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
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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