OpenOnco · Treatment Plan

Treatment plan — Adult T-Cell Leukemia/Lymphoma

PLAN-ATLL-SMOLD-001-V1 · v1 · 2026-06-11

Patient

ATLL-SMOLD-001 · Algorithm: ALGO-ATLL-1L

DiagnosisAdult T-Cell Leukemia/Lymphoma

MOH / ICD-10C91.5

ICD-O-39827/3

Etiological driver

Etiological driver · etiologically_driven archetype

Adult T-Cell Leukemia/Lymphoma

HTLV-1 (Human T-cell Lymphotropic Virus 1) — defining etiology, 100%
CD3+ CD4+ CD25+ CCR4+ FoxP3+ — Treg-like phenotype
TCR αβ rearrangement з clonal HTLV-1 integration
Endemic у Japan, Caribbean, Latin America, Sub-Saharan Africa

Clinical significance of mutations (ESCAT)

Tumor-board context — the engine does not use these tiers to rank tracks

✅ Covered biomarkers (matched in KB)

Biomarker	Variant	ESCAT	Evidence	Clinical significance	Drugs	Sources
No clinically actionable variants matched in this profile.

⚠️ Not included in plan

Biomarker	Status
BIO-HTLV-1	BIO definition in KB; no ESCAT BMA entry — verify with clinician

Primary current-line option

Standard plan

★ DEFAULT

Indication

IND-ATLL-1L-INDOLENT-AZT-IFN

Regimen

AZT (zidovudine) + IFN-α — continuous, dose-adjusted

Drugs + NSZU

Zidovudine (DRUG-ZIDOVUDINE) 1.5-3 g/day divided BID-TID · PO continuous, dose-adjust по hematologic toxicity · PO ✓ NSZU covered
Interferon alfa (DRUG-INTERFERON-ALPHA) 5 MIU/m² SC daily для induction; 5 MIU/m² 3×/тиждень maintenance · SC daily induction, 3×/тиждень maintenance · SC ✓ NSZU covered

Supportive care

SUP-PSYCH-MONITORING-IFN

Hard contraindications

CI-PSYCH-DECOMPENSATED-FOR-INTERFERON

Reason

Primary current-line option selected by ALGO-ATLL-1L at step 2; branch-driving red flag: RF-ATLL-SHIMOYAMA-INDOLENT.

Other current-line alternatives (1 tracks)

Same treatment line; review when biomarker, access, contraindication, or patient-context assumptions change.

Aggressive plan

Indication

IND-ATLL-1L-AGGRESSIVE

Regimen

CHOEP (cyclophosphamide + doxorubicin + vincristine + etoposide + prednisone), 6 cycles

Drugs + NSZU

Cyclophosphamide (DRUG-CYCLOPHOSPHAMIDE) 750 mg/m² · IV day 1 each 21-day cycle · IV ⚠ NSZU — not for this indication
Doxorubicin (DRUG-DOXORUBICIN) 50 mg/m² · IV day 1 each cycle · IV ⚠ NSZU — not for this indication
Vincristine (DRUG-VINCRISTINE) 1.4 mg/m² (cap 2 mg) · IV day 1 each cycle · IV ⚠ NSZU — not for this indication
Etoposide (DRUG-ETOPOSIDE) 100 mg/m² · IV days 1-3 each cycle · IV ⚠ NSZU — not for this indication
Prednisone (DRUG-PREDNISONE) 100 mg · PO days 1-5 each cycle · PO ⚠ NSZU — not for this indication

Supportive care

SUP-PJP-PROPHYLAXIS, SUP-ANTIEMETIC-PREMED, SUP-GCSF-NEUTROPENIA

Hard contraindications

CI-LVEF-LOW-FOR-ANTHRACYCLINE

Reason

Current-line alternative presented for HCP consideration

Why this branch was chosen

Triggers from the patient profile that fired and drove the chosen branch.

Step 2 → branch IND-ATLL-1L-INDOLENT-AZT-IFN

RF-ATLL-SHIMOYAMA-INDOLENT ★ winner: Shimoyama smoldering or chronic-favourable subtype of ATLL. Smoldering: ≥5% circulating abnormal lymphocytes, no organ involvement (skin/lung lesion permitted), LDH normal, BUN normal, albumin normal, no hypercalcemia, no lymphadenopathy or organomegaly. Chronic-favourable: similar to smoldering but lymphadenopathy/organomegaly permitted, LDH ≤2× ULN, BUN ≤ULN, albumin ≥ULN, Ca normal, no CNS/bone/GI/effusion. AZT+IFN-α (anti-HTLV-1 mechanism) yields 5-yr OS ~46% vs ~20% for chemotherapy in these subtypes (Bazarbachi 2010 meta-analysis, JNCI). Aggressive subtypes (acute/lymphoma/chronic-unfavourable) do NOT respond to AZT+IFN — route those to CHOEP+mogamulizumab via RF-ATLL-HIGH-RISK-BIOLOGY. SRC-NCCN-BCELL-2025SRC-ESMO-PTCL-2024

Pre-treatment investigations

Investigations before treatment start · critical / standard / desired · merged across tracks

ID	Name	Priority	Category	Where to order	Needed for
TEST-CBC	Complete Blood Count with Differential	Critical	lab	—	all tracks
TEST-CECT-CAP	CECT chest/abdomen/pelvis	Critical	imaging	—	all tracks
TEST-CMP	Comprehensive Metabolic Panel	Critical	lab	—	all tracks
TEST-FLOW-CYTOMETRY	Flow Cytometry	Critical	histology	CSD Lab ✓ (code TBC)	all tracks
TEST-HBV-SEROLOGY	Hepatitis B Serology Panel (HBsAg, anti-HBc total, anti-HBs)	Critical	lab	—	all tracks
TEST-HCV-ANTIBODY	HCV Antibody	Critical	lab	—	all tracks
TEST-HIV-SEROLOGY	HIV Antibody/Antigen	Critical	lab	—	all tracks
TEST-LDH	Lactate Dehydrogenase	Critical	lab	—	all tracks
TEST-LFT	Liver Function Tests (ALT, AST, bilirubin, ALP, GGT, albumin)	Critical	lab	—	all tracks
TEST-LN-EXCISIONAL-BIOPSY	Excisional LN Biopsy	Critical	histology	—	aggressive
TEST-PREGNANCY	Beta-HCG	Critical	lab	—	all tracks
TEST-ECHO	Echocardiography	Standard	imaging	—	aggressive
TEST-HTLV1-SEROLOGY	HTLV-1/2 antibody screen + confirmatory	Standard	lab	—	all tracks
TEST-PET-CT	FDG PET/CT (whole body)	Standard	imaging	—	all tracks
TEST-NGS-LYMPHOID-PANEL	Lymphoid NGS Panel	Desired	genomic	CSD Lab ✓ (code TBC)	desired (aggressive)

Red flags — PRO / CONTRA aggressive

PRO-AGGRESSIVE

Triggers that push toward the aggressive track

Shimoyama acute or lymphoma subtype (LDH >2×ULN, BUN >ULN, albumin <ULN — any one) — aggressive variant; AZT+IFN-α inadequate, requires intensive chemo (mLSG-15) ± alloSCT.RF-ATLL-HIGH-RISK-BIOLOGY
Hypercalcemia (Ca >12 mg/dL) at diagnosis — hallmark of aggressive ATLL; requires bisphosphonate/calcitonin urgently and predicts aggressive subtype regardless of WBC.RF-ATLL-ORGAN-DYSFUNCTION

CONTRA-AGGRESSIVE

Hard contraindications to escalation

Pre-treatment LVEF <50% is an absolute contraindication to anthracycline-containing regimens (R-CHOP, Pola-R-CHP, ABVD, BV-AVD, etc.). Cardiotoxicity from doxorubicin is dose-cumulative and often irreversible; starting with already-impaired function risks acute decompensation.CI-LVEF-LOW-FOR-ANTHRACYCLINE

What NOT to do

Explicit prohibitive rules, each grounded in a regimen / supportive care / contraindication entity

Standard plan (IND-ATLL-1L-INDOLENT-AZT-IFN)

Do not give AZT+IFN for acute / lymphoma type — poor response, delays chemo cycle.
Do not skip depression screening before IFN — IFN-induced depression is fatal (suicide risk).
Do not neglect hypercalcemia treatment — bisphosphonates + hydration.
Do not give IFN during pregnancy — teratogenic.
Do not skip TSH monitoring — IFN may induce thyroiditis.

Aggressive plan (IND-ATLL-1L-AGGRESSIVE)

Do not give AZT+IFN for acute — wasted time, progression.
Do not skip mogamulizumab if available — overall survival benefit.
Do not give mogamulizumab before planned allo-SCT — pre-existing GVHD risk increased.
Do not neglect hypercalcemia treatment — bisphosphonates + hydration mandatory.
Do not give vincristine intrathecally — fatal.
Do not give full-dose anthracycline if LVEF <50%.

Monitoring schedule

Monitoring schedule by treatment phase

Aggressive plan · MON-R-CHOP-REGIMEN

Phase	Window	Tests	Checkpoints
baseline	Within 2 weeks before cycle 1	TEST-CBC, TEST-CMP, TEST-LFT, TEST-LDH, TEST-B2-MICROGLOBULIN, TEST-HBV-SEROLOGY, TEST-HCV-ANTIBODY, TEST-HIV-SEROLOGY, TEST-PET-CT, TEST-LN-EXCISIONAL-BIOPSY, TEST-FLOW-CYTOMETRY, TEST-CD20-IHC, TEST-ECHO, TEST-PREGNANCY, TEST-BM-ASPIRATE, TEST-BM-TREPHINE	Confirm CD20+ DLBCL histology; rule out double-hit (FISH for MYC/BCL2/BCL6) Confirm HBV status + entecavir prophylaxis plan if HBsAg+ or anti-HBc+ Baseline LVEF ≥50% before doxorubicin IPI calculation documented (age, ECOG, LDH, stage, extranodal sites) CNS-IPI calculation if anatomic risk sites or composite score concerning Fertility preservation discussion (sperm banking / oocyte cryo) for childbearing-age
on_treatment	Day 1 of every 21-day cycle	TEST-CBC, TEST-CMP, TEST-LFT	ANC ≥1500 + platelets ≥100K before each cycle (delay or G-CSF if not) Neuropathy grade documented (CTCAE) — vincristine modification if ≥2 LVEF re-check after cumulative doxorubicin ~300 mg/m²
interim_response_assessment	After cycles 2-4 (interim PET-CT)	TEST-PET-CT, TEST-LDH	Lugano response criteria + Deauville score If Deauville 4-5 with mass progression → consider salvage or trial
end_of_treatment	After cycle 6 (within 6-8 weeks)	TEST-PET-CT, TEST-CBC, TEST-CMP, TEST-LDH	Confirm CR vs PR vs SD vs PD by Lugano/Deauville Begin survivorship plan: cardiac surveillance schedule, vaccination catch-up, second-cancer screening
follow_up_short	Every 3 months × 2 years post-treatment	TEST-CBC, TEST-CMP, TEST-LFT, TEST-LDH	Surveillance for relapse (~40% relapse risk by 2 years overall) HBV reactivation monitoring continues for 12 months post anti-CD20
follow_up_long	Every 6 months years 3-5, then annually	TEST-CBC, TEST-LFT, TEST-ECHO	Late cardiomyopathy screening (LVEF) annually if cumulative dox >300 Annual second-malignancy screening (skin, breast, etc. age-appropriate)

Timeline

Treatment timeline — derived from regimen + monitoring schedule

Aggressive plan

Baseline

Within 2 weeks before cycle 1

Induction · CHOEP (cyclophosphamide + doxorubicin + vincristine + etoposide + prednisone), 6 cycles

21-day cycles × 6 (consider autoSCT consolidation in fit younger)

Response assessment

After cycles 2-4 (interim PET-CT)

Follow-up

Every 3 months × 2 years post-treatment

MDT brief

Discussion questions (4, 2 blocking)

BLOCKING OQ-HBV-SEROLOGY
Has HBV serology (HBsAg, anti-HBc total) been done? Status must be known before starting anti-CD20 therapy.
Anti-CD20 without HBV prophylaxis in HBsAg+/anti-HBc+ patients carries significant reactivation risk (CI-HBV-NO-PROPHYLAXIS).
→ infectious_disease_hepatology
BLOCKING OQ-CD20-CONFIRMATION
Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
Anti-CD20 therapy is the backbone of most lines of treatment; absence of CD20 expression fully changes the regimen.
→ pathologist
OQ-STAGING-COMPLETE
Has complete staging been done (Lugano + PET/CT or CT)?
Prognosis and track selection depend on stage and tumor burden.
→ radiologist
OQ-LDH-CURRENT
What is the current LDH? Marker of tumor burden and transformation.
LDH is part of the prognostic indices of indolent lymphomas.
→ hematologist

MDT talk tree (5 steps)

#	Owner	Topic	Action
1	infectious_disease_hepatology	Infection / hepatic safety BLOCKING	Has HBV serology (HBsAg, anti-HBc total) been done? Status must be known before starting anti-CD20 therapy.
2	pathologist	Pathology confirmation BLOCKING	Is CD20+ status confirmed by histology (IHC)? Without CD20+, rituximab/obinutuzumab are not indicated.
3	hematologist	Staging / disease burden	What is the current LDH? Marker of tumor burden and transformation.
4	radiologist	Staging / disease burden	Has complete staging been done (Lugano + PET/CT or CT)?
5	clinical_pharmacist	Specialist review	Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.

Skills (required) — mandatory virtual specialists (1)

Hematologist / oncohematologist required
Lymphoma diagnosis — leading specialty for treatment management.
Owns: OQ-LDH-CURRENT

Skills (recommended) — for consideration (2)

Clinical pharmacist recommended
Chemoimmunotherapy regimen — drug-drug interactions, dose adjustments, premedication.
Pathologist (general) recommended
Confirm lymphoma histology + assess transformation risk (DLBCL/Richter).
Owns: OQ-CD20-CONFIRMATION

Data quality

Incomplete for MDT sign-off. MDT sign-off is incomplete until critical clinical data gaps are resolved.

Biomarker coverage: 1/1 known (100%), 0 missing, 0 default-track gaps
Missing critical: cd20_ihc_status, hbsag, anti_hbc_total, lugano_stage
Missing recommended: ldh_ratio_to_uln, fib4_index, pet_ct_date
Unevaluated RedFlags: RF-ATLL-HIGH-RISK-BIOLOGY, RF-ATLL-HYPERCALCEMIA, RF-ATLL-INFECTION-SCREENING, RF-ATLL-ORGAN-DYSFUNCTION, RF-ATLL-SHIMOYAMA-INDOLENT, RF-ATLL-TRANSFORMATION-PROGRESSION, RF-CHRONIC-HTLV-1-MALIGNANCY-PREVENTION

Missing data for doctor action

Priority	Clinical item	Owner	Why it matters	Next action	Blocks
CRITICAL	CD20 IHC status `cd20_ihc_status`	pathologist	Confirms CD20-directed therapy is biologically appropriate.	Verify CD20 IHC result, specimen, method, and report date.	-
CRITICAL	HBsAg `hbsag`	infectious_disease_hepatology	Identifies active HBV infection and prophylaxis need before anti-CD20 or other immunosuppressive therapy.	Order or document HBsAg before treatment start.	-
CRITICAL	Total anti-HBc `anti_hbc_total`	infectious_disease_hepatology	Detects prior HBV exposure and reactivation risk.	Order or document total anti-HBc and decide prophylaxis/monitoring.	-
CRITICAL	Lugano stage `lugano_stage`	radiologist	Defines lymphoma extent and supports tumor-burden and response-assessment decisions.	Document Lugano stage from PET/CT or contrast CT staging.	-
RECOMMENDED	LDH ratio to ULN `ldh_ratio_to_uln`	medical_oncologist	Supports prognostic scoring and aggressive-biology flags.	Enter LDH with local upper limit of normal.	-
RECOMMENDED	FIB-4 liver fibrosis index `fib4_index`	infectious_disease_hepatology	Screens hepatic fibrosis risk before hepatotoxic therapy or antiviral coordination.	Calculate FIB-4 from age, AST, ALT, and platelet count.	-
RECOMMENDED	PET/CT date `pet_ct_date`	radiologist	Shows whether baseline staging is recent enough for treatment planning and later response comparison.	Document baseline PET/CT date or explain alternative staging modality.	-

Technical MDT skill metadata (3/16 activated in this plan)

All registered virtual specialists. ✓ — activated for this case; ○ — not activated (available for other clinical scenarios).

Specialist	skill_id	Version	Last reviewed	Domain
Cellular therapy specialist (CAR-T)	`cellular_therapy_specialist`	v0.1.0	2026-04-25	cellular_therapy
Clinical pharmacist	`clinical_pharmacist`	v0.1.0	2026-04-25	clinical_pharmacy
Hematologist / oncohematologist	`hematologist`	v0.1.0	2026-04-25	hematology_oncology
Hematopathologist (lymphoma / leukemia / myeloma)	`hematopathologist`	v0.1.0	2026-04-25	hematopathology
Infectious disease / hepatology	`infectious_disease_hepatology`	v0.1.0	2026-04-25	infectious_diseases
Medical oncologist (solid-tumor chemotherapist)	`medical_oncologist`	v0.1.0	2026-04-25	solid_oncology
Molecular geneticist / molecular oncologist	`molecular_geneticist`	v0.1.0	2026-04-25	molecular_oncology
Palliative care	`palliative_care`	v0.1.0	2026-04-25	palliative_care
Pathologist (general)	`pathologist`	v0.1.0	2026-04-25	pathology
Primary care / family physician	`primary_care`	v0.1.0	2026-04-25	primary_care
Psycho-oncologist	`psychologist`	v0.1.0	2026-04-25	psychosocial
Radiation oncologist	`radiation_oncologist`	v0.1.0	2026-04-25	radiation_oncology
Radiologist	`radiologist`	v0.1.0	2026-04-25	diagnostic_imaging
Social worker / case manager	`social_worker_case_manager`	v0.1.0	2026-04-25	psychosocial
Surgical oncologist	`surgical_oncologist`	v0.1.0	2026-04-25	surgical_oncology
Transplant specialist (BMT)	`transplant_specialist`	v0.1.0	2026-04-25	cellular_therapy

Sources cited

SRC-NCCN-BCELL-2025: NCCN Clinical Practice Guidelines in Oncology: B-Cell Lymphomas (v.2.2025)

Experimental options (clinical trials)

Third plan track — open-enrollment trials from ClinicalTrials.gov. Render-time metadata; engine selection is not affected by this block (CHARTER §8.3). Last synced: 2026-06-11.

NCT	Title	Phase	Status	Sponsor	UA	Signals	Eligibility (excerpt)
NCT06698003	A Study of Mogamulizumab to Prevent Adult T-cell Leukemia/Lymphoma in People With HTLV-1	PHASE2	RECRUITING	Memorial Sloan Kettering Cancer Center	—	Biomarker: enriched Single country
NCT07555431	Dolutegravir Versus Dolutegravir in Combination With Tenofovir for the Treatment of HTLV-1 Infection	PHASE2	RECRUITING	Carlos Brites	—	Biomarker: enriched Single country

Verify recruitment status directly with the trial site. ctgov data can lag behind current UA-site status.

Option availability in Ukraine

Per-track UA registration · NSZU · cost · access pathway. Render-time metadata; engine selection does not depend on these fields (CHARTER §8.3).

Option	UA registration	NSZU	Cost orientation	Access pathway
Standard plan AZT (zidovudine) + IFN-α — continuous, dose-adjusted (REG-AZT-IFN-A)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Aggressive plan CHOEP (cyclophosphamide + doxorubicin + vincristine + etoposide + prednisone), 6 cycles (REG-CHOEP)	✓ registered	✓ covered	₴-? — verify pathway	NSZU formulary
Trial · NCT06698003 A Study of Mogamulizumab to Prevent Adult T-cell Leukemia/Lymphoma in People With HTLV-1 No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor
Trial · NCT07555431 Dolutegravir Versus Dolutegravir in Combination With Tenofovir for the Treatment of HTLV-1 Infection No UA site listed — international referral required	— unknown	— unknown	self-pay: ₴0/course	Trial sponsor

Cost information is orientation. Verify with a specific pharmacy / foundation / trial site. Status updated: 2026-06-11.

plan_id: PLAN-ATLL-SMOLD-001-V1 | version: 1 | generated: 2026-06-11T11:52:06.106775+00:00

Per FDA non-device CDS positioning (CHARTER §15): Outpatient oncology treatment planning to support tumor-board discussion. Not a medical device; not for autonomous clinical decision-making.

Per FDA non-device CDS positioning (CHARTER §15): Both treatment options below are presented for review. The engine's selection of a 'recommended' default does not constitute a clinical decision. Final treatment selection requires HCP judgment incorporating information not available to the system.

This document is an informational resource supporting tumor-board discussion (per CHARTER §11). It is not a system that makes clinical decisions. Every recommendation must be verified by the treating physician.