What is the treatment approach for lymphoma with lung infiltrate?

Treatment Approach for Lymphoma with Lung Infiltrate

The treatment approach for lymphoma with lung infiltrate should be determined by the specific lymphoma subtype, with concurrent chemoradiotherapy being the standard of care for most cases involving pulmonary infiltration. 1

Diagnostic Evaluation

• Histological verification is mandatory, especially in relapses occurring >12 months after initial diagnosis, to confirm lymphoma subtype and rule out other etiologies 1
• Complete staging workup should include:
  • CT scan of chest, abdomen, and neck 1
  • PET-CT scan (recommended for routine staging) 1
  • Bone marrow aspirate and biopsy 1
  • Complete blood count, routine blood chemistry including LDH, B2M, and uric acid 1
  • Screening for HIV, HBV, and HCV 1

Treatment Strategy by Lymphoma Type

Follicular Lymphoma with Lung Infiltrate

• For localized disease (Stage I-II) involving the lung:

  • Involved-site radiotherapy (ISRT, 24-30 Gy) is the preferred approach with curative intent 1
  • In cases where ISRT is not feasible for lung involvement, systemic therapy as indicated for advanced stages should be applied 1

• For advanced disease (Stage III-IV) with lung infiltration:

  • Obinutuzumab or rituximab in combination with CHOP or bendamustine is recommended if complete remission and long PFS are therapeutic goals 1
  • For more aggressive clinical course, obinutuzumab/rituximab-CHOP should be applied 1
  • Extended anti-infectious prophylaxis should be considered after bendamustine-containing induction therapy due to risk of pulmonary complications 1

Diffuse Large B-Cell Lymphoma with Lung Infiltrate

• For patients with adequate performance status (no major organ dysfunction, age below 65 years):

  • Conventionally dosed salvage chemotherapy followed by high-dose treatment with stem-cell support in responsive patients 1
  • Common salvage regimens include R-DHAP, R-ESHAP, R-EPOCH, or R-ICE 1
  • Addition of rituximab is not recommended in cases refractory to previous rituximab-containing chemotherapy 1

• For patients not suitable for high-dose therapy:

  • Conventionally dosed salvage regimens (e.g., R-IMVP16, R-GEMOX) may be used and combined with involved-field radiotherapy 1
  • Individualized palliative care for elderly, comorbid patients 1

Classical Hodgkin Lymphoma with Lung Infiltrate

• For relapsed disease with lung involvement:
  • High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard of care 1
  • Nivolumab is indicated for classical Hodgkin lymphoma that has relapsed or progressed after autologous HSCT and brentuximab vedotin, or after 3+ lines of systemic therapy including autologous HSCT 2

Special Considerations for Lung Infiltrates

• Pulmonary infiltrates in lymphoma patients may represent:

  • Direct lymphomatous infiltration of lung parenchyma 3
  • Infectious complications (common differential diagnosis) 3
  • Treatment-related pneumonitis 1

• For rapidly progressive pulmonary infiltration by lymphoma:

  • Urgent biopsy (transbronchial or surgical) may be needed to distinguish between infection and lymphomatous infiltration 4, 3
  • Early initiation of appropriate therapy is critical as rapidly progressive pulmonary lymphoma can be fatal 4

• For oligoprogressive disease in the lung:

  • Stereotactic radiation therapy can safely and durably control sites of extra-CNS oligoprogressive disease 5
  • Higher radiation doses (single-fraction equivalent dose >25 Gy) show better local control rates 5

Response Evaluation

• Appropriate structural imaging evaluation should be carried out mid-treatment and after completion of chemotherapy 1
• PET-CT after completion of induction chemotherapy is recommended for prognostic reasons 1
• Patients with inadequate response (less than partial response) should be evaluated for early salvage regimens 1

Treatment Complications and Follow-up

• Monitor for potential development of second malignancies, including lung cancer, which can occur as a long-term complication in lymphoma survivors 6
• Regular follow-up should include history and physical examination every 3 months for 2 years, every 6 months for 3 more years, and then once a year 1
• Radiological examinations at 3,6,12, and 24 months, then as needed for evaluation of suspicious symptoms 1