Contents

Welcome Back-up of Red Book ET Disclaimer Abbreviations General Drug Administration and Dosage Symbols and Units Using this Documentation Getting around the documentation Searching the documentation Changing your font size Printing Sending feedback Administration Introduction Administrative Arrangements for the Haematology Service Organisation of Laboratory Services Organisation of Inpatient and Outpatient Services Hospital/Departmental Meetings Ancillary Services and Advice for Patients Cost Implications of Clinical Decisions Leave Inability to Report for Duty Information for Registrars and House Surgeons Registrar Handy Hints Cluster Location Manual Incidents and Consumer Feedback House Surgeon Handy Hints Managing Electronic Results in Haematology Bone Marrow Aspiration and Trephine Biopsy Techniques Haematology Case Notes Consent Forms for Haematology Patients Standard Operating Procedures Clinical Procedures Protocol for Bone Marrow Aspirate and Trephine Biopsy Bone Marrows Prevention of Bleeding after Bone Marrow Biopsy Collection of Sample Aspiration Procedure Bone Marrow Trephine Samples for Surface Markers, Cytogenetics and Molecular Oncology Clinical Trials Admissions Medical Responsibilities Doctors Referring Patients to B6 Assessment of New Admissions to B6 Laboratory Results Nursing Responsibilities Clerical Responsibilities After-Hours Electronic Transfer of Radiology Images from Other Hospitals MRSA Discharges and Coding Discharges Coding Guidelines for Managing Patients Out-of-Hours Outpatient Calls Inpatients Causing Concern Haematology Day Ward General Arrangements Medical Cover for Day Ward Weekend Laboratory Tests Haematology Outpatients Intensive Care Unit (ICU) ICU Background Information Referral of Patients to ICU ICU Response Time Transfer of Patients to ICU ICU Management of Haematology Patients Haematology Management of Patients in ICU Other Support Available to Haematology Patients in ICU Communications Discharge from ICU Referral for chemotherapy in Timaru Day Ward Haemostasis Service Service Description/Staffing Referrals Requirements for Patients Referred for Outpatient DVT/PE Treatment Initial Management On Call Arrangements Incidents and Consumer Feedback Incident Reporting Patient (Consumer) and Family Feedback Cardiopulmonary Resuscitation Inpatient Deaths Medical Responsibility Nursing Staff Responsibility Outpatient Clinics Time of Outpatient Clinics Nurse-Led Clinics Referrals Adolescent and Young Adults (AYA) AYA Cancer Service Invasive Procedures Fertility Preservation Supportive Care eviQ B6 exercise guide Monitoring Vital Signs Venous Access Central Venous Access Devices (CVAD) - Hickman© Catheter Indications for Use Catheter Insertion Catheter Care Blood Sampling Ethanol Locks Ethanol Treatment Catheter Complications Blockage or Slowing Occlusion Restoring Catheter Patency Catheter-Related Thrombosis Catheter Breakage Catheter Removal Before Procedure Removal of Catheter PICC/Midlines Indications for Use Referrals Care of PICC/Midlines Portacaths Peripheral Vein Cannulas Contributing Factors for Problems Care of Cannula Cannula Infection CDHB Visual Phlebitis scale Psychological Support Anxiety in Cancer Patients Drug Treatment of Anxiety in Patients with Cancer Antidepressants Depression in Cancer Patients Drug Treatment of Depression in Patients with Cancer Pre-Transplant Psychological Assessment Staff Support Services Nutritional Support Levels of Nutrition Support Level 1 - Oral diet and Nutritional Supplements Level 2 - Enteral nutrition Level 3 - Parenteral nutrition Safe Eating and Low Immunity Diet Guidelines Nutrition support for patients undergoing an Allogeneic Stem Cell Transplant Cultural Considerations for Nutrition Support Prescribing Nutritional Supplement Drinks IV fluid and electrolyte replacement Magnesium Deficiency Potassium Administration Mucositis Pain Management General Comments Concerning Pain Relief Steroid-induced Hyperglycaemia Haematology Patients Ward Management Confusion and Delirium Nausea and Vomiting Definitions Chemotherapy and Emetogenic Potential Cytotoxic Schedules and Choice of Antiemetics Breakthrough Nausea and Vomiting Antiemetics for Outpatients Oral Hygiene/Acute Dental Care Laxatives Tumour Lysis Syndrome (TLS) Prophylaxis High Risk (>5% risk TLS) Intermediate Risk (1-5% risk TLS) Standard Risk (<1% risk TLS) Management of Tumour Lysis Syndrome Aggressive Hydration Rasburicase (recombinant form of urate oxidase) Rasburicase Dosage Hyperkalaemia Hyperphosphataemia Hypocalcaemia Renal Failure Fertility and Menstruation Issues General comments Gonadal Function and Stem Cell Transplants Women and SCT Men and SCT Ovarian Tissue Storage Embryo Freezing Semen Storage Information for Health Care Team Procedure to Organise a Freeze Therapy Induced Menopause Initial Assessment Initiating Treatment Monitoring of Treatment Management of Bleeding Complications Available Preparations Prevention of Menorrhagia Osteoporosis Prophylaxis Pathogenesis Drug Interactions and Osteoporosis Management Prophylaxis Treatment of Osteoporosis Lumbar Puncture Procedure A national standard for intrathecal chemotherapy in New Zealand Background Key Points Intrathecal Chemotherapy Training for Specialist Registrars Performance Scores ECOG Performance Status Karnofsky Performance Status Palliative Care Performance Score Sorror Score before Transplant Table 1. Definitions of comorbidities included in the HCT-CI Table 2. HCT-CI scores, 2 year survival and hazard ratios for NRM (Non-Relapse Mortality) WHO Performance Status Palliative Care Post-transplant Re-immunisation Schedule Infection Including Prophylaxis Prevention of Infection Quick look infection prevention and control isolation requirements in B6 Protective Isolation Purpose Associated Documents Definitions Hand Hygiene Single Rooms Clothing Visitors Aprons and gowns Masks B6 Maintenance HEPA Filter Maintenance Isolation Room Maintenance Temperature Maintenance Microbial Testing Preventing Infections Low Bacterial Diet Bacterial Infections Hepatitis B Prevention Herpetic Infections Pneumocystis Prophylaxis CMV Prevention CMV Monitoring Allografts (Standard or RIC) Allografts (Standard or RIC) at LOW Risk for CMV viraemia Other intensively treated patients Fungal Infections Fungal Prophylaxis Itraconazole Interactions with Posaconazole, Itraconazole and Voriconazole Influenza and Respiratory Illnesses Toxoplasmosis Prophylaxis Prevention of Infection Pre-splenectomy and in Splenic Atrophy Oral Hygiene Patients Undergoing High Dose Chemotherapy Dental Referrals Mouthcare Mucositis Topical Pain Relief Systemic Pain Relief Suspected Herpes Simplex Angular Cheilitis Lip Care Xerostomia Oral cryotherapy for the prevention of high dose melphalan induced stomatitis Perianal Care Prevention of Diarrhoea Summary of Antimicrobial Prophylaxis for SCT Vaccination Policy in Haematology Patients Vaccination in Splenectomised/Splenic Atrophy patients Vaccination Prophylaxis post-SCT Vaccination for Myeloma Patients Treatment of Infection in Haematology Patients Management of the Septic Immunosuppressed Patient Treatment of Fungal Infections Superficial Candidiasis (Mouth, Throat, Oesophagus) Systemic Candidiasis Invasive Aspergillus Infection (IAI) / Fungal PCR Tests Voriconazole Liposomal Amphotericin B Caspofungin Posaconazole Treatment of Herpetic Infections Herpes Simplex Herpes Zoster Aciclovir - Dosage in Renal Impairment Respiratory Tract Infections Community-Acquired Pneumonia Upper Respiratory Viruses Ribavirin for RSV Infections Diarrhoea and C. difficile Faecal Specimen Testing Clostridium Difficile Toxoplasmosis - Treatment Clinical Features Pneumocystis Pneumonia Clinical Features Investigations/Diagnosis Treatment Acquired CMV Infection - Treatment Clinical Features Diagnosis Treatment Drug Usage in Haematology Drug Prescribing PHARMAC Rules and Regulations Prescribing Requirements Patients' Own Medications Verbal Orders Standing Orders Outpatient Prescribing Special Authority Numbers / Named Patient Pharmaceutical Assessment (NPPA) Controlled drugs All At Once (Stat) Dispensing and Close Controls Medication Availability Unregistered Medicines (Section 29, Medicines Act 1981) Medicines Access Programmes, including Compassionate Supply Medication Information for Patients Prescription Charts Individualised Template Aplastic Anaemia Acute Lymphoblastic Leukaemia Chronic Lymphocytic Leukaemia Hairy Cell Leukaemia Acute Myeloid Leukaemia Intrathecal Chemotherapy MDS Myeloma Non-Hodgkin Lymphoma Rituximab - any indication Oral Chemo Templates Supportive Care Sheets Cytotoxic Drugs Chemotherapy Protocols Calculating the Dose of Cytotoxic Drugs Prescription and Preparation of Cytotoxic Drugs Prescription of Cytotoxic Drugs Preparation of Cytotoxic Drugs Guidelines for Rounding of Cytotoxic Drug Doses Administration of Cytotoxic Drugs Management of Extravasation of Cytotoxic Drugs Vesicant Drugs Irritant Drugs (This List is Not Exhaustive) Dosage Adjustments in Renal Impairment Dosage Adjustments in Hepatic Impairment Cytotoxic Drug Interactions Oral Cytotoxics Lumbar Punctures and Intrathecal Cytotoxics Lumbar Puncture Procedure Intrathecal Chemotherapy Bookings Flowchart: Organising Intrathecal Chemotherapy Method of Lumbar Puncture Examination of CSF High-Dose Methotrexate Monoclonal Antibodies Rituximab Alemtuzumab Obinuzumab Complications of Cytotoxic Chemotherapy Nausea and Vomiting Tumour Lysis Syndrome Cardiotoxicity and Cytotoxic Drugs Anthracyclines Prevention Management of Established Cardiac Failure Reaction to Cytarabine (Cytarabine Syndrome) Treatment WHO Toxicity Gradings Chemotherapy Drugs - Patient Information Leaflets Prednisone Withdrawal Protocol Step 1: Reduce steroids to physiological replacement dosage (5 mg/day) Step 2: Monitor for recovery of normal steroid secretion Blood Transfusion Local Transfusion Services Organisation – NZBS and B6 Ordering of Blood Products Collection and Administration of Blood Transfusions Issuing Blood Products to B6 Blood Product Information Blood Transfusion Red Cell Transfusion Blood Filters CMV Negative Blood Irradiated Blood Blood Component Therapy and SCT Guidelines for ABO Incompatibility Rhesus Incompatibility Major ABO Incompatibility i.e., A, B, or AB donor and O recipient Minor Incompatibility, i.e. O donor and A, B, AB recipient or A1 donor and A2 Recipient Mixed, Major and Minor Incompatibility i.e., A Donor to B Recipient, Or B Donor to A Recipient Rh (D) incompatibility Minor ABO Incompatibility with Donor PBSC Product Transfusion Support Recommendations for ABO-Incompatible HPC Transplantation. Platelet Transfusions Indications Verbal Orders HLA Typing and Antibody Testing Transfusion Reactions Mild Transfusion Reaction: Diagnosis and Treatment Severe Transfusion Reaction: Diagnosis and Treatment Delayed Transfusion Reactions Pathophysiology Clinical Manifestations Laboratory Diagnosis and Evaluation Management and Prevention Transfusion Related Acute Lung Injury (TRALI) Pathophysiology Clinical Signs Laboratory Diagnosis and Evaluation Management Transfusion-associated Circulatory Overload Pathophysiology Clinical Features Investigations Management Transfusion of Infected Blood Pathophysiology Clinical Manifestations Laboratory Diagnosis and Evaluation Management and Prevention Transfusion - Associated Graft-Versus-Host Disease Pathophysiology Risk Groups Clinical Manifestations Prevention Further Reading Post-Transfusion Purpura Pathophysiology Clinical Manifestations Laboratory Testing Management Use of Anti-D Intravenous Immunoglobulin (IVIG) and Evogam (S/C) Indications for IVIG usage Replacement Therapy Therapeutic Treatment Dosage For Replacement Therapy For Immunomodulatory Therapy Indications for Evogam Treating Adults who Decline Blood Products (including Jehovah's Witnesses) General Principles of Treatment Communication Health-Care Directives Blood Products and Alternatives Documentation and Liaison Checklist of Products/Procedures to Establish Acceptability Potential clinical situations that may be encountered when caring for patients who decline blood products The adult patient requiring elective surgery who declines blood products– ‘bloodless surgery’ Bloodless surgery: Maximising the pre-operative haemoglobin level Bloodless surgery: Estimating the maximum allowable blood loss (MABL) Bloodless surgery: Reducing blood loss Bloodless surgery: Post operative anaemia Acute bleeding in the adult patient who declines blood products The critically ill and anaemic adult patient who declines blood products The adult obstetric patient who declines blood products Antenatal care Labour and postnatal care including management of massive obstetric haemorrhage References Checklist of Products/Procedures to Establish Acceptability Flowchart: Elective Surgery in Patients who Decline Blood Products Flowchart: Acute Bleeding in Patients who Decline Blood Products NZBS Autologous Blood Collection and Transfusion Therapeutic Plasmapheresis Overall Supervision and Responsibility The Transfusion Medical Officer/ Haematologist on Call Notification of NZBS Apheresis Nurses Practical Details of Apheresis Procedure IV Access Medical Examination of the Patient Paediatric Patients/Donors Volume and Access Considerations Replacement Fluids and Schedules for Plasma Exchange Cytapheresis Expected/Physiological Effects vs Untoward/Adverse Effects of Therapeutic Apheresis Physiological and Adverse effects of Therapeutic Apheresis Further Detailed Management of Complications (Therapeutic Apheresis) Patient Information and Consent Costs of NZBS Blood Products Blood banking issues with Anti-CD38 and CD47 monoclonal antibodies Anti-CD38 Antibodies (Daratumumab) Effect on Serologic Testing Management Anti-CD47 Antibodies Effect on Serologic Testing Management Anaemia General Considerations and Causes Anaemia Due to Decreased Red Cell Production Iron Deficiency Causes of Iron Deficiency Increased Iron Requirements Inadequate Iron Supply Clinical and Laboratory Assessment Management Oral Iron Treatment Parenteral Iron Anaemia of Chronic Inflammation Megaloblastic Anaemia Vitamin B12 Deficiency Causes Clinical Effects Diagnosis Management Folate Deficiency Causes Diagnosis Management Other Causes of Megaloblastic Anaemia Pure Red Cell Aplasia Introduction and Key Points Classification Diagnosis Management Aplastic Anaemia Overview Clinical Presentation Classification Diagnosis Assessment of Severity and Prognosis Assessment of Severity Prognosis Pre-Treatment Investigations Management Key Points Outline of Treatment for Severe AA Supportive Care in Aplastic Anaemia Stem Cell Transplantation Immunosuppression - ATG/ALG and Cyclosporin ATG/ALG Guidelines Test Dose Administration following test dose Side Effects Treatment of Side Effects Administration and Monitoring Contraindications of ALG/ATG Treatment Relapsed / Refractory Disease Moderate Aplastic Anaemia Aplastic Anaemia Patient Information Booklet Anaemia Due to Increased Red Cell Destruction Thalassaemias Abnormal Haemoglobins Red Cell Membrane and Enzyme Defects Immune Mediated Haemolytic Anaemia Diagnosis and Management Paroxysmal Nocturnal Haemoglobinuria (PNH) Introduction and Key Points Clinical Presentation Pathogenesis Diagnosis Management Anaemia in the Elderly Neutropenia Causes of Neutropenia Drug-Induced Neutropenia Clozapine Induced Neutropenia – Prevention and Management Thrombocytopenia Iron Overload – Transfusional Desferrioxamine (DFO) Thrombotic Disorders DVT/PE Venous Thromboembolism - DVT and PE The Incidence of DVT Surgical VTE Prophylaxis Bleeding following New Oral Anticoagulants (e.g. dabigatran) Axillary Vein Thrombosis Superficial Vein Thrombosis Inferior Vena Caval (IVC) Filter Indications Outpatient DVT/PE Treatment - The Haemostasis Service Heparin-induced Thrombocytopenia (HIT) Management of HIT Bivalirudin therapy Dose modifications of the Bivalirudin dosage regimen Patients scheduled for a switch to oral anticoagulation Physiological Anticoagulants HRT/OCP & Thrombosis Air Travel and Venous Thrombosis Anti-Phospholipid Syndrome (APS) Cardinal Features Treatment Recommendations Thrombosis + Antiphospholipid Antibody Positive (ACL or LAC) Pregnant + Antiphospholipid Antibody Positive (ACL or LAC) Pregnancy & Thrombosis Prophylaxis Complications Investigation for DVT/PE Treatment DVT or Pulmonary Embolus Prophylaxis of DVT/PE Disseminated Intravascular Coagulation Pathophysiology Diagnosis of DIC Clinical Causes Management of DIC Inherited Bleeding Disorders Management National Guidelines General Principles of Treatment Specialist Management Terminology Pain Relief Acute Joint Bleeding Recovery Dosing Recording Treatment Vaccinations Hepatitis B Vaccination Hepatitis A Prophylaxis Haemophilia A Haemophilia B Management of Bleeding Haemarthroses Muscle Bleeds Major Head Injury or Intra Cerebral Bleed Surgery Minor Procedures - Endoscopy & Skin Lesions Major Procedures - General or Orthopaedic Surgery Dental Procedures Routine Extraction with Local Anaesthetics Dental Extraction with Surgical Flaps (General Anaesthesia) Chronic Knee Synovitis Intra-articular Injections Haematuria Mild Haemophilia Desmopressin Factor VIII Concentrates Patients with Inhibitors to Factor VIII Introduction Information Required Acute Bleeding Management Acquired Haemophilia Acquired Factor VIII Deficiency Obstetric Management of Carrier Women Management of Mother (Carrier Women) Potential New Case of Haemophilia Von Willebrand Disease Background Minor Bleeds Surgery and Major Bleeds Doses of FVIII-VWF Concentrate (Biostate) for VWF Patients Unresponsive to desmopressin (avail. from Blood Bank) Pregnancy Platelet Disorders Congenital Platelet Function Defects Acquired Platelet Function Defects Uraemia Hepatic Cirrhosis Myeloproliferative Disorders Genetic Testing DNA Diagnosis of Haemophilia A & B Product Information Recombinant Factor VIII Advate Adynovate (extended half-life rFVIII) Plasma Derived Factor VIII Biostate - CSL FVIII Recombinant Factor IX Rixubis Alprolix (extended half-life FIX) Recombinant Activated Factor VII (NovoSeven) Feiba NF FXIII Concentrate Desmopressin Tranexamic Acid Uses Side Effects Conjugated Oestrogens (e.g. Premarin) Acute Myeloid Leukaemia Overview Clinical Features Classification Laboratory Diagnosis Morphology of Blood and Bone Marrow Immunophenotyping Cytogenetics DNA Analysis The Decision to Treat Pre-Treatment Investigations for New AML Patients Management of AML Introduction and Key Questions Current Trials in AML Supportive Care Emergencies in Acute Leukaemia AML 19 AML (other than APML) comparisons AML 19 Trial Information Remission Criteria Management of non-trial patients Management of older patients with Acute Myeloid Leukaemia Management of Relapse or Refractory Patients Idarubicin / Cytarabine Protocol Pre-treatment Assessment Dose Modifications Initial Treatment Palliative Care Low dose cytarabine as per AML14 trial Etoposide/Thioguanine Hydroxyurea Hyperleucocytosis Acute Promyelocytic Leukaemia Overview Clinical Features Laboratory Diagnosis Prognosis and the Decision to Treat Pre-Treatment Investigations Management AML19 APML Induction Consolidation Maintenance Supportive Care Differentiation (ATRA) syndrome Other Side Effects of Tretinoin (ATRA) Remission Criteria Treatment of non-trial patients Management of Relapse or Refractory Patients Arsenic Treatment Supportive Care Myelodysplasia Overview Classification Diagnosis Assessment of Prognosis IPSS-R WPSS IPSS CMML Score Management Key Points Supportive Care Low Risk MDS Erythropoeitin and GCSF High risk MDS Allogenic Stem Cell Transplantation MPD - CML, CNL, PV, ET, PMF, CEL-NOS, Mastocytosis Introduction Chronic Myeloid Leukaemia - BCR-ABL Positive (CML) Clinical Findings Investigation of Suspected CML Morphology Prognostication Treatment Management of Leucostasis Management of CP CML Treatment of AP and BP CML Monitoring and Response Response Definitions, Treatment Goals and Failures Management of Suboptimal Response, Treatment Failure, and Loss of Response Monitoring and Management of Effects/Toxicity Pregnancy and TKI Therapy Treatment-free Remission – Stopping TKI Therapy Further Reading Chronic Neutrophilic Leukaemia (CNL) Polycythaemia Vera (PV) Diagnostic Criteria Clinical Assessment for Raised Hb Investigation of Suspected PV Treatment Response Assessment Referral to GP for Shared Care PV Refractory or Intolerant Hydroxyurea Long-term Outcomes in PV and Management of Transformation Further Reading Essential Thrombocythaemia (ET) Diagnostic Criteria Management Referral to GP for Shared Care Hydroxyurea-Refractory and -Intolerant ET Long-term Outcomes in ET and Management of Transformation Further Reading Primary Myelofibrosis (PMF) Diagnostic Criteria Prognosis Management Allografting Further Reading Eosinophilia Causes of Eosinophilia Chronic Eosinophilic Leukaemia – Not Otherwise Specified (CEL-NOS) Diagnostic Criteria for CEL Prognosis and Management of CEL-NOS Idiopathic Hypereosinophilic Syndrome (HES) Myeloid and Lymphoid Neoplasms with Eosinophilia and Abnormalities of PDGFRA, PDGFRB, FGFR1, or with PCM1-JAK2 Treatment Further Reading Mastocytosis Classification Systemic Mastocytosis (SM) Diagnostic Criteria for SM Management Further Reading Acute Lymphoblastic Leukaemia Overview Clinical Features Laboratory Diagnosis Morphology Classification Immunophenotyping Cytogenetics DNA Analysis Prognosis, Risk Factors and the Decision to Treat Prognosis Risk Factors The Decision to Treat Pre-Treatment Investigations for New ALL and Burkitt's Lymphoma Patients Management Introduction and Key Questions Current Trials in ALL Non-trial Patients Philadelphia-negative adult ALL Philadelphia-positive adult ALL Induction chemotherapy Supportive Care Emergencies in Acute Leukaemia L-Asparaginase Administration and Toxicity Management of Anaphylaxis L-asparaginase – bleeding and thrombosis AALL1732 Document CNS disease and intrathecal Chemotherapy UKALL 14 UKALL 14 Prescription Sheets COG Trials for High-risk B-ALL Burkitt Leukaemia/Lymphoma Treatment Modified OPAL Protocol Initial Therapy and Prescription Sheets Consolidation Treatment Remission Maintenance Oral Maintenance Therapy Management of Relapse and Refractory Patients Palliative Care CLL, HCL, & LGL Leukaemia Mature B-cell Leukaemias Chronic Lymphocytic Leukaemia/Small Lymphocytic Lymphoma (CLL/SLL) Overview Clinical Features Laboratory Diagnosis Morphology of blood, marrow, and lymph nodes Immunophenotyping Cytogenetics DNA Analysis Classification, Staging, and Prognosis Investigations for the New Patient With CLL Monoclonal B-cell lymphocytosis Management of B-CLL Treatment of Newly-Diagnosed Non-trial Patients Chlorambucil Fludarabine and Cyclophosphamide Bendamustine and Rituximab Obinutuzumab and Chlorambucil Rituximab Management of Early Stage B-CLL - Information for general practitioners Monitoring and Supportive Care Dose Modifications Adverse Effects Supportive Measures Vaccines Antiemetics Blood products Splenectomy Monoclonal Antibodies in CLL Transplantation in CLL Autologous stem cell transplantation Relapsed or Refractory Patients Hairy Cell Leukaemia (HCL) Clinical and Laboratory Assessment Prognosis Management B-cell Prolymphocytic Leukaemia Mature T- and NK-Cell Leukaemias T/NK Large Granular Lymphocyte Leukaemia Mycosis/Fungoides/Sezary Syndrome Lymphoma Non-Hodgkin Lymphoma Introduction Classification Lymphoma MDT Laboratory Diagnosis Staging The Ann Arbor Staging System Prognosis, Risk Factors, and the Decision to Treat International Prognostic Index for Aggressive Lymphoma (IPI) Revised IPI (RIPI) Enhanced IPI (Derived by National Comprehensive Cancer Network, NCCN) FLIPI Score for Follicular Lymphoma Pre-Treatment Investigations for Aggressive NHL Current Trials in NHL Management of Non-Trial Patients Assessment of Response CNS Directed Therapy Treatment of Lymphoma Chemotherapy for Diffuse Large B-cell NHL CHOP + Rituximab (R-CHOP21) Modifications to R-CHOP21 Primary CNS Lymphoma Salvage Protocols ICE-G and IVE-G +/- Rituximab Vinorelbine and Gemcitabine for Relapsed T-cell NHL or Hodgkin Lymphoma Chemotherapy Schedules for Burkitt's and Burkitt-like tumours CODOX-M /IVAC Chemotherapy Schedules for Indolent NHL Bendamustine + Rituximab CVP + Rituximab (R-CVP) Chlorambucil Maintenance therapy in indolent lymphoma Management of elderly patients with lymphoma Stem Cell Grafts in NHL and Hodgkin Lymphoma NHL subtypes Follicular Lymphoma (FL) Diagnosis and Grading Morphology of the Lymph Node Other Laboratory Features Management Marginal Zone Lymphomas (MZL) MALT Lymphoma Management Anti-tumour treatments Splenic Marginal Zone Lymphoma Management Nodal Marginal Zone Lymphoma Mantle Cell Lymphoma (MCL) Management Diffuse Large B-Cell Lymphoma (DLBCL) Management Mediastinal Large B-Cell Lymphoma Anaplastic Large Cell Lymphoma (ALCL) Management Peripheral T-Cell Lymphoma (PTL) Management Burkitt Lymphoma/Leukaemia Waldenstrom's Macroglobulinaemia (Lymphoplasmacytoid Lymphoma) Management Primary CNS Lymphoma AIDS-related Lymphoma (ARL) Post-transplant lymphoproliferative disorders (PTLD) Hodgkin Lymphoma Plasma Cell Neoplasms MGUS Assessment of M proteins Low Risk MGUS Higher Risk MGUS MGUS Prognosis Management of MGUS - Information for general practitioners Smouldering Myeloma Diagnosis Prognosis Guidelines for Follow Up Multiple Myeloma Key Points Current Trials in Myeloma Clinical Findings Laboratory and Radiological Findings Diagnostic Criteria Prognosis, Risk Factors and the Decision to Treat Investigations Required for the New Patient Likely to Receive Intensive Treatment Management Key Points Induction therapy Transplant Eligible Transplant Ineligible Thalidomide Lenalidomide Bortezomib Bortezomib, Cyclophosphamide, Dexamethasone (CyBorD) C thal Dex or thalidomide, cyclophosphamide and dexamethasone VMP or Bortezomib (Velcade) Melphalan and Prednisone Thalidomide Melphalan Prednisone (MPT) Cyclophosphamide plus Dexamethasone Melphalan plus Prednisone Vincristine, Adriamycin, and Dexamethasone (VAD) Etoposide High Dose Oral Dexamethasone Idarubicin and Dexamethasone (ZDex) Monitoring Treatment for Multiple Myeloma Stem Cell Schedules – Autograft and Allografts Bisphosphonate Treatment Complications of Bisphosphonate Treatment Calcium and Vitamin D Deficiency Osteonecrosis of the Jaw (ONJ) Other toxicities Prescribing IV Bisphosphonate Pamidronate Zoledronic acid Specific Complications of Myeloma Bony or Nerve Compression Pain Hypercalcaemia Spinal Cord Compression Infections Renal failure Plasmacytoma Solitary Bone Plasmacytoma Extra Medullary Plasmacytoma POEMS Syndrome Amyloidosis Introduction Clinical features Diagnosis Evaluation of organ involvement Management Further reading Heavy Chain Disease Plasma Cell Leukaemia Haemophagocytic Lymphohistiocytosis Primary HLH Secondary HLH Diagnosis Macrophage activation syndrome (MAS) Treatment References Stem Cell Transplantation (SCT) Introduction, Administration and Quality – SCT Introduction Historical Background Stem Cell Grafting in Christchurch Publications Key Events of the Stem Cell Programme in Christchurch Transplant Activity Administration Haematopoietic Stem Cell Transplant Committee Referral of Patients for Stem Cell Grafts Stem Cell Accreditation Foundation for Accreditation of Cellular Therapy (FACT) Patient Information Websites Reference Sources for Stem Cell Grafting Information Quality Documentation Indications for SCT General Principles for Making Transplant Decisions Information Sources Helpful in Making Transplant Decisions Summary of Current Indications for SCT at Christchurch Acute Myeloid Leukaemia Allogeneic SCT in First Remission SCT in Second or Subsequent Remissions Acute Lymphoblastic Leukaemia SCT in First Remission Philadelphia-positive ALL SCT in Relapsed Patients References Burkitt Leukaemia/Lymphoma References Chronic Myeloid Leukaemia References Chronic Lymphocytic Leukaemia Recommended reading Myeloma International guidelines Autologous transplant as 1st line consolidation Tandem autologous transplant as 1st line therapy High-risk myeloma Up-front or delayed autologous transplant? 2nd autologous transplant in relapsed myeloma following ASCT1 Allogeneic transplant following ASCT for myeloma in 1st remission Allogeneic transplant for relapsed myeloma Amyloidosis Autologous transplantation Patient selection is crucial Allogeneic transplantation Recommended reading Myelodysplasia Primary myelofibrosis (PMF) and MF secondary to ET/PRV Aplastic Anaemia Lymphoma Diffuse Large B cell Lymphoma and transformed low-grade lymphoma Indolent NHL Hodgkin Lymphoma Pre-Transplant Patient Assessment Initial Patient Assessment Geriatric Comprehensive Assessment Consents for SCT Conditioning Schedules for SCT SCT Conditioning Cyclophosphamide/TBI Conditioning Busulphan/Cyclophosphamide Conditioning Cyclophosphamide + ATG Conditioning Fludarabine/Melphalan/Alemtuzumab Conditioning Fludarabine/TBI Conditioning BEAM Conditioning High Dose Melphalan Conditioning Acute Myeloid Leukaemia Standard Allografts RIC SCTs MDS Standard Allografts RIC SCTs Acute Lymphoblastic Leukaemia Standard Allografts RIC SCTs Chronic Myeloid Leukaemia Standard Allografts RIC SCTs Chronic Lymphocytic Leukaemia Non Hodgkin Lymphoma and Hodgkin Lymphoma Autologous SCT Standard Allografts RIC SCTs Myeloma Autografts Standard myeloablative conditioning Aplastic Anaemia Intrathecal Therapy and SCT IT Methotrexate and SCT Busulphan Dosing Prevention of Seizures Busulphan Concentration and Dose Adjustment Appendices Cyclophosphamide/MESNA Detailed Schedule Details of TBI Treatment Busulphan Administration and Dose Adjustment BEAM Detailed Schedule High Dose Melphalan Cyclophosphamide + ATG Detailed Schedule Cyclophosphamide ATG/ALG Guidelines Test Dose Administration following test dose Side Effects Administration and Monitoring Contraindications of ALG/ATG Treatment Infusion of Cellular Therapy Products Stem Cell Mobilisation Autologous Stem Cell Mobilisation - Cyclophosphamide/G-CSF Allogeneic Stem Cell Mobilisation - G-CSF Autologous Stem Cell Mobilisation - G-CSF Post Chemotherapy Autologous G-CSF primed Bone Marrow Harvest Anticoagulation during Stem Cell Harvest Allogeneic Transplants Introduction The HLA system Conventional Myeloablative Allografts Conventional Myeloablative Protocols Infection Prophylaxis GvHD Prophylaxis Reduced Intensity Conditioning (RIC) Allografts Introduction RIC Protocols Infection Prophylaxis GvHD Prophylaxis Chimerism Analyses GvHD Management Post Transplant Donor Lymphocyte Infusions (DLI) Definition of Disease Progression Guidelines for post-transplant management of patients in the absence of GvHD DLI Decision-making Guidelines for High Risk Patients without GvHD and off all Immunosuppression Work-Up Prior to DLI Doses, Collection and Administration of DLI Further Reading Myelosuppression Post RIC SCT/DLI Donor Searches Sibling Donor Searches Extended Family Searches (EFS) One Antigen Mismatched Related SCT Unrelated Donor (MUD) Searches Termination of MUD Search Family Mismatched SCT Donor Search Donor Selection Assessment and Consent Selection of the Donor Donor Assessment for Allograft - Standard or RIC Donor Consent Donor Follow-up If the Donor is a Minor or a Mentally Incompetent Adult Allogeneic Bone Marrow or Peripheral Blood Harvest and Infusion Donor Hospital Admission Donor Bone Marrow Harvest Donor Peripheral Blood Harvest Cord Blood Transplantation (CBT) Historical Aspects Indications for Cord Blood Transplantation Fuller Information about Cord Blood Transplants Procedure for Harvest of Related Cord Blood Stem Cells Transplant Schedules Autologous Transplants Autologous Stem Cell Harvest and Infusion Autologous Haematopoietic Stem Cell Harvest – Peripheral Blood and Bone Marrow Bone Marrow Harvests Peripheral Blood Stem Cell Harvests Autologous Bone Marrow Harvest and Cryopreservation Peripheral Blood Stem Cell Harvesting and Mobilisation Protocols General Comments Peripheral Blood Stem Cell Mobilisation Protocols G-CSF Primed Bone Marrow Harvests Use of Fresh (Non-cryopreserved) Bone Marrow in Autologous BMT Overnight Storage of PBSC Harvest Transplant Schedules Discharge and Follow Up Discharge to Other Centres Autologous Patients Allogeneic Patients Shared Protocols and Documentation Post-Transplant Follow-Up Re-referral Criteria Contact Us Complications of SCT Graft versus Host Disease (GvHD) Introduction Acute Graft Versus Host Disease (aGvHD) Clinical Features and Grading of Severity Pathogenesis of Acute GvHD Diagnosis of acute GVHD Initial Management of Acute GvHD Steroid tapering What dose of steroid? When to start 2nd line treatment Management of steroid-refractory acute GvHD Which 2nd line treatment to choose Further reading Supportive Care Skin Gastro-intestinal Maintenance of Adequate Nutritional Status Chronic GvHD (cGvHD) Clinical Features Pathogenesis Diagnosis and Grading and Severity Assessment Histology of cGvHD Management Localised cGvHD 1st line therapy of cGvHD 2nd line and beyond therapy of chronic GvHD Results of an EBMT survey on 1st and 2nd line therapy of chronic GvHD Prognosis of cGvHD Pulmonary GvHD Clinical symptoms Diagnosis Differential diagnosis Grading of pulmonary GvHD Lung function score Prognosis Management Monitoring Essential reading Management of oral chronic GVHD Diagnosis Assessment and Grading Management Further Reading Veno Occlusive Disease of the Liver (VOD) Pathogenesis Clinical Features and Diagnosis Grading of VOD Prognosis Management of VOD Bacterial Infection in SCT Viral infection in SCT Hepatitis B CMV EBV Toxoplasma Infusion-related Reactions in HCT Introduction Adverse Reactions (AR) References Microbial contamination of cellular therapy products Transplant Associated Microangiopathy (TAM) Diagnosis Pathophysiology Prognosis Management Engraftment failure Introduction Engraftment and Chimerism Approach to the Patient with Graft Failure Management of Graft Failure Late Effects Screening after Allogeneic Transplant Late follow-up of transplant survivors - summary for referring physicians and GPs Long term Complications and Follow-up Cancer Screening in HCT Survivors Vaccination Prophylaxis post-SCT Stem Cell Transplants - Information for patients Information about autologous transplants Information about allogeneic transplants Reporting Data to International Registries Resources Information for General Practitioners Essential thrombocythaemia - joint management between specialist care and primary care Management of Early Stage B-CLL - Information for general practitioners Primary polycythaemia - joint management between specialist care and primary care Splenectomy Management Management of MGUS - Information for general practitioners Information for Patients Aplastic Anaemia Patient Information Booklet Chemotherapy Drugs - Patient Information Leaflets Ovarian Tissue Storage Information Patient Information Websites Reviews, Feedback, and Document Control Managing Unscheduled Updates to the documentation Managing Scheduled Reviews of the documentation Archive Process Review Schedule Summary of Updates September 2023 June 2023 January 2023 2022 November 2022 September 2022 August 2022 June 2022 May 2022 February 2022 2021 December 2021 September 2021 July 2021 June 2021 May 2021 March 2021 2020 December 2020 November 2020 August 2020 July 2020 May 2020 April 2020 March 2020 February 2020 January 2020 2019 December 2019 November 2019 October 2019 September 2019 August 2019 July 2019 June 2019 May 2019 March 2019 February 2019 January 2019 2018 December 2018 November 2018 October 2018 September 2018 August 2018 July 2018 June 2018 April 2018 March 2018 February 2018 January 2018 2017 December 2017 November 2017 October 2017 September 2017 August 2017 July 2017 June 2017 May 2017 April 2017 March 2017 January 2017 2016 December 2016 November 2016 October 2016 September 2016 August 2016 July 2016 June 2016 May 2016 April 2016 March 2016 February 2016 2015 November 2015 September 2015 July 2015 May 2015 April 2015 March 2015 January 2015 2014 December 2014 November 2014 October 2014 September 2014 August 2014 June 2014 May 2014 April 2014 March 2014 February 2014 January 2014 2013 December 2013 November 2013 October 2013 September 2013 August 2013 July 2013 June 2013 May 2013 April 2013 March 2013 February 2013 2012 December 2012 November 2012 October 2012 September 2012 July 2012 June 2012 May 2012 April 2012 March 2013 February 2012 2011 December 2011 November 2011 October 2011 August 2011 July 2011 May 2011 April 2011 February 2011 2010 November 2010 October 2010 August 2010 July 2010 June 2010 April 2010 January 2010 2009 December 2009 August 2009 July 2009 June 2009 April 2009 January 2009 2008 November 2008 October 2008 September 2008 August 2008 July 2008 March 2008 February 2008 October 2007