Standard Treatment Approach for Non-Hodgkin Lymphoma (NHL)
The standard treatment for Non-Hodgkin lymphoma is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), with specific regimens tailored based on NHL subtype, patient age, and International Prognostic Index (IPI). 1, 2
Diagnosis and Staging
- Diagnosis requires an excisional lymph node biopsy providing adequate tissue for histopathological examination and immunohistochemistry 2
- Fine needle aspirations or core biopsies are appropriate only for patients requiring emergency treatment or those not suitable for curative therapy 2
- The histological report should include diagnosis according to the WHO classification with CD20 immunohistochemistry 2
- Staging workup should include:
- Staging follows the Ann Arbor system with mention of bulky disease 2
- International Prognostic Index (IPI) should be calculated for prognostic purposes 2
Treatment Approach by Patient Category
CD20+ Diffuse Large B-Cell Lymphoma (DLBCL)
Young Low-Risk Patients (aaIPI ≤1)
- Six to eight cycles of R-CHOP given every 21 days is the standard treatment 2, 1
- Eight doses of rituximab should be administered during the treatment course 2, 1
- Consolidation by radiotherapy to sites of bulky disease has not proven beneficial 2
Young High-Risk Patients (aaIPI ≥2)
- Six to eight cycles of R-CHOP given every 14-21 days 2, 1
- Central nervous system relapse prophylaxis is recommended 2, 1
- Dose reductions due to hematological toxicity should be avoided 2
Patients Older Than 60 Years
- Eight cycles of R-CHOP given every 21 days is the standard 2, 1
- If R-CHOP is given every 14 days, six cycles are sufficient 2
- Prophylactic use of hematopoietic growth factors is justified in case of febrile neutropenia 2
T-Cell Lymphoma
- CHOP without rituximab remains the standard treatment 2
- Shortening the interval between CHOP cycles to two weeks with growth factor support may be considered 2
Response Evaluation and Monitoring
- Radiological tests should be performed after 2-4 cycles and after the last cycle of treatment 2
- PET scanning, when positive at baseline, is part of the updated response criteria 2, 1
- Bone marrow aspirate/biopsy should be repeated at the end of treatment if initially involved 2
- Patients with incomplete or lacking response should be evaluated for early salvage regimens 2
Follow-Up Protocol
- History and physical examination every 3 months for 2 years, every 6 months for 3 more years, and then once a year 2
- Blood count and LDH at 3,6,12, and 24 months, then only as needed 2
- Minimal adequate radiological examinations at 6,12, and 24 months after end of treatment 2
- Evaluation of thyroid dysfunction in patients with irradiation to the neck at 1,2, and at least at 5 years 2
- Women who received chest irradiation at premenopausal age should be screened for secondary breast cancers 2
Management of Relapsed/Refractory Disease
- Histological verification should be obtained whenever possible, especially for relapses occurring >12 months after initial diagnosis 2, 1
- For suitable patients (adequate performance status, age <65-70 years), salvage regimens with rituximab plus chemotherapy followed by high-dose therapy with stem cell support is recommended 2, 1
- Common salvage regimens include R-DHAP (rituximab, cisplatin, cytarabine, dexamethasone) or R-ICE (rituximab, ifosfamide, carboplatin, etoposide) 1, 3
Important Considerations
- In cases with high tumor load, special precautions (e.g., corticosteroid pre-phase) are required to avoid tumor lysis syndrome 2, 1
- Rituximab is FDA-approved for previously untreated diffuse large B-cell, CD20-positive NHL in combination with CHOP or other anthracycline-based chemotherapy regimens 4
- Elderly patients (>65 years) may experience more adverse reactions, including serious infections, malignancies, and cardiovascular events 4
- Dose reductions due to hematological toxicity should be avoided to maintain treatment efficacy 2