previous presentations and topics have included: Elderly AML, Venetoclax-based regimens in AML, Acute promyelocytic leukemia, NK Cell Lymphoma, Hodgkin Lymphoma, How to decide optimal donor selection for allogeneic stem cell transplantation, among others. At the conclusion of this presentation, the powerpoint slides are distributed to a drive that can be easily accessible and the presenter summarizes the data.