Adult Non-Hodgkin Lymphoma Treatment (Professional) (cont.)
Treatment for Aggressive, Stage I and Contiguous Stage II Adult NHL
Patients with stage I or contiguous stage II diffuse large B-cell lymphoma are candidates for combination chemotherapy with or without involved-field radiation therapy (IF-XRT).
The following drug combinations are referred to in this section:
- R-CHOP: rituximab, an anti-CD20 monoclonal antibody, + cyclophosphamide + doxorubicin + vincristine + prednisone.
Standard Treatment Options for Aggressive, Stage I and Contiguous Stage II Adult NHL
Standard treatment options for aggressive, stage I and contiguous stage II adult NHL include the following:
- R-CHOP with or without IF-XRT.
R-CHOP with or without IF-XRT
Four prospective randomized trials have evaluated the comparison of CHOP or more intensive CHOP-based chemotherapy alone versus combined–modality therapy with CHOP and IF-XRT.[1,2,3,4,5]
Evidence (CHOP vs. CHOP with IF-XRT):
- In a randomized trial with 7 years' median follow-up, 576 patients older than 60 years with early-stage disease received four cycles of CHOP with or without IF-XRT; there was no difference in 5-year event-free survival (EFS) (61% vs. 64%, P = .5) or overall survival (OS) (72% vs. 68%, P = .6).[Level of evidence: 1iiA]
- A randomized trial of 401 patients comparing eight cycles of CHOP to three cycles of CHOP with IF-XRT was initially reported as having an OS advantage for the combined–modality arm at 5 years, but a re-evaluation for OS at 9 years showed no difference in either arm of the study.[Level of evidence: 1iiA]
- A randomized study (EST-1484) of 210 patients who attained a radiologic complete remission after eight cycles of CHOP compared IF-XRT with no further therapy; there was no difference in OS at 10 years (68% vs. 65%, P = .24).[Level of evidence: 1iiA]
- A randomized trial of 631 patients younger than 60 years compared more intensive CHOP-based chemotherapy versus three cycles of CHOP with IF-XRT; with 4 years' median follow-up, the intensive chemotherapy was superior in 5-year EFS (82% vs. 74%, P > .001) and 5-year OS (90% vs. 81%, P = .001).[Level of evidence: 1iiA]
The confirmation of efficacy for rituximab in advanced-stage disease as evidenced in SWOG-S0014 (NCT00005089), for example, has suggested the use of R-CHOP with or without radiation therapy but its use is only supported by retrospective comparisons.[Level of evidence: 3iiiDiii]
- R-CHOP (rituximab + cyclophosphamide + doxorubicin + vincristine + prednisone); four to six cycles.
- R-CHOP (three to six cycles) + IF-XRT.
Evidence (R-CHOP vs. CHOP):
- A randomized study (DSHNHL-1999-1A) of 1,222 patients older than 60 years compared R-CHOP given every 2 weeks for six or eight cycles to CHOP given every 2 weeks for six or eight cycles. Although patients with early stage disease were included in this trial, most patients had advanced stage disease.
- With a median follow-up of 72 months, the EFS favored R-CHOP given every 2 weeks for six or eight cycles (EFS at 6 y, 74% vs. 56%; P < .001).
- The OS favored R-CHOP for only six cycles because of increased toxicity in the eight-cycle arm (OS at 6 y, 90% vs. 80%, P = .0004.[Level of evidence: 1iiA]
- There has been no comparison to standard R-CHOP or CHOP given every 3 weeks. There are no comparative studies to establish an optimal number of chemotherapy cycles for patients with early stage disease.
Treatment Options Under Clinical Evaluation for Aggressive, Stage I and Contiguous Stage II Adult NHL
Treatment options under clinical evaluation include the following:
- R-ACVBP (rituximab + doxorubicin + cyclophosphamide + vindesine + bleomycin + prednisone).
Current Clinical Trials
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with aggressive, stage I adult non-Hodgkin lymphoma and aggressive, contiguous stage II adult non-Hodgkin lymphoma. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
- Bonnet C, Fillet G, Mounier N, et al.: CHOP alone compared with CHOP plus radiotherapy for localized aggressive lymphoma in elderly patients: a study by the Groupe d'Etude des Lymphomes de l'Adulte. J Clin Oncol 25 (7): 787-92, 2007.
- Miller TP, Dahlberg S, Cassady JR, et al.: Chemotherapy alone compared with chemotherapy plus radiotherapy for localized intermediate- and high-grade non-Hodgkin's lymphoma. N Engl J Med 339 (1): 21-6, 1998.
- Miller TP, Leblanc M, Spier C, et al.: CHOP alone compared to CHOP plus radiotherapy for early stage aggressive non-Hodgkin's lymphomas: update of the Southwest Oncology Group (SWOG) randomized trial. [Abstract] Blood 98 (11): A-3024, 2001.
- Horning SJ, Weller E, Kim K, et al.: Chemotherapy with or without radiotherapy in limited-stage diffuse aggressive non-Hodgkin's lymphoma: Eastern Cooperative Oncology Group study 1484. J Clin Oncol 22 (15): 3032-8, 2004.
- Reyes F, Lepage E, Ganem G, et al.: ACVBP versus CHOP plus radiotherapy for localized aggressive lymphoma. N Engl J Med 352 (12): 1197-205, 2005.
- Persky DO, Unger JM, Spier CM, et al.: Phase II study of rituximab plus three cycles of CHOP and involved-field radiotherapy for patients with limited-stage aggressive B-cell lymphoma: Southwest Oncology Group study 0014. J Clin Oncol 26 (14): 2258-63, 2008.
- Pfreundschuh M, Schubert J, Ziepert M, et al.: Six versus eight cycles of bi-weekly CHOP-14 with or without rituximab in elderly patients with aggressive CD20+ B-cell lymphomas: a randomised controlled trial (RICOVER-60). Lancet Oncol 9 (2): 105-16, 2008.
- Pfreundschuh M, Kuhnt E, Trümper L, et al.: CHOP-like chemotherapy with or without rituximab in young patients with good-prognosis diffuse large-B-cell lymphoma: 6-year results of an open-label randomised study of the MabThera International Trial (MInT) Group. Lancet Oncol 12 (11): 1013-22, 2011.