Adult Non-Hodgkin Lymphoma Treatment - National Cancer Institute 6/9

Adult Non-Hodgkin Lymphoma Treatment - National Cancer Institute

Adult Non-Hodgkin Lymphoma Treatment (PDQ®)–Health Professional Version

Treatment Option Overview for Adult NHL

In This Section

• Current Clinical Trials

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 Non-Hodgkin Lymphoma (NHL)

Stage	Standard Treatment Options
IF-XRT = involved-field radiation therapy; P13K = phosphatidylinositol 3-kinase; R-CHOP = rituximab, an anti–CD20 monoclonal antibody, cyclophosphamide, doxorubicin, vincristine, and prednisone.
Indolent Stage I and Indolent, Contiguous Stage II Adult NHL	Radiation 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 NHL	Watchful waiting for asymptomatic patients
	Rituximab with or without chemotherapy
	Maintenance rituximab
	Obinutuzumab
	P13K inhibitors
	Lenalidomide and rituximab
	Radiolabeled anti-CD20 monoclonal antibodies
Indolent, Recurrent Adult NHL	Chemotherapy (single agent or combination)
	Rituximab
	Obinutuzumab
	Lenalidomide
	Radiolabeled anti-CD20 monoclonal antibodies
	Palliative radiation therapy
Aggressive Stage I and Aggressive, Contiguous Stage II Adult NHL	R-CHOP with or without IF-XRT
Aggressive, Noncontiguous Stage II/III/IV Adult NHL	R-CHOP
	Other combination chemotherapy
Lymphoblastic Lymphoma/Acute Lymphocytic Leukemia	Intensive therapy
	Radiation therapy
Diffuse, Small, Noncleaved-Cell/Burkitt Lymphoma	Aggressive multidrug regimens
	Central nervous system (CNS) prophylaxis
Aggressive, Recurrent Adult NHL	Bone 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 can be included in these studies. Standardized guidelines for response assessment have been suggested for use in clinical trials.[1]

Several retrospective reviews suggest routine surveillance scans after attaining clinical complete remission after induction therapy for diffuse large B-cell lymphoma offer little to no value. Prognostic value is also difficult to identify for an interim positron emission tomography-computed tomography scan during induction therapy for diffuse large B-cell lymphoma.[2-5]

Aggressive lymphomas are increasingly seen in 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 can be assessed before treatment with rituximab and/or chemotherapy.[6,7] Patients with detectable hepatitis B viral loads benefit from prophylaxis with entecavir in the context of rituximab therapy.[8,9] Patients with a resolved hepatitis B virus (HBV) infection (HBsAg negative + HBcAb positive) are at risk of reactivation of HBV and require monitoring of HBV DNA. Prophylactic nucleoside therapy lowered HBV reactivation from 10.8% to 2.1% in a retrospective study of 326 patients.[10] Similarly, prophylaxis for herpes zoster with acyclovir or valacyclovir and prophylaxis for pneumocystis with trimethoprim/sulfamethoxazole or dapsone are usually applied with rituximab with or without combination chemotherapy.

In addition to screening for HIV among patients with aggressive lymphomas, active hepatitis B or hepatitis C can be assessed before treatment with rituximab and/or chemotherapy.[6,7] Even patients with undetectable hepatitis B viral loads after remote past infection benefit from prophylaxis with entecavir in the context of rituximab therapy.[8,9] Similarly, prophylaxis for herpes zoster with acyclovir or valacyclovir 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,[11-19] thyroid,[20,21] spleen,[22] testis,[23-25] paranasal sinuses,[26-29] bone,[30,31] orbit,[32-36] and skin.[37-46]

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

Current Clinical Trials

Use our advanced clinical trial search to find NCI-supported cancer clinical trials that are now enrolling patients. The search can be narrowed by location of the trial, type of treatment, name of the drug, and other criteria. General information about clinical trials is also available.

References

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2. Mamot C, Klingbiel D, Hitz F, et al.: Final Results of a Prospective Evaluation of the Predictive Value of Interim Positron Emission Tomography in Patients With Diffuse Large B-Cell Lymphoma Treated With R-CHOP-14 (SAKK 38/07). J Clin Oncol 33 (23): 2523-9, 2015. [PUBMED Abstract]
3. Thompson CA, Ghesquieres H, Maurer MJ, et al.: Utility of routine post-therapy surveillance imaging in diffuse large B-cell lymphoma. J Clin Oncol 32 (31): 3506-12, 2014. [PUBMED Abstract]
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22. Morel P, Dupriez B, Gosselin B, et al.: Role of early splenectomy in malignant lymphomas with prominent splenic involvement (primary lymphomas of the spleen). A study of 59 cases. Cancer 71 (1): 207-15, 1993. [PUBMED Abstract]
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44. El-Helw L, Goodwin S, Slater D, et al.: Primary B-cell lymphoma of the skin: the Sheffield Lymphoma Group Experience (1984-2003). Int J Oncol 25 (5): 1453-8, 2004. [PUBMED Abstract]
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