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