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Non-hodgkin's%20lymphoma Management
Observation
- A “watch and wait” approach should be offered to patients who are asymptomatic, with clinically non-progressive localized disease, or with residual disease after treatment
- May be considered when potential toxicity of ISRT or systemic therapy outweighs potential clinical benefit; referral to a radiation oncologist is preferred
Follow Up
- Prognosis depends on the patient’s age, performance status, serum LDH, clinical disease stage and presence or absence of extranodal site involvement
- >2 prognostic factors increase the chances for recurrence and decreases overall survival
- PET scan only indicated in patients suspected of disease relapse and not as routine surveillance scan
- Patients undergoing Alemtuzumab treatment should be monitored for cytomegalovirus (CMV) reactivation using quantitative polymerase chain reaction (PCR) assay every 2-3 weeks during therapy and every 2 month after completion of treatment
- PET should be done simultaneously or separately with contrast-enhanced diagnostic CT in patients suspected of disease relapse
- PET-CT score of 1, 2, or 3 with or without a residual mass on 5-point scale (5-PS), with no evidence of fluorodeoxyglucose (FDG)-avid disease in bone marrow or
- On CT, target nodes/nodal masses must regress to ≤1.5 cm in longest transverse diameter of a lesion (LDi) with no extralymphatic sites of disease, organ enlargement must regress to normal and with normal morphology of the bone marrow
- PET-CT score of 4 or 5 with reduced uptake compared with baseline, no new progressive lesions and residual uptake higher than uptake in normal marrow but reduced compared to baseline or
- On CT ≥50% decrease in sum of the product of the perpendicular diameters for multiple lesions (SPD) of up to 6 target measurable nodes and extranodal sites, absent or no increase in non-measured lesion and regression of spleen length by >50% beyond normal
- PET-CT score of 4 or 5 with no significant change in FDG uptake from baseline at interim or end-of-treatment,no new or progressive lesions and no change in bone marrow from baseline or
- On CT <50% decrease in SPD from baseline of up to 6 dominant measurable nodes and extranodal sites, without evidence consistent with progression
- PET-CT score of 4 or 5 with an increase in intensity of uptake from baseline and/or new FDG-avid foci consistent with lymphoma at interim or end-of-treatment assessment or
- On CT will have ≥1 of the following:
- An individual node/lesion must be abnormal with LDi >1.5 cm and increase by ≥50% from cross product of the LDi and perpendicular diameter (PPD) nadir and an increase in LDi or shortest axis perpendicular to the LDi (SDi) from nadir of 0.5 cm for lesions ≤2 cm or 1.0 cm for lesions >2 cm
- Splenic length in the setting of splenomegaly must increase by >50% of the extent of its prior increase beyond baseline or if without prior splenomegaly, must increase by ≥2 cm from baseline
- Recurrent or new splenomegaly
- New or clear progression of preexisting nonmeasured lesions
- Regrowth of previously resolved lesions, a new node >1.5 cm in any axis or if <1.0 cm in any axis, its presence must be unequivocal and must be attributable to lymphoma or assessable disease of any size unequivocably attributable to lymphoma, and/or
- New or recurrent involvement of the bone marrow
- Based on visual assessment of FDG uptake in the involved sites relative to that of the liver and mediastinum
| 1 | No uptake above background |
| 2 | Uptake ≤ mediastinum |
| 3 | Uptake > mediastinum but ≤ liver |
| 4 | Uptake moderately > liver |
| 5 | Uptake markedly higher than liver and/or new lesions |
| X | New areas of uptake unlikely to be related to lymphoma |
Histologic Transformation
- Histologic transformation to DLBCL can occur with FL, nodal MZL, and CLL (known as Richter’s Transformation)
- Patients with FL or nodal MZL with minimal or without previous therapy and with histological transformation to DLBCL will receive 1st-line therapy for DLBCL
- Patients with FL or nodal MZL with histological transformation to DLBCL after multiple lines of prior therapies including ≥2 chemoimmunotherapy regimens for indolent or transformed disease may be enrolled in a clinical trial or given anti-CD19 CAR T-cell therapy, Loncastuximab tesirine, Polatuzumab vedotin with or without Bendamustine and Rituximab, Ibritumomab tiuxetan, Tafasitamab with Lenalidomide or ISRT
- Chemoimmunotherapeutic regimens such as OFAR (Oxaliplatin, Fludarabine, Cytarabine, Rituximab), hyper-CVAD (Cyclophosphamide, Vincristine, Doxorubicin, Dexamethasone alternating with high-dose Methotrexate and Cytarabine) with Rituximab, DA-EPOCH-R (Etoposide, Prednisone, Vincristine, Cyclophosphamide, Doxorubicin with Rituximab) and RCHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, Prednisone) may be given in patients with Richter’s transformation
- HSCT may also be considered for chemotherapy-sensitive transformed CLL
