What are the treatment options for Hodgkin’s and Non-Hodgkin’s lymphoma in the neck lymph nodes?

Treatment Options for Hodgkin's and Non-Hodgkin's Lymphoma in the Neck Lymph Nodes

The treatment of lymphoma in the neck lymph nodes depends on the specific type (Hodgkin's vs. Non-Hodgkin's), disease stage, and risk factors, with combined modality approaches being the standard of care for most patients. 1

Diagnosis and Staging

• Diagnosis requires an excisional lymph node biopsy providing adequate tissue for histopathological examination and immunohistochemistry 1
• Core biopsies may be appropriate only in patients requiring emergency treatment 1
• Staging workup should include:
  • Contrast-enhanced CT scan of neck, chest, and abdomen 1
  • PET-CT if available (preferred for accurate staging) 1
  • Bone marrow biopsy (not required if PET-CT is performed) 1
  • Complete blood count, ESR, and comprehensive blood chemistry including LDH 1
  • Screening for hepatitis B, hepatitis C, and HIV 1

Treatment of Hodgkin's Lymphoma in Neck Lymph Nodes

Limited Stage (Stage I-II without risk factors)

• For stage IA NLPHL (nodular lymphocyte-predominant Hodgkin lymphoma) without risk factors: Involved-site radiotherapy (ISRT) at 30 Gy alone is standard treatment 1
• For classical HL (cHL): Combined modality therapy with abbreviated chemotherapy followed by involved-field radiation is standard 1, 2
  • Typically 2-4 cycles of ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) followed by 30 Gy involved-field radiotherapy 1, 3

Intermediate Stage (Stage I-II with risk factors)

• Four cycles of ABVD followed by 30 Gy involved-field radiotherapy is standard 1
• PET-guided treatment approaches may allow omission of radiotherapy in selected patients with complete metabolic response, though this remains investigational 1

Advanced Stage (Stage III-IV)

• Six to eight cycles of ABVD or BEACOPPescalated (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) 1
• Consolidative radiotherapy may be considered for sites of initial bulky disease 1

Treatment of Non-Hodgkin's Lymphoma in Neck Lymph Nodes

For CD20+ Large B-cell NHL (most common type)

• Six to eight cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) given every 21 or 14 days (with growth factor support for 14-day cycles) is the standard treatment for all stages 1
• Treatment strategies should be stratified according to International Prognostic Index (IPI) and patient factors 1
• Consolidation radiotherapy to sites of bulky disease has not proven beneficial 1

For CD20+ NLPHL (Nodular Lymphocyte-Predominant Hodgkin Lymphoma)

• R-CHOP (rituximab-CHOP) has shown promising results in retrospective studies 1
• Rituximab may be added due to CD20 expression on LP cells 4

Treatment of Relapsed/Refractory Disease

Hodgkin Lymphoma

• High-dose chemotherapy (HDCT) followed by autologous stem cell transplantation (ASCT) is the standard of care 1
• Salvage regimens like DHAP, IGEV, or ICE can be used before HDCT and ASCT 1
• Brentuximab vedotin is an option for patients failing ASCT 1
• Nivolumab and pembrolizumab are approved for patients with disease recurrence after HDCT, ASCT, and brentuximab vedotin therapy 1

Non-Hodgkin Lymphoma

• Salvage chemotherapy followed by high-dose therapy and autologous stem cell transplant 2
• For patients ineligible for transplant, various chemotherapy regimens or targeted therapies may be used 1

Special Considerations for Neck Involvement

• Evaluation of thyroid function is recommended in patients receiving neck irradiation at 1,2, and at least at 5 years post-treatment 1
• Consultation with an ear, nose, and throat specialist should be considered for patients with head and neck involvement 1
• Ultrasound examination may reveal additional pathological lymph nodes in the neck that are not detected by physical examination 5

Response Evaluation and Follow-up

• Interim response evaluation should be conducted during treatment to exclude disease progression 1
• PET-CT is preferred for response assessment in FDG-avid lymphomas 1
• Follow-up should include:
  • History, physical examination, and laboratory analysis every 3 months for the first half year, every 6 months until the fourth year, and once a year thereafter 1
  • CT scans to confirm remission status, then only as clinically indicated 1
  • Regular thyroid function monitoring if the neck was irradiated 1

Prognosis

• With modern treatment strategies, 80-90% of Hodgkin lymphoma patients achieve permanent remission and can be considered cured 1
• Prognosis for NHL varies based on subtype, stage, and risk factors, with R-CHOP providing significant improvement in outcomes for B-cell lymphomas 1