non-hodgkin's%20lymphoma
NON-HODGKIN'S LYMPHOMA

Non-Hodgkin's lymphoma is a heterogeneous group of lymphoproliferative malignancies.
It is the most common hematologic cancer.
The most common subtypes are the diffuse large B-cell and follicular lymphoma. The subtypes are based on the malignant cell's morphology, genetic features, immunohistological characteristics, and stage of maturation.

Palliative Therapy

  • A “watch & wait” approach should be offered to patients who are asymptomatic, with clinically non-progressive localized disease, or with residual disease after treatment
Autoimmune Cytopenias
  • Most common forms in NHL patients include autoimmune hemolytic anemia, immune thrombocytopenic purpura & pure red blood cell aplasia
  • Treatment includes administration of corticosteroids; Rituximab, intravenous immunoglobulin (IVIg), or Cyclosporin may be given for patients unresponsive to corticosteroid therapy
    • Splenectomy may also be considered for steroid-refractory patients
Infection/Reactivation
Cytomegalovirus (CMV) reactivation
  • Occurs in 25% of patients undergoing treatment with Alemtuzumab
  • Prophylaxis with Ganciclovir may be considered in patients with increasing viral load during treatment

Hepatitis B Virus

  • Increased risk for HBV reactivation in patients undergoing treatment with anti-CD20 monoclonal antibody
  • Prophylaxis with Entecavir is recommended for patients on immunosuppressive cytotoxic therapy with positive Hepatitis B surface antigen (HBsAg), HBsAg negative but Hepatitis B core antibody (HBcAb) positive, or elevated HBsAb levels with increasing HBV DNA load
    • Studies show that Lamivudine is an effective prophylactic option for patients with positive HBsAg & history of chemotherapy/immunotherapy, but with high incidence for resistance development
    • Adenofir/Tenofovir may be combined with Lamivudine for patients unresponsive to Lamivudine monotherapy
  • Viral load should be monitored using PCR monthly during & every 3 month after treatment
  • Prophylactic regimen should be continued until 12 month after NHL treatment
Hepatitis C Virus
  • Most frequently occurs in NHL patients with B-cell lymphomas (eg DLBCL, MZL)
  • Patients may be initially treated with antivirals (eg Pegylated interferon, Ribavirin, Telaprevir, Boceprevir)
    • Direct acting antivirals may be combined with triple antiviral therapy in asymptomatic patients with low-grade B-cell NHL & hepatitis C infection
Progressive Multifocal Leukoencephalitis (PML)
  • A demyelinating disease caused by the latent John Cunningham (JC) polyoma virus which infects the CNS in immunocompromised patients
  • Administration of Ofatumumab & Rituximab is associated with increased risk of developing PML
  • There is currently no effective treatment for PML, thus prevention is highly advised
    • Monitoring of signs & symptoms & CSF analysis using PCR is recommended
Tumor Flare Reaction
  • An immune response composed of splenomegaly, fever, rashes, painful lymphadenopathy & bone pain
  • Commonly occurs in CLL patients undergoing Lenalidomide treatment
  • Corticosteroid administration is recommended for management of inflammation & lymphadenopathy
  • Antihistamines may be used to manage pruritus with rashes
  • Prophylaxis may be considered for patients on Lenalidomide treatment who may be predisposed to tumor flare reactions
Tumor Lysis Syndrome
  • Cellular destruction secondary to chemotherapy causing severe lymphadenopathy, hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, which may lead to acute renal failure
    • Appears 12-72 hours after initiation of chemotherapy
  • Prophylaxis prior to chemotherapy is recommended especially for patients treated with Venetoclax
    • May give Allopurinol prior to initiation of chemotherapy to control uric acid levels
    • Proper hydration is advised
    • Rasburicase is recommended for patients with hyperuricemia unresponsive to Allopurinol, acute renal failure, patients with high bulk disease in urgent need of treatment, or if proper hydration is difficult
  • Monitor serum electrolytes, renal function & cardiac function should be monitored regularly; proper hydration is advised

Venous Thromboembolism

  • May be prevented by administration of low-dose Aspirin in patients with severely increased platelet
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With the dramatic evolution of sequencing technology and emergence of effective targeted therapies, using a comprehensive molecular approach to guide treatment decisions is becoming more accessible and applicable in the clinic. At the recent Foundation Medicine meeting in Hong Kong, Dr Alexander Drilon, clinical director of the Early Drug Development Service at Memorial Sloan Kettering Cancer Center (MSKCC), New York, US, discussed the current landscape and potential benefits of comprehensive molecular profiling in non-small cell lung cancer (NSCLC).