1. Indolent lymphomas
The standard management of low-grade NHL is controversial and ranges from the ?watch and wait? approach pioneered at Stanford University to the use of combination regimens containing anthracycline, such as FND (fludarabine [Fludara], Novantrone [mitoxantrone], dexamethasone).
1. Radiation therapy
The treatment of choice is irradiation alone to the entire involved lymphoid region, as defined by the Rai and Ann Arbor staging classifications, or the involved region plus one additional uninvolved region on each side of the involved nodes.
The recommended dose is 30 Gy for nonbulky disease showing prompt regression, with 36 Gy delivered for bulky or slowly regressive disease.
Extended field irradiation
As the majority of relapses occur outside the radiation fields, often in adjacent or distal lymph nodes, extended-field or total lymphoid irradiation has been used to try to improve cure rates. Clinical series have shown improvement in freedom from relapse only, with no significant difference in long-term survival.
2. Adjuvant chemotherapy
The issue of whether adjuvant chemotherapy improves the prognosis of patients with early-stage low-grade NHL remains unresolved.
Some have advocated adjuvant chemotherapy to selected patients with stage II disease with unfavorable prognostic factors, such as systemic symptoms or more than two (or discontiguous) nodal sites, and to those with follicular grade 2 histology.
(chlorambucil [Leukeran] (daily dose, 0.1-0.2 mg/kg) or cyclophosphamide (1.5-2.5 mg/kg) with or without prednisone. Oral pulse chlorambucil (16 mg/m2 for 5 days at 3- week intervals) usually results in a faster antitumor response than daily single agent alkylator therapy.
(cyclophosphamide, vincristine, and prednisone).
cyclophosphamide + vincristine + procarbazine + prednisone.
cyclophosphamide + doxorubicin + vincristine + prednisone.
More intensive combination, CHOP-B (bleomycin [Blenoxane]) , is reported not to have any advantage vs single-agent cyclophosphamide.
The purine analogs, such as fludarabine and cladribine (2- CdA [Leustatin]), have significant antitumor activity in low-grade NHL and are being studied in combination regimens.
FND: fludarabine + mitoxantrone ? dexamethasone.
Rituximab (Rituxan), either alone or combined with these agents (eg, CVP or CHOP), is being investigated.
Radiolabelled antibodies ibritumomab tiuxetan (Zevalin) and tositumomab/iodine-131 have shown encouraging results.
The use of interferon (IFN)-alfa (Intron A, Roferon-A) concomitantly with or as an adjuvant to conventional chemotherapy in follicular lymphoma appears to prolong disease-free survival, but its impact on overall survival and curability is controversial.
For select patients, allogeneic stem-cell transplantation should be considered as a potentially curative approach.
Irradiation therapy here is used locally for palliation of symptomatic sites of disease and is extremely effective.
Total-body irradiation is used as part of preparative regimens for BMT and has produced up to 80% CRR, 25% Relapse free survival at 5yrs.
Older patients with asymptomatic, indolent NHL are often observed closely without any initial therapy. The decision to use any of the standard or newer modalities should be individualized, based on the presence of poor prognostic features and the patient?s tolerance to planned therapy.
Special types of indolent lymphoma
MALT marginal zone lymphoma
Relapsed low grade lymphoma
In general, treatment with standard agents rarely produces a cure in patients whose disease has relapsed.
Favorable survival after relapse has been associated with:
Even the most favorable subset, however, has a 10-fold greater mortality compared with age-adjusted US population rates.
Long-term freedom from second relapse, however, is uncommon and multiple relapses will usually occur.
Bone marrow transplantation
Bone marrow transplantation is still under evaluation but should be considered in the context of a clinical trial. This is usually preceded by 2 cycles of CHOP, however, preparative drug regimens have varied; some investigators also use total-body irradiation.
For relapse that remains low grade, chemotherapy with single alkylating agents (often given orally) or with combinations such as cyclophosphamide, vincristine, and prednisone is often used.
Significant activity for fludarabine and 2-chlorodeoxyadenosine has been demonstrated in relapsed low-grade lymphomas, both as single agents and in combination with other drugs.
Rituximab results in a 40% to 50% response rate in patients who relapse with indolent B-cell lymphomas. Rituximab can also be combined with combination chemotherapy.
Radiolabeled monoclonal antibodies
Durable responses to radiolabeled monoclonal antibodies, such as yttrium-90 ibritumomab (commercially available) and iodine-131 tositumomab, have also been reported; subsequent chemotherapy regimens can be delivered at the time of relapse following radioimmunotherapy.
Histologic transformation of low-grade NHL to a more aggressive histology is well recognized, occurring in 30%-70% of patients during the course of their. Indolent lymphomas may relapse with an aggressive histology (i.e., histologic conversion). Sometimes, an aggressive lymphoma may relapse as a small cell (indolent) lymphoma. Such a situation occurs with indolent lymphoma in the bone marrow and with aggressive lymphoma in a nodal site. Patients may present in such a manner, and chemotherapy might successfully eradicate the peripheral disease while failing to eliminate the small cell component from the bone marrow. The clinical significance and natural history of this pattern of disease are not well defined. Progression to DLBC lymphoma at 5% per year.
Histologic conversions should be treated with the regimens described in the aggressive, recurrent adult non-Hodgkin's lymphoma. The durability of the second remission may be short, and clinical trials, such as bone marrow transplantation, should be considered.
2. Intermediate to high grade lymphoma
Stage I/IIA nonbulky (limited stage)
Prior to the 1970s, most patients with stage I/II large cell lymphoma (intermediate grade in the Working Formulation) were treated with irradiation alone, with overall cure rates of 40%-50%. Patients with pathologically favorable stage I/II disease had even better outcomes, but relapse rates, even in these patients, were still 20%-30%. Pathologic staging, therefore, selected a group suitable for irradiation alone.
Combined-modality therapy includes 3 cycles of CHOP in addition to irradiation.
Stage I/IIA bulky
Chemotherapy + adjuvant radiotherapy
For patients with bulky disease, a minimum of six cycles of CHOP is typically administered. Irradiation doses of 30-35 Gy, delivered in 1.75-3.0 Gy over 3-4 weeks after completion of systemic therapy, appear to be adequate.
Stage III/IV disease
The following recommended treatment strategies should be adjusted according to the level of risk, as defined by the prognostic factors validated by the IPI:
1. Age ≤ 60 years at low or intermediate risk (IPI)
Younger patients at low or intermediate risk (ie, normal LDH level and ambulatory performance status) have 5-year survival rates > 50%. They should be treated with six to eight cycles of a standard doxorubicin-containing regimen, such as CHOP.
1. CHOP + rituximab
The addition of rituximab to CHOP has become routine in the United States and is also being employed with combined-modality therapy.
The classic regimen is CHOP. Newer regimens, such as m-BACOD (methotrexate, bleomycin, Adriamycin, cyclophosphamide, Oncovin, and dexamethasone; Dana-Farber Cancer Center), ProMACE-CytaBOM (prednisone, methotrexate, Adriamycin, cyclophosphamide, etoposide, cytarabine, bleomycin, and Oncovin; National Cancer Institute [NCI]), and MACOP-B (methotrexate, Adriamycin, cyclophosphamide, Oncovin, prednisone, and bleomycin; Vancouver). Randomized comparisons have failed to show an advantage of the third-generation regimens over CHOP.
A recently reported investigation suggests an advantage with the addition of etoposide to the CHOP regimen (CHOEP) given every 2 or 3 weeks.
3. Bone marrow transplantation
Bone marrow transplantation can be used in the setting of a clinical trial. Several randomized prospective trials evaluated the role of autologous bone marrow or stem cell transplantation consolidation versus chemotherapy alone in patients in first remission with diffuse large cell lymphoma. Although most of these trials demonstrated significant increases in EFS (by 10% to 20%) among patients who received high-dose therapy, significant differences in OS could not be demonstrated prospectively in any of the series.
2. Age ≤ 60 years at high intermediate or high risk
The 5-year survival rate in younger patients deemed at high intermediate or high risk (high LDH level and/or nonambulatory performance status) is < 50%. Since the clinical features that correlate with relapse are also associated with a decreased likelihood of achieving an initial remission, these patients should be offered participation in clinical trials of dose-intensive treatment strategies aimed at improving the rates and durability of complete responses.
3. Age > 60 years
All patients older than age 60 should undergo evaluation of cardiac, pulmonary, and renal function and coexistent illness, which may complicate therapy.
Most older patients with advanced-stage aggressive NHL have 5-year survival rates < 50% as a result of decreased initial response, poor tolerance to therapy, and the need for dose reduction because of age. Approaches to elderly patients should include interventions aimed at preserving or increasing dose intensity and improving tolerance of therapy with the use of cytokines and infusional chemotherapy.
Patients with compromised cardiac function require individualized approaches, such as the use of a regimen that does not contain an anthracycline (eg, CVP, C [cyclophosphamide]-MOPP, or CEPP [cyclophosphamide, etoposide, procarbazine, and prednisone]); a reduction in total anthracycline dose (eg, by alternating CHOP with C-MOPP or CEPP); or the administration of doxorubicin by continuous infusion. Similarly, bleomycin should not be used in patients with compromised pulmonary function.
Irradiation may be added if there is localized residual disease after
chemotherapy completion to improve local control. Irradiation can also be
delivered to prechemotherapy areas of bulky disease, again to enhance local
control. These recommendations are based on the observation that when DLBCL
relapses after definitive chemotherapy, it usually does so in initially
Special types of aggressive disease
Disease site or potential toxicities may influence the treatment plan:
In younger patients, a brief period of chemotherapy (3-4 cycles of CHOP) followed by local irradiation may be used to prevent sterility in men and early menopause in women.
Lymphomas of the head and neck: chemotherapy alone to avoid the acute mucositis and long-term xerostomia associated with radiation therapy fields.
Gastric or small intestinal lymphoma at high risk of perforation or life-threatening hemorrhage may require surgical resection. Alternatively, chemotherapy followed by local irradiation may allow gastric preservation in some patients. Fully resected gastric or small intestinal lymphoma should be followed by chemotherapy.
Primary brain lymphomas continue to be problematic. At present, the recommended approach is chemotherapy, high-dose methotrexate ? other drugs that penetrate the CNS (i.e. cytarabine [Ara-C], procarbazine, vincristine, thiotepa [Thioplex], temozolomide [Temodar]), in conjunction with radiation therapy. Optimal dose and scheduling of radiation therapy remain to be determined (long-term neurotoxicity may be excessive in older populations).
Testicular lymphoma: orchiectomy followed by combination chemotherapy with an anthracycline-containing regimen has improved the results of therapy for primary testicular lymphoma. Because of the increased risk of recurrence in the CNS and opposite testis, intrathecal chemotherapy (though controversial because relapse is primarly CNS parenchymal disease) and irradiation to the contralateral testis are recommended.
Relapsed high grade lymphoma
Bone marrow transplantation
Bone marrow transplantation is the treatment of choice for patients whose lymphoma has relapsed. Preparative drug regimens have varied; some investigators also use total-body irradiation. Similar success has been achieved using autologous marrow, with or without marrow purging, and allogeneic marrow.
In general, retreatment with standard agents rarely produces a cure in patients whose lymphomas relapse. Patients who relapse with aggressive lymphoma after 3 years in remission have similar prognoses to de novo lymphoma using curative therapy. Several salvage chemotherapy regimens are available.
Rituximab can induce responses in 33% of patients with relapsing aggressive lymphoma of appropriate phenotype (CD20-positive).
Radiolabeled anti-CD20 monoclonal antibodies, such as iodine-131 tositumomab and yttrium-90 ibritumomab, induce 60% to 80% response rates in patients with relapsed or refractory B-cell lymphoma.
Denileukin difitox, a fusion protein combining diptheria toxin and interleukin-2, resulted in a 25% objective response rate in 45 heavily pretreated patients with aggressive B-cell non-Hodgkin's lymphoma (CD25, i.e., interleukin-2 receptor, expression was not correlated with response).
AIDS related lymphoma
Outside the context of a clinical trial, low-dose chemotherapy should be considered for most patients with HIV infection and a CD4 lymphocyte count under 200. Although m-BACOD was used in the randomized trial, many clinicians now employ half-dose cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP).
Prognosis and survival
Indolent lymphomas usually have a long overall survival (8-12 years). Median disease-free survival is almost always between 1.5 and 3 years, and median overall survival ranges from 5 to 7 years. Patients with stage III disease have a better prognosis than patients with stage IV disease. Overall, 75% of patients with stage III disease can be expected to survive 5 years.
International Prognostic Index Scoring for intermediate to high grade lymphoma