What are the next steps in managing a patient with Non-Hodgkin lymphoma (NHL) who has undergone radiation and targeted therapy, such as rituximab?

Management of Non-Hodgkin Lymphoma After Radiation and Targeted Therapy

For patients with Non-Hodgkin lymphoma who have completed radiation and targeted therapy (such as rituximab), the recommended next steps include structured follow-up with regular clinical examinations, blood tests, and imaging studies, with salvage therapy options available for those who relapse. 1

Follow-up Protocol

Clinical Monitoring

• History and physical examination every 3 months for 1 year, every 6 months for 2 more years, and then once a year with attention to development of secondary tumors or other long-term side-effects of chemotherapy 1
• Focus on symptoms or signs that might indicate disease recurrence or treatment-related complications 1

Laboratory Monitoring

• Blood count and LDH at 3,6,12, and 24 months 1
• After 24 months, blood tests only as needed for evaluation of suspicious symptoms or clinical findings in patients suitable for further therapy 1
• Monitor for treatment-related complications, including hypogammaglobulinemia which may occur after rituximab therapy 2

Imaging Studies

• Minimal adequate radiological examinations (CT scan) at 6,12, and 24 months after end of treatment 1
• Routine surveillance with PET scan is not recommended 1
• High-risk patients with curative options may require more frequent imaging controls 1

Management of Relapsed Disease

Diagnosis of Relapse

• Histological verification should be obtained whenever possible 1
• Biopsy is mandatory for relapses occurring >12 months after the initial diagnosis, especially to ensure CD20 positivity for potential rituximab retreatment 1
• Image-guided core biopsy may be appropriate in this context 1

Treatment Options for Relapsed Disease

For Younger Patients with Good Performance Status (<65-70 years)

• Salvage regimen with rituximab and chemotherapy followed by high-dose treatment with stem-cell support is recommended for suitable patients 1
• Recommended salvage regimens include:
  • R-DHAP (rituximab, cisplatin, cytosine-arabinoside, dexamethasone) 1
  • R-ICE (rituximab, ifosfamide, carboplatin, etoposide) 1
  • R-ESHAP (rituximab, etoposide, methylprednisolone, cytarabine, cisplatin) 1
• High-dose regimen typically uses BEAM (carmustine, etoposide, cytosine-arabinoside, melphalan) 1
• Response evaluation should be performed after 3-4 cycles of salvage regimen (before high-dose treatment) and after completion of all therapy 1

For Older Patients or Those with Comorbidities

• Patients not suitable for high-dose therapy may be treated with the same or alternative salvage regimens such as:
  • R-GEMOX (rituximab, gemcitabine, oxaliplatin) 1
  • R-IMVP16 (rituximab, ifosfamide, methotrexate, etoposide) 1
• These regimens may be combined with involved-field radiotherapy 1
• Modern radiation therapy approaches use involved-site radiation therapy rather than extended fields 3

Special Considerations

Monitoring for Treatment Complications

• Monitor for rituximab-related side effects, including:
  • Infusion-related reactions 4
  • Prolonged B-cell depletion 4
  • Hypogammaglobulinemia and increased risk of infections 2
• Consider immunoglobulin replacement therapy in patients with recurrent infections and hypogammaglobulinemia 2

Response Assessment

• PET-CT is highly recommended for post-treatment assessment to define complete remission according to the revised response criteria 1
• If PET positivity leads to therapeutic consequences, histological confirmation is strongly recommended 1

Prognosis and Expectations

• Overall, >30% of diffuse large B-cell lymphoma will ultimately relapse 1
• Early identification of relapse is important as salvage therapy can still be curative in some patients 5
• Follow-up of patients in second response should follow the same protocol as after first-line treatment 1