What is lymphoma?

From the Guidelines

Lymphoma patients should be treated with rituximab in combination with chemotherapy regimens as the standard of care for first-line therapy, as it has been shown to improve progression-free survival. This approach is based on the recommendations outlined in the NCCN Guidelines for the diagnosis and management of patients with follicular lymphoma (FL), a common subtype of indolent non-Hodgkin's lymphoma (NHL) 1. The incorporation of rituximab into chemotherapy regimens has become a widely accepted standard of care for first-line therapy for patients with FL.

Some key points to consider in the management of lymphoma include:

• The heterogeneity of non-Hodgkin's lymphomas, which originate in B lymphocytes, T lymphocytes, or natural killer cells 1
• The importance of maintenance and consolidation therapy with rituximab and radioimmunotherapy to improve progression-free survival in patients experiencing response to first-line therapy 1
• The chronic nature of follicular lymphoma, characterized by multiple recurrences with current therapies 1

In terms of symptoms and diagnosis, it is essential to be aware of:

• Painless swollen lymph nodes, fever, night sweats, weight loss, and fatigue as common symptoms of lymphoma
• The importance of early diagnosis for better outcomes, as many lymphomas are highly treatable or even curable, especially when detected in early stages.

From the FDA Drug Label

RITUXAN is a CD20-directed cytolytic antibody indicated for the treatment of: Adult patients with Non-Hodgkin's Lymphoma (NHL) Relapsed or refractory, low grade or follicular, CD20-positive B-cell NHL as a single agent. Previously untreated follicular, CD20-positive, B-cell NHL in combination with first line chemotherapy and, in patients achieving a complete or partial response to a rituximab product in combination with chemotherapy, as single-agent maintenance therapy Non-progressing (including stable disease), low-grade, CD20-positive, B-cell NHL as a single agent after first-line cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy. Previously untreated diffuse large B-cell, CD20-positive NHL in combination with (cyclophosphamide, doxorubicin, vincristine, and prednisone) (CHOP) or other anthracycline-based chemotherapy regimens Pediatric patients aged 6 months and older with mature B-cell NHL and mature B-cell acute leukemia (B-AL) Previously untreated, advanced stage, CD20-positive, diffuse large B-cell lymphoma (DLBCL), Burkitt lymphoma (BL), Burkitt-like lymphoma (BLL) or mature B-cell acute leukemia (B-AL) in combination with chemotherapy.

Lymphoma Treatment: Rituximab (IV) is indicated for the treatment of various types of lymphoma, including:

• Non-Hodgkin's Lymphoma (NHL)
• Diffuse large B-cell lymphoma (DLBCL)
• Burkitt lymphoma (BL)
• Burkitt-like lymphoma (BLL)
• Mature B-cell acute leukemia (B-AL) The recommended dose for adult and pediatric B-cell NHL is 375 mg/m2 2.

From the Research

Lymphoma Diagnosis and Treatment

• Lymphoma is a group of malignant neoplasms of lymphocytes with more than 90 subtypes, traditionally classified as non-Hodgkin or Hodgkin lymphoma 3
• The Lugano classification system incorporates symptoms and the extent of the disease as shown on positron emission tomography/computed tomography (PET/CT) to stage lymphoma, which is then used to determine treatment 3
• Chemotherapy treatment plans differ between the main subtypes of lymphoma, with non-Hodgkin lymphoma treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) with or without rituximab (R-CHOP), and Hodgkin lymphoma treated with combined chemotherapy with ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) 3

Role of PET/CT in Lymphoma Diagnosis and Treatment

• 18F-FDG PET/CT is the imaging modality of choice for the accurate initial staging of most lymphomas, with high sensitivity in detecting nodal involvement and extra-nodal disease 4
• PET/CT has excellent Negative Predictive Value (NPV>95%) in the detection of bone marrow involvement in Hodgkin's lymphoma, rendering bone marrow biopsy not absolutely necessary 4
• Interim PET/CT shows high NPV for final treatment response and for increased progression-free survival in Hodgkin's lymphoma, and is also investigated in non-Hodgkin lymphomas 4
• PET/CT is highly recommended for post-treatment assessment of lymphomas, with excellent NPV and superior diagnostic accuracy compared with CT 4

Comparison of Bone Marrow Biopsy and PET/CT

• Bone marrow biopsy is the standard method for investigating bone marrow involvement, but PET/CT has been shown to be highly effective in detecting bone marrow involvement in lymphoma patients 5, 6, 7
• PET/CT may replace bone marrow biopsy in detecting bone marrow involvement in aggressive lymphoma subtypes such as diffuse large B-cell lymphoma (DLBCL) and Hodgkin lymphoma (HL) 5, 6
• The diagnostic accuracy of PET/CT in identifying bone marrow involvement in DLBCL patients has been shown to be high, with sensitivity, specificity, and overall diagnostic accuracy of 93.61%, 93.93%, and 93.84%, respectively 7

Survival and Prognosis

• The presence of bone marrow involvement at the time of diagnosis is associated with poor prognosis and short overall survival (OS) in both PET/CT and bone marrow biopsy methods 5
• PET/CT may be used to evaluate the response to treatment and predict survival in lymphoma patients, with a favorable PET response associated with better progression-free survival and overall survival 4, 5