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treatment of non-Hodgkin lymphoma🚧 施工中
treatment of non-Hodgkin lymphoma
(Lancet 2017;390:298)
• Treatment and prognosis determined by histopathologic classification rather than stage
• Rituximab (anti-CD20; NEJM 2012;366:2008) if CD20+
• Indolent: generally no cure (except allo HSCT), goal sx mgmt (bulky dis, cytopenia, “B” sx)
Follicular Lymphoma Int’l Prog. Index (FLIPI; Blood 2004;104:1258): risk factors = age >60, stage III/IV, Hb <12 g/dL, >4 nodal areas, LDH >nl. 5-yr OS 52–90% based on score.
Initial: RT if localized, rituximab + chemo (bendamustine, CVP, fludarabine), ibrutinib.
Obinutuzumab (anti-CD20) + chemo w/ obin maint ↑ PFS but ↑ tox (NEJM 2017;377:1331).
Maintenance: rituximab in indolent, aggressive, and relapsed disease (Lancet 2011;377:42)
Hairy cell: cladribine; oral BRAF inhibitor if relapsed/refractory (NEJM 2015;373:1733)
Gastric MALT: ✓ H. pylori; can cure by treating H. pylori if ⊕; RT for relapsed/refractory
• Aggressive: goal is cure (Am J Hematol 2019;94:604), treatment depends on subtype
International Prognostic Index (IPI; Blood 2007;109:1857): risk factors = age >60 y, stage III/IV, ≥2 extranodal sites, PS ≥2, LDH >nl. 4-yr OS 55–94% based on score.
R-CHOP (rituximab, cyclophosphamide, doxorubicin = hydroxydaunorubicin, vincristine = Oncovin, prednisone) (NEJM2002;346:235 & 2008;359:613) DLBCL 10-y PFS = 45%; overall survival = 55% (Blood 2010;116:2040)
+ Radiation for localized or bulky disease
Consider CNS prophylaxis w/ intrathecal vs. systemic high-dose MTX if paranasal sinus, testicular, breast, periorbital, paravertebral, or bone marrow involved; also w/ ≥2 extranodal sites + ↑ LDH. Controversial (Blood 2021;139:413).
Refractory/relapsed disease: salvage chemo; high-dose chemo + auto-HSCT (JCO 2001;19:406); allo-HSCT if beyond 2nd relapse (JCO 2011;29:1342)
CAR-T (qv): axicabtagene (NEJM 2017;377:2531), tisagenlecleucel (NEJM 2019;380:45), lisocabtagene (Lancet 2020;396:839), brexucabtagene (mantle cell; NEJM 2020; 382:1331)
Mantle cell: ibrutinib for relapsed/refractory disease (Lancet2016;387:770)
• Highly aggressive
Burkitt: dose-adjusted EPOCH-R (NEJM 2013;369:1915) or CODOX-M/IVAC (cyclophosphamide, vincristine, doxorubicin, high-dose methotrexate, ifosfamide, etoposide, high-dose cytarabine rituximab) (Blood 2008;112:2248)
All Pts receive CNS & tumor lysis syndrome prophylaxis
Rituximab ↑ event-free survival (Lancet 2016;387:2402)
High-grade B-cell lymphoma w/ rearrangements of MYC and BCL2 and/or BCL6: “double-/triple-hit”, assoc. w/ poor prognosis. Often use DA-R-EPOCH.