Adult Non-Hodgkin Lymphoma Treatment (Professional) (cont.)
Treatment Option Overview for Adult NHL
Treatment of non-Hodgkin lymphoma (NHL) depends on the histologic type and stage. Many of the improvements in survival have been made using clinical trials (experimental therapy) that have attempted to improve on the best available accepted therapy (conventional or standard therapy).
In asymptomatic patients with indolent forms of advanced NHL, treatment may be deferred until the patient becomes symptomatic as the disease progresses. When treatment is deferred, the clinical course of patients with indolent NHL varies; frequent and careful observation is required so that effective treatment can be initiated when the clinical course of the disease accelerates. Some patients have a prolonged indolent course, but others have disease that rapidly evolves into more aggressive types of NHL that require immediate treatment.
Radiation techniques differ somewhat from those used in the treatment of Hodgkin lymphoma. The dose of radiation therapy usually varies from 25 Gy to 50 Gy and is dependent on factors that include the histologic type of lymphoma, the patient's stage and overall condition, the goal of treatment (curative or palliative), the proximity of sensitive surrounding organs, and whether the patient is being treated with radiation therapy alone or in combination with chemotherapy. Given the patterns of disease presentations and relapse, treatment may need to include unusual sites such as Waldeyer ring, epitrochlear, or mesenteric nodes. The associated morbidity of the treatment must be considered carefully. The majority of patients who receive radiation are usually treated on only one side of the diaphragm. Localized presentations of extranodal NHL may be treated with involved-field techniques with significant (>50%) success.
Table 4. Standard Treatment Options for NHL
|Stage||Standard Treatment Options|
|CNS = central nervous system; CHOP = cyclophosphamide plus doxorubicin plus vincristine plus prednisone; IF-XRT = involved-field radiation therapy; NHL = non-Hodgkin lymphoma; R-CHOP = rituximab, an anti-CD20 monoclonal antibody, plus cyclophosphamide plus doxorubicin plus vincristine plus prednisone.|
|Indolent, Stage I and Contiguous Stage II Adult NHL|| Radiation therapy|
|Rituximab with or without chemotherapy |
|Other therapies as designated for patients with advanced-stage disease|
|Indolent, Noncontiguous Stage II/III/IV Adult NHL||Watchful waiting for asymptomatic patients|
|Purine nucleoside analogs|
|Alkylating agents (with or without steroids)|
|Combination chemotherapy |
|Yttrium-90 labeled ibritumomab tiuxetan and iodine-131-labeled tositumomab|
|Indolent, Recurrent Adult NHL||Chemotherapy (single agent or combination)|
|Radiolabeled anti-CD20 monoclonal antibodies|
|Palliative radiation therapy|
|Aggressive, Stage I and Contiguous Stage II Adult NHL||R-CHOP with or without IF-XRT|
|Aggressive, Noncontiguous Stage II/III/IV Adult NHL||R-CHOP|
|Other combination chemotherapy|
|Adult Lymphoblastic Lymphoma||Intensive therapy|
|Diffuse Small Noncleaved-Cell/Burkitt Lymphoma||Aggressive multidrug regimens|
|Central nervous system (CNS) prophylaxis|
|Aggressive, Recurrent Adult NHL||Bone marrow or stem cell transplantation|
|Re-treatment with standard agents|
|Palliative radiation therapy|
Even though standard treatment in patients with lymphomas can cure a significant fraction, numerous clinical trials that explore improvements in treatment are in progress. If possible, patients should be included in these studies. Standardized guidelines for response assessment have been suggested for use in clinical trials.
Aggressive lymphomas are increasingly seen in human immunodeficiency virus (HIV)-positive patients; treatment of these patients requires special consideration. (Refer to the PDQ summary on AIDS-Related Lymphoma Treatment for more information.) In addition to screening for HIV among patients with aggressive lymphomas, active hepatitis B or hepatitis C should be assessed prior to treatment with rituximab and/or chemotherapy.
Several unusual presentations of lymphoma occur that often require somewhat modified approaches to staging and therapy. The reader is referred to reviews for a more detailed description of extranodal presentations in the gastrointestinal system,[3,4,5,6,7,8,9,10,11] thyroid,[12,13] spleen, testis,[15,16] paranasal sinuses,[17,18,19,20] bone,[21,22] orbit,[23,24,25,26,27] and skin.[28,29,30,31,32,33,34,35,36,37]
(Refer to the PDQ summary on Primary CNS Lymphoma Treatment for more information.)
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