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Adult Non-Hodgkin Lymphoma Treatment (PDQ®)

Treatment Option Overview for Adult NHL

Treatment of non-Hodgkin lymphoma (NHL) depends on the histologic type and stage. Many of the improvements in survival have been made using clinical trials (experimental therapy) that have attempted to improve on the best available accepted therapy (conventional or standard therapy).

In asymptomatic patients with indolent forms of advanced NHL, treatment may be deferred until the patient becomes symptomatic as the disease progresses. When treatment is deferred, the clinical course of patients with indolent NHL varies; frequent and careful observation is required so that effective treatment can be initiated when the clinical course of the disease accelerates. Some patients have a prolonged indolent course, but others have disease that rapidly evolves into more aggressive types of NHL that require immediate treatment.

Radiation techniques differ somewhat from those used in the treatment of Hodgkin lymphoma. The dose of radiation therapy usually varies from 25 Gy to 50 Gy and is dependent on factors that include the histologic type of lymphoma, the patient’s stage and overall condition, the goal of treatment (curative or palliative), the proximity of sensitive surrounding organs, and whether the patient is being treated with radiation therapy alone or in combination with chemotherapy. Given the patterns of disease presentations and relapse, treatment may need to include unusual sites such as Waldeyer ring, epitrochlear, or mesenteric nodes. The associated morbidity of the treatment must be considered carefully. The majority of patients who receive radiation are usually treated on only one side of the diaphragm. Localized presentations of extranodal NHL may be treated with involved-field techniques with significant (>50%) success.

Table 4. Standard Treatment Options for NHL
StageStandard Treatment Options
CNS = central nervous system; CHOP = cyclophosphamide, doxorubicin, vincristine, and prednisone; IF-XRT = involved-field radiation therapy; NHL = non-Hodgkin lymphoma; R-CHOP = rituximab, an anti-CD20 monoclonal antibody, cyclophosphamide, doxorubicin, vincristine, and prednisone.
Indolent, Stage I and Contiguous Stage II Adult NHLRadiation therapy
Rituximab with or without chemotherapy
Watchful waiting
Other therapies as designated for patients with advanced-stage disease
Indolent, Noncontiguous Stage II/III/IV Adult NHLWatchful waiting for asymptomatic patients
Rituximab
Purine nucleoside analogs
Alkylating agents (with or without steroids)
Combination chemotherapy
Yttrium-90–labeled ibritumomab tiuxetan
Maintenance rituximab
Indolent, Recurrent Adult NHLChemotherapy (single agent or combination)
Rituximab
Lenalidomide
Radiolabeled anti-CD20 monoclonal antibodies
Palliative radiation therapy
Aggressive, Stage I and Contiguous Stage II Adult NHLR-CHOP with or without IF-XRT
Aggressive, Noncontiguous Stage II/III/IV Adult NHLR-CHOP
Other combination chemotherapy
Adult Lymphoblastic LymphomaIntensive therapy
Radiation therapy
Diffuse, Small, Noncleaved-Cell/Burkitt LymphomaAggressive multidrug regimens
Central nervous system (CNS) prophylaxis
Aggressive, Recurrent Adult NHLBone marrow or stem cell transplantation
Re-treatment with standard agents
Palliative radiation therapy

Even though standard treatment in patients with lymphomas can cure a significant fraction, numerous clinical trials that explore improvements in treatment are in progress. If possible, patients should be included in these studies. Standardized guidelines for response assessment have been suggested for use in clinical trials.[1]

Aggressive lymphomas are increasingly seen in human immunodeficiency virus (HIV)-positive patients; treatment of these patients requires special consideration. (Refer to the PDQ summary on AIDS-Related Lymphoma Treatment for more information.)

In addition to screening for HIV among patients with aggressive lymphomas, active hepatitis B or hepatitis C should be assessed prior to treatment with rituximab and/or chemotherapy.[2,3] Even patients with undetectable hepatitis B viral loads after remote past infection benefit from prophylaxis with entecavir in the context of rituximab therapy.[4] Similarly, prophylaxis for herpes zoster with acyclovir or valcyclovir and prophylaxis for pneumocystis with trimethoprim/sulfamethoxazole or dapsone are usually applied with rituximab with or without combination chemotherapy.

Several unusual presentations of lymphoma occur that often require somewhat modified approaches to staging and therapy. The reader is referred to reviews for a more detailed description of extranodal presentations in the gastrointestinal system,[5-13] thyroid,[14,15] spleen,[16] testis,[17-19] paranasal sinuses,[20-23] bone,[24,25] orbit,[26-30] and skin.[31-40]

(Refer to the PDQ summary on Primary CNS Lymphoma Treatment for more information.)

References

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  2. Niitsu N, Hagiwara Y, Tanae K, et al.: Prospective analysis of hepatitis B virus reactivation in patients with diffuse large B-cell lymphoma after rituximab combination chemotherapy. J Clin Oncol 28 (34): 5097-100, 2010. [PUBMED Abstract]
  3. Dong HJ, Ni LN, Sheng GF, et al.: Risk of hepatitis B virus (HBV) reactivation in non-Hodgkin lymphoma patients receiving rituximab-chemotherapy: a meta-analysis. J Clin Virol 57 (3): 209-14, 2013. [PUBMED Abstract]
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  • Updated: December 5, 2014