Treatment of Non- Hodgkin’s Lymphoma

Precursor B cell Lymphoblastic Leukemia

• Remission induction with combination therapy

• Consolidation phase: – High dose systemic therapy– Treatment to eliminate CNS disease

• Continuing therapy: prevent relapse and effect cure

Precursor B cell Lymphoblastic Leukemia

• Combination therapy used:– Rituximab- fludarabine- cyclophosphamide

• Associated with grade III or IV neutropenia

– Cyclophophamide- vincristine- prednisone– Cyclophosphamide- doxorubicin- vincristine-

prednisone

B Cell Chronic Lymphoid Leukemia/ Small Lymphocytic Leukemia

• Most common:– Chlorambucil: orally; few immediate side effects

• Chosen in elderly patients who require therapy

– Fludarabine: IV; with significant immune suppression• more active agent; with significant incidence of complete

remission• Regimens inclusive of this drug is chosen for young patients

presenting with leukemiarequiring therapy• Second line agent for patients with tumors unresponsive to

chlorambucin

B Cell Chronic Lymphoid Leukemia/ Small Lymphocytic Leukemia

• Rai stage O and Binet stage A ( no manifestations of disease other than BM involvement and lymphocytosis– Followed without a specific therapy

• With adequate number of circulating normal blood cells, asymptomatic– Require treatment for the first few years of

follow up

B Cell Chronic Lymphoid Leukemia/ Small Lymphocytic Leukemia

• Rai stage III or IV or Binet stage C (Bone Marrow failure)– Require initial therapy– Immune manifestations should be managed

independently of antileukemic therapy

MALT Lymphoma

• Radiation and Surgery– Because it is often localized

• Eradication of H. pylori infection

• With more extensive diseases: Chlorambucil

Mantle Cell Lymphoma

• With disseminated disease: aggressive combination chemotherapy regimens+ autologous/ allogeneic BM transplantation

• Localized diseases: combination chemotherapy + radiotherapy

• Asymptomatic, elderly patient: observation + single- agent chemotherapy

Follicular Lymphoma

• Asymptomatic patient, older patient: watchful waiting

• For those who require treatment: single- agent chlorambucil or cyclophosphamide or combination therapy with CVP or CHOP

• For patients with localized follicular lymphoma: radiotherapy

Follicular Lymphoma

• Most responsive to chemotherapy and radiotherapy

• Active therapies:– Fludarabine– Interferon α: prolong survival in patients on

doxorubicin- containing combination therapies– Monoclonal antibodies with or without

radionuclides– Lymphoma vaccines

Diffuse Large B Cell Lymphoma

• Initial Treatmant: combination chemotherapy regimen= CHOP + Rituximab– Stage I or non bulky stage II: 3-4 cycles + field

radiotherapy– Bulky stage II, stage III, stage IV: 6-8 cycles

or 4 cycles then reevaluate -> complete remission -> 2 more cycles, then therapy discontinued

Diffuse Large B Cell Lymphoma

• IPI : predict favorable responses– Score 0-1: 5 year survival >70 %– Score 4-5: 5 year survival ~20%

• For refractory cases or relapse– Salvage therapy– Alternative combination therapy– Autologous bone marrow transplantation

Burkitt’s Lymphoma

• Treatment should begin 48 hrs after diagnosis

• High doses of cyclophosphamide

• Prophylactic therapy to CNS mandatory

• Hairy cell leukemia: Cladribine

• Splenic marginal zone lymphoma: splenectomy, chlorambucil

• Lymphoplasmacytic lymphoma: Chlorambucil, fludarabine and cladribine

• Nodal marginal zone lymphoma: treatment same as follicular lymphoma

Precursor T Cell Lymphoblastic Leukemia

• Very intensive remission induction and consolidation regimens

• Leukemia- like regimens: for older children and young adults

• With high levels of LDH or BM, CNS involvement: BM transplantation

Anaplastic Large T/ Null Cell Lymphoma

• Treatment regimens same as for other aggressive lymphomas (diffuse large B cell lymphoma)

• Rituximab is omitted

• Mycoises Fungoides – Localized early stage: radiotherapy- total skin

electron beam irradiation– More advanced disease: topical

glucocorticoids, topical nitrogen mustard, phototherapy, psoralen with PUVA, electron beam radiation, IFN, Antibodies, fusion toxins and systemic cytotoxic therapy

• Adult T Cell Lymphoma/ Leukemia– Combination chemotherapy regimens