What is the treatment plan for a patient diagnosed with lymphoma, rather than lung cancer?

Treatment Plan for Lymphoma

For CD20-positive diffuse large B-cell lymphoma (the most common type), the standard curative treatment is R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) given every 21 days for 6-8 cycles. 1, 2

Initial Diagnostic Requirements

Before initiating treatment, confirm the diagnosis and complete staging:

• Obtain excisional lymph node biopsy (not fine needle aspiration) with WHO classification and CD20 immunohistochemistry to determine B-cell versus T-cell lineage 1, 2, 3
• Complete staging workup including CT chest/abdomen/pelvis, bone marrow aspirate and biopsy, complete blood count, LDH, uric acid, and screening for HIV, hepatitis B and C 1, 2, 4
• Calculate International Prognostic Index (IPI) using age, stage, LDH, performance status, and number of extranodal sites for prognostic stratification 1, 2
• Stage according to Ann Arbor system with notation of bulky disease (>10 cm) 1, 3

Treatment Algorithm by Lymphoma Subtype

CD20-Positive Large B-Cell Lymphoma (Most Common)

Standard curative regimen: R-CHOP every 21 days for 8 cycles 1, 2

• Rituximab 375 mg/m² IV
• Cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP chemotherapy)
• Consider shortening interval to 14 days with growth factor support in select cases 1

Critical management points:

• Avoid dose reductions for hematological toxicity; instead use prophylactic growth factors (G-CSF) if febrile neutropenia develops 1
• Document cumulative anthracycline dose due to cardiotoxicity risk 1

T-Cell Lymphoma

Standard regimen: CHOP chemotherapy alone (rituximab not indicated as T-cells lack CD20) every 21 days for 8 cycles 1

High-Risk Patients (IPI ≥2)

• Consider prophylactic CNS treatment with intrathecal cytarabine or methotrexate at time of diagnostic lumbar puncture, particularly if bone marrow, testis, spine, or skull base involvement 1, 4
• High-dose chemotherapy with stem cell transplantation remains investigational in first-line setting 1

Response Monitoring

Perform radiological assessment:

• After 2-4 cycles of therapy 1, 3
• After completion of all treatment 1
• Whenever response is questioned 1

If bone marrow or CSF initially involved: Repeat bone marrow biopsy/lumbar puncture at end of treatment 1, 4

For inadequate response: Immediately evaluate for salvage chemotherapy regimens 2, 3

Radiotherapy Considerations

Consolidation radiotherapy to bulky disease sites has NOT proven benefit and is not routinely recommended 1

Exception: May consider involved-field radiation in select cases with residual masses after chemotherapy 1

Relapsed/Refractory Disease

For chemosensitive relapsed disease in transplant-eligible patients:

• Salvage chemotherapy (R-DHAP, R-ESHAP, R-ICE, or R-EPOCH) followed by high-dose chemotherapy with autologous stem cell transplantation is standard 1, 2
• Rituximab shows considerable single-agent activity even after failed transplantation in CD20-positive disease 1

Surveillance After Treatment Completion

Clinical monitoring:

• History and physical examination every 3 months for 2 years, then every 6 months for 3 additional years, then annually 1, 2
• Monitor specifically for secondary malignancies including transformation 1, 3

Laboratory monitoring:

• Complete blood count and LDH at 3,6,12, and 24 months, then only as clinically indicated 1, 2
• TSH monitoring at 1,2, and 5 years if neck irradiation received 1, 3

Imaging surveillance:

• CT scans at 6,12, and 24 months after treatment completion 1, 3

Special considerations:

• Women receiving chest radiation before age 25 require clinical breast cancer screening and mammography starting at age 40-50 1

Critical Pitfalls to Avoid

• Do not use fine needle aspiration alone for initial diagnosis—inadequate tissue for proper classification 2, 3
• Do not reduce chemotherapy doses for cytopenias—use growth factor support instead to maintain dose intensity 1
• Do not delay salvage therapy in patients with inadequate response—early intervention improves transplant outcomes 2, 3
• Do not omit hepatitis B screening—reactivation with rituximab can be fatal 4