1. Lymphoma NICE guidelines July 2016
SSG 1/3/17

2. Diagnosis Consider excision biopsy first line
“risk of surgical procedure outweighs the potential benefits” – needle core biopsy
Excision if first core non-diagnostic
Consider MYC FISH in all HG B-NHL
BCL2 and BCL6 FISH if MYC rearranged
Interpret FISH results together with age and IPI and explain potential prognostic value to patients
Do not use IHC for COO prognostication

3. PET/CT Offer PET/CT at diagnosis for
Stage I DLBCL
Stage I or localised II FL
Stage I or II BL with low risk features
If the results will alter management
Do not routinely offer for interim assessment
Offer PET/CT at completion of treatment
DLBCL BL
Consider pre ASCT in HG NHL

4. FL – 1st line
Offer RT first line in localised stage IIA if treatable within suitable RT volume
Offer rituximab induction therapy for asymptomatic advanced FL
R-CVP, R-CHOP, R-MCP, R-CHVP1, R-chlorambucil recommended first line in symptomatic, advanced FL. R-benda not considered as subject of another appraisal.
R maintenance recommended as option for those responding to 1st line therapy.

5. r/r FL R-chemo, R-maintenance, R-monotherapy all acceptable
Offer ASCT in 2nd or subsequent remission if fit enough
Consider allograft if ASCT failed or not possible

6. Transformed FL Consider ASCT consolidation
Consider allograft if needed more than one line of therapy
Do not offer auto/allo to people presenting concurrently with LG and HG disease, responding to first line therapy

7. MALT NHL H. pylori eradication, even if negative
Consider W+W if residual disease and no high risk features
R-chemo or gastric radiotherapy for high risk residual disease (H.pylori –ve at diagnosis or t(11;18), or for those with symptomatic disseminated disease

8. Mantle cell NHL RT for localised disease
W+W for non-progressive/asymptomatic
Bortezomib (VR-CAP) if unsuitable for ASCT
Rituximab up-front
Cytarabine-containing regimen for younger, fitter patients
Consolidate with ASCT if chemosensitive
Bendamustine not considered
Maintenance R every 2 months until disease progression in less fit, every 2 months for 3 years post ASCT

9. DLBCL – 1st line
Consider 30Gy consolidation RT to sites of initial bulk
Offer CNS prophylaxis if
Testis, breast, renal or adrenal involvement
IPI 4 or 5
Consider CNS prophylaxis if IPI 2 or 3

10. DLBCL salvage
Consider R-GDP – as effective as other salvage regimens and less toxic. Primarily aiming to get to ASCT, but also beneficial if not followed by transplantation
Offer ASCT if fit enough and at least a PR
Consider allograft if ASCT fails or not possible

11. Burkitt’s
R-BFM, R-CODOX-M/R-IVAC, R-HyperCVAD or R-LMB are recommended
Consider DA-EPOCH-R plus IT/IV MTX in low-risk BL
If not fit enough, consider R-CHOP, R-CHOEP, DA-EPOCH-R

12. PTCL
Consider CHOP with ASCT in first CR/PR

13. Information and support
Explain to patients with LG NHL about the risk of transformation to HG NHL

14. DLBCL Follow-up Offer regular clinical assessment
Consider stopping regular assessment 3 years after EOT
Do not offer LDH surveillance or routine surveillance imaging

15. Survivorship
Provide EOT summaries