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Lymphoma, Follicular: Treatment & Medication
Updated: Nov 3, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- The rare patient who presents with localized disease should be treated with radiation therapy with curative intent; approximately half of these patients will be cured with radiation alone. Unfortunately, fewer than 10% of patients with follicular lymphoma present with localized disease.
- The treatment for advanced stage disease is considered palliative, because most follicular lymphomas are disseminated and incurable at the time of diagnosis. Many experts recommend observation until the patient develops systemic symptoms, such as fever, weight loss, or bulky lymphadenopathy, because early therapy has not been shown to impact overall survival. Patients in whom treatment is deferred should be followed closely for complications such as ureteral or biliary obstruction. No universally accepted first-line treatment strategy exists for stage III/IV follicular lymphoma.
- Single-agent chemotherapy is an option for patients with symptomatic disease.5 Single agents tend to have lower response rates and provide a shorter duration of disease control than do combination chemotherapy regimens. Nonetheless they are appropriate for selected patients, because they may be simpler to administer, induce less toxicity, and palliate symptoms.
- Chlorambucil is an oral alkylating agent that is often reserved for elderly patients with a poor performance status or those who wish to defer intravenous therapy. Few patients will have a complete response and there is no impact on overall survival.
- Single-agent fludarabine must be administered intravenously and causes a significant degree of myelosuppression and immunosuppression. There is also some concern that therapy with fludarabine may impair the ability to collect hematopoietic stem cells for an autologous stem cell transplant. Fludarabine is associated with higher response rates than single-agent chlorambucil is, but with no impact on overall survival.
- Rituximab (Rituxan), a monoclonal antibody targeting the CD20 antigen expressed on the cell surface of most lymphoma cells, has demonstrated efficacy as a single agent and as part of combination chemotherapy regimens. It is generally well tolerated but is significantly more expensive than most other therapies; there has been no definitive improvement found in overall survival when the drug is administered as a single agent. Clinical trials using rituximab as maintenance therapy suggested that this strategy prolonged progression-free survival in patients who had an objective response or stable disease following rituximab monotherapy.6,7
- Combining multi-agent chemotherapy and rituximab is the most common first line treatment strategy in the United States. Several studies have compared combination chemotherapy with and without rituximab; the rituximab containing regimens generally produce a higher response rate and a more durable response. A meta-analysis confirmed an improvement in overall survival in patients with follicular lymphoma, associated with the addition of rituximab to combination chemotherapy regimens.
- Combination chemotherapy regimens vary; they include the following:
- Rituximab, cyclophosphamide, vincristine, prednisone (R-CVP)
- Rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP)
- Fludarabine, cyclophosphamide, rituximab (FCR)
- Rituximab, fludarabine, cyclophosphamide, mitoxantrone (R-FCM)
- Fludarabine, rituximab (FR)
- Hematopoietic stem cell transplantation has a role in the treatment of follicular lymphoma, especially in younger patients with relapsed or recurrent disease. Allogeneic hematopoietic stem cell transplantation can induce long-term remissions in patients with follicular lymphoma, but transplant-related mortality is high. Autologous hematopoietic stem cell transplantation has a low transplant-associated mortality and prolongs progression-free survival; in one randomized, controlled trial, improvement in overall patient survival was observed. However, most patients eventually relapse after undergoing this therapy, and there is an increased rate of secondary malignancies. Hematopoietic stem cell transplantation is generally reserved for patients with relapsed or refractory disease.
- Follicular lymphoma is inherently radiosensitive, so the development of targeted radioimmunotherapy9 to the CD20 marker expressed on B cells has been a significant advance. It enables the delivery of cytocidal doses of radiation to all sites of disseminated disease. Currently, 2 agents are available for this type of treatment: iodine-131 – labeled tositumomab (Bexxar) and yttrium-90 – labeled ibritumomab tiuxetan (Zevalin).8 Both agents have produced high response rates in patients with relapsed or refractory and treatment-naive follicular lymphoma.
- Iodine-131 – labeled tositumomab and yttrium-90 – labeled ibritumomab tiuxetan have demonstrated improvements in progression-free survival but not in overall patient survival. Ongoing clinical trials are utilizing these agents in consolidation therapy following an initial chemotherapy regimen or as part of a hematopoietic stem cell transplantation regimen, in an attempt to achieve a complete response in a higher proportion of patients.
- The use of radioimmunoconjugates is limited in United States by the need for highly trained staff and specialized equipment, the expense of therapy, the risk for secondary malignancies, and the relatively short duration of follow-up.
Surgical Care
The role of the surgeon is to obtain an excisional biopsy adequate to establish the diagnosis. The surgeon should be instructed about the proper handling of the specimen and the special tests required because the biopsy might require special handling. The surgeon should probably discuss these issues with the pathologist prior to performing the biopsy.
Consultations
Radiation oncologist: Radiation therapy with curative intent should be used in patients with stage I disease, although this represents a minority of cases of follicular lymphoma. Radiation therapy also can be used to treat localized or bulky lymphadenopathy that is causing obstruction or when a more urgent response is desired to relieve obstruction. Radiation therapy usually is tolerated well and, in many instances, can spare the patient the need for additional chemotherapy. The radiation oncologist is also involved in the care of patients receiving radioimmunotherapy.
Medication
All of the medications listed below should only be ordered by physicians who have training and/or experience in antineoplastic agents.
Antineoplastic Agent, Alkylating Agent
These agents inhibit cell growth and proliferation.
Chlorambucil (Leukeran)
A bifunctional alkylating agent of the nitrogen mustard type that has been found to be active against selected human neoplastic diseases. Chlorambucil is known chemically as 4-[bis(2chlorethyl)amino]benzene butanoic acid.
Entire daily dose may be given at one time. These dosages are for initiation of therapy or for short courses of treatment. The dosage must be carefully adjusted according to the response of the patient and must be reduced as soon as an abrupt fall in the white blood cell count occurs.
Adult
0.4 mg/kg PO once q2wk, titrate as needed; or daily dosing as 0.1-0.2 mg/kg PO daily for 3-6 weeks as needed; usual dose for average patient is 4-10 mg/d
Pediatric
Not established
None reported
Documented hypersensitivity; previous resistance to medication; pregnancy
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Because of carcinogenic properties, should not be given to patients with conditions other than malignant lymphomas or chronic lymphatic leukemia; convulsions, infertility, leukemia, and secondary malignancies observed when employed in therapy of malignant and nonmalignant diseases
Most common adverse effect is bone marrow suppression; although bone marrow suppression frequently occurs, usually reversible if chlorambucil withdrawn early enough; irreversible bone marrow failure reported; should not be given at full dosages until 4 wk after a full course of radiation therapy or chemotherapy because of vulnerability of bone marrow to damage under these conditions; if pretherapy leukocyte or platelet counts are depressed from bone marrow disease process prior to institution of therapy, treatment should be instituted at reduced dosage
GI disturbances (eg, nausea and vomiting, diarrhea, and oral ulceration) occur infrequently
Tremors, muscular twitching, confusion, agitation, ataxia, flaccid paresis, and hallucinations reported as rare adverse effects that resolve upon discontinuation of the drug
Rare, focal, and/or generalized seizures reported to occur in both children and adults at both therapeutic daily doses and pulse-dosing regimens and in acute overdose
Skin hypersensitivity (including rare reports of skin rash progressing to erythema multiforme, toxic epidermal necrolysis, and Stevens-Johnson syndrome) reported
Other reported adverse reactions include pulmonary fibrosis, hepatotoxicity and jaundice, drug fever, peripheral neuropathy, interstitial pneumonia, sterile cystitis, infertility, leukemia, and secondary malignancies
Cross-hypersensitivity (skin rash) may occur between chlorambucil and other alkylating agents
Cyclophosphamide (Cytoxan)
Cyclic polypeptide that suppresses some humoral activity. Chemically related to nitrogen mustards. Activated in the liver to its active metabolite, 4-hydroxycyclophosphamide, which alkylates the target sites in susceptible cells in an all-or-none type reaction. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.
Biotransformed by cytochrome P-450 system to hydroxylated intermediates that break down to active phosphoramide mustard and acrolein. Interaction of phosphoramide mustard with DNA is considered cytotoxic.
In high doses, affects B cells by inhibiting clonal expansion and suppression of production of immunoglobulins. With long-term low-dose therapy, affects T-cell functions.
Adult
CHOP regimen: 750 mg/m2 IV on day 1, repeat q3wk
CVP regimen: 750 mg/m2 IV on day 1, repeat q3wk
R-FCM regimen: 200 mg/m2 IV on days 1-3, repeat q3wk
FCR regimen: 300 mg/m2 IV on days 1-3, repeat q3wk
Oral regimens: 50-100 mg/m2/d PO continuously or 400-1000 mg/m2 PO in divided doses for 4-5 d or 400-1800 mg/m2 (30-50 mg/kg) IV in divided doses over 2-5 d; may repeat at 2- to 4-wk intervals
Pediatric
Not established
Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; toxicity may increase with chloramphenicol; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase leukopenic activity; concurrent etanercept may increase risk of developing noncutaneous solid malignancies; thiazide diuretics may prolong cyclophosphamide-induced leukopenia; coadministration with succinylcholine may increase neuromuscular blockade by inhibiting cholinesterase activity
Documented hypersensitivity; severely depressed bone marrow function
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Regularly examine hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; may cause sterility; nausea and vomiting are common with intravenous dosing regimen; anorexia, diarrhea, mucositis, and stomatitis are also seen; potentially fatal acute hemorrhagic cystitis may occur; facial flushing, headache, and rash may also occur
Antineoplastic, Antimetabolite
Interfere with metabolic pathways necessary for the survival of target cells.
Fludarabine (Fludara)
Contains fludarabine phosphate, a fluorinated nucleotide analog of the antiviral agent vidarabine, 9-b-D-arabinofuranosyladenine (ara-A) that is relatively resistant to deamination by adenosine deaminase. Dosage may be decreased or delayed based on evidence of hematologic or nonhematologic toxicity. Physicians should consider delaying or discontinuing drug if neurotoxicity occurs. Optimal duration of treatment not clearly established. Recommended that 3 additional cycles of fludarabine be administered following achievement of maximal response, and then drug should be discontinued.
Adult
25 mg/m2 IV over approximately 30 min once daily for 5 d; repeat q28d
FR regimen: 25 mg/m2 IV once daily for 5 d; repeat q28d
FCR regimen: 25 mg/m2 IV once dailyfor 3 d; repeat q28d
R-FCM regimen: 25 mg/m2 IV once daily for 3 d; repeat q28d
Pediatric
Not established
Combination with other purine analogs (eg, pentostatin) because incidence of pulmonary toxicity is unacceptably high when used together
Documented hypersensitivity; breastfeeding; bone marrow suppression
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Perform frequent peripheral blood counts to detect development of anemia, thrombocytopenia, and neutropenia; monitor for tumor lysis syndrome; adjust dose for renal impairment, severe bone marrow suppression, severe neurological effects, or life-threatening and fatal autoimmune hemolytic anemia
Antineoplastic Agent, Anthracycline
These agents inhibit DNA synthesis.
Doxorubicin (Adriamycin)
Cytotoxic anthracycline antibiotic isolated from cultures of Streptomyces peucetius var caesius. Blocks DNA and RNA synthesis by inserting between adjacent base pairs and binding to sugar-phosphate backbone of DNA, which causes DNA polymerase inhibition. Binds to nucleic acids presumably by specific intercalation of anthracycline nucleus with DNA double helix. Also a powerful iron chelator. Iron-doxorubicin complex induces production of free radicals that can destroy DNA and cancer cells. Can also cause DNA strand breakage through effects on topoisomerase II. Maximum toxicity occurs during the S phase of the cell cycle.
Has multiphasic disappearance curve, with half-lives ranging up to 30 h. Does not cross blood-brain barrier but is taken up rapidly by the heart, lungs, liver, kidney, and spleen.
This drug is both mutagenic and carcinogenic. Dosage related to body surface area.
Adult
CHOP regimen: 50 mg/m2 IV once on day 1, repeat q3wk
Pediatric
Not established
May decrease phenytoin, carbamazepine, and digoxin plasma levels; phenobarbital may decrease plasma levels of doxorubicin; cyclosporine may induce coma or seizures; mercaptopurine increases toxicity of doxorubicin; cyclophosphamide increases cardiac toxicity of doxorubicin; trastuzumab increases the incidence and severity of cardiac dysfunction; sorafenib may increase the plasma levels of doxorubicin
Documented hypersensitivity; severe heart failure, cardiomyopathy, impaired cardiac function, preexisting myelosuppression
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Irreversible cardiac toxicity and myelosuppression may occur; extravasation may result in severe local tissue necrosis; reduce dose in patients with impaired hepatic function
Mitoxantrone (Novantrone)
Incorporated into combination chemotherapy regimens for follicular lymphoma. Inhibits cell proliferation by intercalating DNA and inhibiting topoisomerase II.
Adult
R- FCM regimen: mitoxantrone 8mg/m2/d IV once on day 1; repeat q28 days
Pediatric
None reported
Documented hypersensitivity; baseline LVEF <50% in patients with multiple sclerosis
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in impaired hepatic function and preexisting cardiac disease (cardiotoxicity commonly seen after cumulative dose of 120-160 mg/m2, patients with MS should not receive a cumulative dose >140 mg/m2); CHF may occur either during treatment, or months to years after treatment termination; perform baseline and follow-up cardiac function tests (2D-echo and ejection fraction measurements); when treating MS, LVEF should be reevaluated by echocardiogram or MUGA prior to each dose; secondary acute myelogenous leukemia has been reported after treating cancer or MS
Antineoplastic Agent, Vinca Alkaloid
These agents inhibit cell growth and proliferation at the mitotic phase of the cell cycle.
Vincristine (Oncovin, Vincasar)
Binds to microtubular protein of the mitotic spindle, inhibiting key steps in the cell cycle
Adult
CHOP regimen: 1.4 mg/m2 IV once q3wk maximum single dose not to exceed 2 mg
Pediatric
Not established
Acute pulmonary reaction may occur when taken concurrently with mitomycin-C; asparaginase, CYP450 3A4 inhibitors (eg, itraconazole, posaconazole, voriconazole, quinupristin/dalfopristin, ritonavir, aprepitant), sargramostim, filgrastim, or nifedipine may increase toxicity associated with vincristine; CYP450 3A4 inducers (eg, carbamazepine, phenytoin, phenobarbital, rifampin) may decrease effects of vincristine; coadministration with warfarin may result in elevated supratherapeutic anticoagulation. Concomitant administration with digoxin may result in subtherapeutic digoxin levels.
Documented hypersensitivity; intrathecal administration
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in severe cardiopulmonary disease, hepatic impairment (adjust dose), or pre-existing neuromuscular dysfunction; Constipation, paralytic ileus, and urinary tract disturbances may occur
Corticosteroids
Have anti-inflammatory effects in disorders of many organ systems. Corticosteroids also are lympholytic and modify the body's immune responses to diverse stimuli.
Prednisone (Deltasone, Orasone, Sterapred)
Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear cell activity. Induction of cell death in immature lymphocytes.
Adult
60-100 mg PO qd for 5 d; repeat q21d
Pediatric
Not established
Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; concurrent use with NSAIDs may increase the risk of gastrointestinal ulceration; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Documented hypersensitivity; viral, connective tissue, and fungal or tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Prolonged use of corticosteroids may produce posterior subcapsular cataracts and glaucoma with possible damage to optic nerves and may enhance establishment of secondary ocular infections due to fungi or viruses
Average and large doses of hydrocortisone or cortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium; effects are less likely to occur with synthetic derivatives, except when used in large doses; dietary salt restriction and potassium supplementation may be necessary
All corticosteroids increase calcium excretion
Administration of live or live attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids; killed or inactivated vaccines may be administered to patients receiving immunosuppressive doses of corticosteroids, but response may be diminished
Use of prednisone in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis in which the corticosteroid is used for management of the disease in conjunction with an appropriate antituberculous regimen; if corticosteroids are indicated in latent tuberculosis or tuberculin reactivity, close observation necessary because reactivation of the disease may occur
During prolonged corticosteroid therapy, patients should receive Pneumocystis prophylaxis; if exposed to chicken pox, prophylaxis with varicella-zoster immune globulin (VZIG) may be indicated; if exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated; if chicken pox develops, treatment with antiviral agents may be considered
Monoclonal antibodies
Bind to target cells and recruit immune-effector functions to mediate target-cell lysis.10
Rituximab (Rituxan)
A chimeric murine/human monoclonal antibody directed against the CD20 antigen found on the surface of normal and malignant B lymphocytes. Rituximab binds to the cell surface and activates complement-dependent cytotoxicity and binds to human Fc receptors, mediating cell death through antibody-dependent cellular toxicity.
Can be used as first-line or salvage therapy, as monotherapy, or in addition to combination chemotherapy regimens.
Adult
375 mg/m2 given as IV infusion qwk for 4 doses (days 1, 8, 15, and 22)
375 mg/m2 given as IV infusion qwk for 4 doses (days 1, 8, 15, and 22); repeat every 6 months for up to 16 doses for maintenance therapy
In combination with chemotherapy 375 mg/m2 IV infusion on day 1; repeat q21 - 28 days.
Pediatric
Not established
Prior exposure to monoclonal antibodies may increase the risk for allergic reactions to rituximab
Documented hypersensitivity to murine proteins or any component of formulation
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
An infusion-related symptom complex consisting of fever and chills/rigors may occur; other frequent infusion-related symptoms include nausea, urticaria, fatigue, headache, pruritus, bronchospasm, dyspnea, sensation of tongue or throat swelling (angioedema), rhinitis, vomiting, hypotension, flushing, and pain at disease sites; reactions generally occur within 30 min to 2 h of beginning of first infusion and resolve with slowing or interruption of infusion and with supportive care (IV isotonic sodium chloride solution, diphenhydramine, and acetaminophen)
Mild-to-moderate hypotension that requires interruption of infusion with or without administration of IV isotonic sodium chloride solution may occur
Adverse effects include angioedema, bronchospasm, asthenia, throat irritation, flushing, tachycardia, anorexia, leukopenia, thrombocytopenia, anemia, peripheral edema, dizziness, depression, respiratory symptoms, night sweats, and pruritus
Severe thrombocytopenia, arrhythmias, neutropenia, anemia, aplastic anemia (pure red cell aplasia), chills, leukopenia, hypotension, bronchospasm, urticaria, headache, abdominal pain, asthenia, hypertension, nausea, vomiting, coagulation disorder, angioedema, arthralgia, pain, rhinitis, increased cough, dyspnea, bronchiolitis obliterans, hypoxia, asthma, pruritus, and rash may occur
Hepatitis B virus reactivation with fulminant hepatitis, hepatic failure, and death may occur.
Tositumomab and Iodine 131 (Bexxar)
Murine IgG2a lambda monoclonal antibody directed against the CD20 antigen, found on surface of normal and malignant B lymphocytes. Radiolabeled tositumomab (ie, iodine I131 tositumomab) is administered following nonradiotherapeutic version to direct treatment precisely to the malignancy. Possible mechanisms of action include apoptosis, complement-dependent cytotoxicity, antibody-dependent cytotoxicity, and ionizing radiation. Indicated for CD20 positive non-Hodgkin lymphoma that has relapsed following chemotherapy and is refractory to rituximab.
Adult
Dosimetric step: Tositumomab 450 mg IV infused over 1 h, followed by iodine I-131 tositumomab (5 mCi I-131 and 35 mg tositumomab) IV infused over 20 min
Therapeutic step (7-14 d following dosimetric step): Tositumomab 450 mg IV infused over 1 h, followed by iodine I131 (precise dose is dependent on current platelet count)
Pediatric
Not established
No formal drug interaction studies have been performed. Due to the frequent occurrence of severe and prolonged thrombocytopenia, the potential benefits of medications that interfere with platelet function and/or anticoagulation should be weighed against the potential increased risk of bleeding and hemorrhage. Coadministration with other drugs causing bone marrow suppression may cause additive effects
Documented hypersensitivity to tositumomab or murine antibodies
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
May cause severe or life-threatening cytopenias (ie, 71% experience grade 3 or 4); may cause hypersensitivity, including anaphylaxis; may cause secondary malignancies or hypothyroidism; infusion-related symptoms (eg, fever, rigors, chills, sweating) may occur; 1 d prior to administration, administer protectant SSKI; administer acetaminophen and diphenhydramine on administration day
Myelodysplastic syndrome (MDS) and/or acute leukemia were reported in 10% of patients enrolled in clinical studies and 3% of patients included in expanded access programs
Ibritumomab tiuxetan (Zevalin)
A murine monoclonal antibody that targets the CD20 antigen, which is chelated to the radioisotopes indium-111 or yttrium-90. Used in conjunction with rituximab to treat B-cell non-Hodgkin lymphoma (NHL) or rituximab-refractory follicular NHL. The regimen consists of 2 low doses of rituximab, an imaging dose, 2-3 whole body scans, and a therapeutic dose, which are all delivered on an outpatient basis over 8 d.
Adult
Day 1: Rituximab (250 mg/m2) IV. Followed by ibritumomab 1.6 mg (5 mCi indium111) within 4 hours, IV push over 10 min; followed by a whole body scan at 2-24 h
Day 2-6: Biodistribution is assessed. The first image is 2 to 24 hours after In-111 ibritumomab tiuxetan and the second image is 48 to 72 hours after In-111 ibritumomab tiuxetan. A third image, 90 to 120 hours after In-111 ibritumomab tiuxetan, is optional
Day 7-9: Rituximab (250 mg/m2) IV infused over 4-5 h; followed by ibritumomab 0.4 mCi/kg of yttrium90 IV push over 10 min; not to exceed 32 mCi
Note that the dose of rituximab is lower when used with ibritumomab than when rituximab is used as single agent
Pediatric
Not established
Coadministration with antiplatelet or anticoagulant drugs may increase risk of cytopenias and bleeding
Documented hypersensitivity; prior sensitization to murine proteins; greater than or equal to 25% lymphoma bone marrow involvement; prior myeloablative therapies; platelet count <100,000 cells/mm3; neutrophil count <1500 cells/mm3;
hypocellular bone marrow (<15% cellularity of marked reduction in bone marrow precursors); history of failed stem cell collection; breastfeeding
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Therapeutic regimen, which includes rituximab administration may cause severe, and potentially fatal, infusion reactions (typically occur during first rituximab infusion with time to onset of 30-120 min) and may require interruption of drug administration (signs and symptoms of severe infusion reactions may include hypotension, angioedema, hypoxia, or bronchospasm); treatment may cause severe and prolonged thrombocytopenia and neutropenia; do not administer to those with altered biodistribution (according to body scan results); use only as single course of treatment; follow radionucleotide precautions; decrease Y-90 ibritumomab to 0.3 mCi/kg with mild thrombocytopenia (ie, 100,000-149,000 platelets/mm3); severe mucocutaneous reactions, some with fatal outcomes, have been reported with the therapeutic regimen
Myelodysplastic syndrome and/or acute myelogenous leukemia were reported in 2.6% of patients included in clinical studies and expanded access programs.
More on Lymphoma, Follicular |
| Overview: Lymphoma, Follicular |
| Differential Diagnoses & Workup: Lymphoma, Follicular |
 Treatment & Medication: Lymphoma, Follicular |
| Follow-up: Lymphoma, Follicular |
| Multimedia: Lymphoma, Follicular |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics
Lymphoma, Non-Hodgkin
Cutaneous T-Cell Lymphoma
Lymphoma, Cutaneous T-Cell
Non-Hodgkin Lymphoma
Thyroid Cancer
Clinical guidelines
Rituximab for the treatment of follicular lymphoma.
National Institute for Health and Clinical Excellence (NICE) - National Government Agency [Non-U.S.]. 2006 Sep. 20 pages. NGC:005739
Ibritumomab tiuxetan in lymphoma: a clinical practice guideline.
Program in Evidence-based Care - State/Local Government Agency [Non-U.S.]. 2006 Jul 17. 42 pages. NGC:005224
Clinical trials
Idiotypic Vaccination for Follicular Lymphoma Patients
Consolidation Treatment With Y90-Ibritumomab Tiuxetan After R-CHOP Induction in High Risk Patients According to Follicular Lymphoma International Prognostic Index (FLIPI) With Follicular Lymphoma
Bendamustine, Mitoxantrone, and Rituximab (BMR) for Patients With Untreated High Risk Follicular Lymphoma
Radiotherapy Versus Radiotherapy Plus Chemotherapy in Early Stage Follicular Lymphoma
Keywords
follicular lymphoma, non-Hodgkin's lymphoma, nodular lymphomas, low-grade lymphomas, indolent lymphomas, non-Hodgkin lymphoma, lymphoid tissue, lymph nodes, spleen, bone marrow, primary extranodal lymphoma
