hematology and oncology
Non Hodgkin Lymphomas
Treatment of Non Hodgkin Lymphomas
Watch and wait (for indolent, largely asymptomatic lymphomas) Chemotherapy Radiation therapy (most common in patients with limited-stage disease and sometimes in those with advanced-stage disease) Immunotherapy (eg, monoclonal antibodies targeting CD20, CD19, or CD79, or chimeric antigen receptor T cells [CAR T cells]) Targeted drugs (eg, BTK [Bruton tyrosine kinase] inhibitors, PI3K [phosphoinositide 3-kinase] inhibitors, cereblon inhibitors) Sometimes Hematopoietic Stem Cell Transplantation (autologous or allogeneic) Treatment varies considerably with cell type, which are too numerous to permit detailed discussion. Generalizations can be made regarding limited vs advanced disease and aggressive vs indolent forms. Burkitt Lymphoma and For stage I indolent non-Hodgkin lymphoma (uncommon because most patients have stage II o IV when diagnosed), external beam radiation therapy can be the sole initial treatment. Regional radiation therapy may offer long-term control and possibly cure in about 40% of stage I patients. Stage II indolent non-Hodgkin lymphoma is most commonly treated as advanced-stage disease. Limited-stage aggressive non-Hodgkin lymphomas can be managed with a combination of chemotherapy plus radiation therapy or with chemotherapy alone (plus anti-CD20 monoclonal antibodies for B-cell lymphomas). Patients with stage I Burkitt Lymphoma are treated with intensive combination chemotherapy with meningeal prophylaxis. Stage II non-Hodgkin lymphoma is managed as advanced stage disease in many circumstances. Most patients with all types of non-Hodgkin lymphoma who have stage II to IV disease are candidates for chemoimmunotherapy. In these cases, radiation therapy may be used to limit the number of cycles of chemoimmunotherapy or provide localized treatment for residual sites of bulk disease. Forindolent lymphomas, treatment varies considerably. Because these lymphomas are highly treatable but not reliably curable, treatment may not be recommended initially for asymptomatic patients, although some patients are given anti-CD20 immunotherapy usingrituximabalone. This strategy can delay the need for myelosuppressive chemotherapy, but early immunotherapy alone has not been shown to impact overall survival. Patients with symptoms or bulky disease that puts vital organs at risk are treated with chemoimmunotherapy. In selected cases (eg, chemo-refractory with limited bone marrow involvement), radiolabeled anti-CD20 antibody can be used to target radiation to the tumor cell with potentially fewer effects on nearby normal organs. In patients withaggressive B-cell lymphomas(eg, diffuse large B cell), the standard drug combination isrituximabpluscyclophosphamide, hydroxydaunorubicin (doxorubicin),vincristine, andprednisone(R-CHOP). A complete response with disease regression is expected in 80% of cases, with an overall cure rate of about 60%. These results vary significantly by IPI score. Patients who are disease free at≥24 months from diagnosis have a life expectancy similar to that of the age- and sex-matched population. This key factor can guide follow-up strategies in this patient population. Patients with lower IPI scores may benefit from adding the antibody-drug conjugatepolatuzumab vedotin, a CD79b-directed antibody-drug conjugate to R-CHOP. is different. In these patients, Hematopoietic Stem Cell Transplantation may be offered to initial responders before relapse occurs with the intention of improving the likelihood of cure. In autologous stem cell transplantation, stem cells are obtained from the patient by peripheral blood leukopheresis and are transfused back into the patient after high-dose chemotherapy. Similarly, in some younger patients with mantle cell lymphoma who have responded to initial therapy, autologous stem cell transplantation may be is done to prolong remission. Patients with aggressive non-Hodgkin lymphoma not in remission at end of therapy or who relapse are treated with second-line chemotherapy regimens followed by Hematopoietic Stem Cell Transplantation if they are relatively young and in good health. In some patients at very high risk of relapse as well as in those for whom autologous transplant is not feasible or has already failed, stem cells from a matched sibling or unrelated donor (allogeneic transplants) can be effective. In general, the older the patient, the less likely an allogeneic transplantation will be offered because older patients have higher rates of transplantation complications. Patients with diffuse large B-cell lymphoma (DLBCL) who have persistent lymphoma despite at least 2 prior lines of therapy may be candidates for chimeric antigen receptor (CAR) T cells. CAR T cells are T cells (most commonly autologous T cells) that have been genetically engineered to recognize a tumor antigen (eg, CD19). After infusion, they undergo activation and expansion. About one third of patients achieve a durable response from this therapy. Patients not eligible for the above therapies, or for whom they have failed, may receive treatment with various therapies, mostly for palliation. These therapies vary widely and are constantly changing as new treatments are developed. In indolent lymphomas, patients may be managed using a wide variety of strategies depending on Lymphoma-related factors (eg, histopathology, stage, molecular and immunologic characteristics) Patient-related factors (eg, age, comorbidities) The type of and response to prior therapy. Many of the same drugs used for first-line treatment may be given to patients in relapse. In some cases, the same treatment may be repeated if it was previously effective and well tolerated. High-dose chemotherapy with Hematopoietic Stem Cell Transplantation is used occasionally in patients who have high-risk lymphoma biology (including a poor response to chemotherapy), and although cure remains unlikely, remission may be superior to that with secondary palliative therapy alone. Reduced intensity allogeneic transplantation is a potentially curative option in some patients with indolent lymphoma. The mortality rate of patients undergoing myeloablative transplantation has decreased dramatically to 1 to 2% for most autologous procedures and to 15 to 20% for most allogeneic procedures (depending on age). An immediate complication of most therapies is infection that occurs during periods of Neutropenia . Although use of growth factors that stimulate white blood cell production has helped, infection continues to pose a problem. The gastrointestinal adverse effects of chemotherapy can be largely relieved or prevented by antiemetics and bowel programs. Patients receiving anthracyclines are at risk of Overview of Cardiomyopathies and/or After successful treatment, patients should be referred to a cancer survivorship clinic for a care plan that can be implemented by the patient's primary care team. This plan is tailored to the patient's comorbidities and risks specific to the treatment they received. Drugs and radiation therapy have late complications. In the first 10 years after treatment, there is a risk of Myelodysplasia and Iron-Transport Deficiency Anemia or 