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Adult Non-Hodgkin Lymphoma Treatment (PDQ®)

  • Last Modified: 07/02/2014

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Changes to This Summary (07/02/2014)

The PDQ cancer information summaries are reviewed regularly and updated as new information becomes available. This section describes the latest changes made to this summary as of the date above.

General Information About Adult Non-Hodgkin Lymphoma (NHL) Treatment

Added Tan et al. as reference 3.

Late Effects of Treatment for Adult NHL

Added text to state that some patients have osteopenia or osteoporosis at the start of therapy; bone density may worsen after therapy for lymphoma (cited Westin et al. as reference 18).

Indolent NHL

Revised text to include bendamustine with single-agent alkylators, bortezomib, and combination chemotherapy with or without rituximab because it also shows similar response rates (cited Rummel et al. as reference 45).

Revised text to state that for patients with ocular adnexal mucosa-associated lymphoid tissue lymphoma, antibiotic therapy using doxycycline that targeted Chlamydia psittaci resulted in durable remissions for almost one-half of the patients in a review of the literature that included 131 patients (cited Kiesewetter et al. as reference 89).

Aggressive NHL

Added text to state that patients who have diffuse large B-cell lymphoma with coexpression of CD20 and CD30 may define a subgroup with a unique molecular signature, a more favorable prognosis, and possible therapeutic implication for the use of anti-CD30–specific therapy, such as brentuximab vedotin (cited Hu et al. as reference 22).

Added text to state that for patients with relapsed disease, autologous stem cell transplantation (SCT) showed a 50% 3-year progression-free survival (PFS) for 39 patients in a retrospective review (cited Smith et al. as reference 53 and level of evidence [LOE] 3iiiDiii).

Revised text to state that consolidation using high-dose chemotherapy with autologous or allogeneic hematopoietic stem cell support has been applied to patients with advanced-stage peripheral T-cell lymphoma after induction therapy with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)-based regimens and after response to reinduction therapy at first relapse. Also added that the median PFS after first relapse was less than 6 months in one series of 163 patients with peripheral T-cell lymphoma (cited Mak et al. as reference 91).

Added Dunleavy et al. as reference 120.

Revised text to state that patients who received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) induction showed an overall survival (OS) benefit for rituximab maintenance over interferon-alpha maintenance. Also added that a randomized trial compared bendamustine plus rituximab with R-CHOP and showed improved PFS but no difference in OS (cited Rummel et al. as reference 165 and LOE 1iiDiii).

Added text to state that the combination of lenalidomide and rituximab also shows response rates of around 50% in relapsed patients (cited Wang et al. as reference 179 and LOE 3iiDiv).

Treatment Option Overview for Adult NHL

Added Dong et al. as reference 3. Also added that even patients with undetectable hepatitis B viral loads after remote past infection benefit from prophylaxis with entecavir in the context of rituximab therapy (cited Huang et al. as reference 4). Added that 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.

Added Cheah et al. as reference 19.

Treatment for Indolent, Noncontiguous Stage II/III/IV Adult NHL

Revised text to include obinutuzumab and bendamustine as standard treatment options for indolent, noncontiguous stage II/III/IV adult NHL.

Added text about a selected group of 107 patients with advanced-stage follicular lymphoma who were managed with initial watchful waiting; with a median delay of 55 months, subsequent therapy resulted in equivalent freedom from treatment failure and OS compared with a similar cohort treated immediately with rituximab (cited Solal-Céligny et al. as reference 22 and LOE 3iiiDiii). Also added this implies that watchful waiting remains a relevant approach even in the rituximab era.

Added Rummel et al. as reference 29.

Added text to state that a Cochrane meta-analysis could not identify any OS benefit to adding doxorubicin to chemotherapy regimens with rituximab or to chemotherapy regimens without rituximab (cited Itchaki et al. as reference 36 and LOE 1iiA).

Added text to state that a prospective, randomized trial of 534 patients with previously untreated, advanced-stage follicular lymphoma compared R-CHOP, R-FM (rituximab, fludarabine, mitoxantrone), and R-CVP (rituximab, cyclophosphamide, vincristine, prednisone); with a median follow-up of 34 months, there was no difference in OS, but the 3-year PFS favored R-CHOP and R-FM over R-CVP (cited Federico et al. as reference 39 and LOE 1iiDiii).

Added Obinutuzumab as a new subsection.

Added Bendamustine as a new subsection.

Added text to state that iodine-131–labeled tositumomab became commercially unavailable in 2013.

Added text to state that in a randomized trial of 409 patients with stage III or IV follicular lymphoma who achieved a complete or partial response, yttrium-90 ibritumomab tiuxetan consolidation versus no consolidation was evaluated. The radiolabelled antibody consolidation improved median PFS by 3 years, and median time to next treatment was improved by 5.1 years; however, there was no change in OS (cited Morschhauser et al. as reference 64 and LOE 1iiDiii).

Added text to state that in a prospective, randomized trial of 280 patients with relapsed follicular lymphoma, responders to chemotherapy and autologous SCT consolidation were randomly assigned to four doses of rituximab maintenance or no maintenance (cited Pettengell et al. as reference 66 and LOE 1iiDiii).

Treatment for Indolent, Recurrent Adult NHL

Added text to state that a prospective trial of 631 patients with follicular lymphoma and with a median follow-up of 60 months in the rituximab era (2002–2009) found a 5-year transformation rate to a higher-grade histology (cited Link et al. as reference 7). The median OS following transformation was 50 months, and the 5-year OS rate was 66%, if the transformation occurred more than 18 months after a diagnosis of follicular lymphoma. This series describes a better prognosis for patients with transformation than was experienced by patients in the prerituximab era.

Added text to state that in a prospective trial, 409 patients with follicular lymphoma who responded to induction chemotherapy were randomly assigned to yttrium-90 ibritumomab or no further consolidation; with a median follow-up of 7.3 years, the 8-year PFS favored ibritumomab, but there was no difference in OS (cited Morschhauser et al. as reference 29 and LOE 1iiDiii).

Treatment for Aggressive, Stage I and Contiguous Stage II Adult NHL

Added Ketterer et al. as reference 9.

Treatment for Aggressive, Noncontiguous Stage II/III/IV Adult NHL

Added text to state that dose intensification of R-CHOP by a 14-day versus a 21-day cycle did not result in improved outcomes (cited Cunningham et al. as reference 3).

Added Schmitz et al. and Delarue et al. as references 17 and 18, respectively. Also added that none of these trials establishes a survival advantage for reduced intervals between cycles or for increasing doses of the chemotherapy.

Added Stiff et al. as reference 49.

Added text to include radiation therapy consolidation to sites of bulky disease as a treatment option under clinical investigation for aggressive, noncontiguous stage II/III/IV adult NHL.

Added text to state that after R-CHOP induction chemotherapy, the addition of involved-field radiation therapy to sites of initial bulky disease or to extralymphatic sites remains controversial (cited Held et al., Kahl, and Phan et al. as references 51, 52, and 53, respectively). Also added that increased risks, such as long-term toxicities, must be considered.

Non-Hodgkin Lymphoma During Pregnancy

Added text to state that in a review of 121 patient case reports, one-half of the patients had very aggressive lymphomas, such as Burkitt lymphoma, and one-half of the patients had involvement of the breast, ovaries, uterus, or placenta. Also added that half of the patients received therapy antepartum, and the 6-month survival was reported at 53%, with a live-birth rate of 83% (cited Horowitz et al. as reference 6 and level of evidence 3iiiDiv).

This summary is written and maintained by the PDQ Adult Treatment Editorial Board, which is editorially independent of NCI. The summary reflects an independent review of the literature and does not represent a policy statement of NCI or NIH. More information about summary policies and the role of the PDQ Editorial Boards in maintaining the PDQ summaries can be found on the About This PDQ Summary and PDQ NCI's Comprehensive Cancer Database pages.