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Lymphoma, Mediastinal: Treatment & Medication
Updated: Oct 12, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Emergency care for patients with superior vena cava syndrome consists of the initiation of chemotherapy. Emergency radiation is usually not necessary.
- Patients are initially treated with 6 cycles of chemotherapy.
- Cyclophosphamide, doxorubicin (Adriamycin), vincristine, and prednisone combined with rituximab (CHOP-R) is the most commonly used regimen in the United States. Rituximab is a monoclonal anti-CD20 agent that destroys B lymphocytes. When combined with CHOP-R, chemotherapy greatly improves cure rates in large cell lymphoma, with minimal additive side effects. Traditionally CHOP-R is administered every 3 weeks. A recent European study suggested that, in patients with high serum lactic acid dehydrogenase (LDH) levels, biweekly administration with growth factor (filgrastim) support may be advantageous.
- Others, mainly in Europe, use the methotrexate, doxorubicin (Adriamycin), cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B) regimen, which is also routinely combined with rituximab. Other regimens include etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab (EPOCH-R) and LNH 87.
- In many centers, involved-field radiation is administered to the mediastinum after completion of the chemotherapy.
- In other centers, patients undergo high-dose chemotherapy and autologous stem cell transplantation after the completion of combination chemotherapy.
- Management is guided by an evaluation of the response based on CT and gallium or positron emission tomography (PET) scans. The authors recommend autologous stem cell transplantation only if the PET scan findings remain positive after chemotherapy is completed.
- For patients with recurrent lymphoma, high-dose chemotherapy and autologous or allogeneic stem cell transplantation are the treatments of choice.
Surgical Care
Obtaining the diagnostic biopsy often requires surgery. Surgery has no other role.
Consultations
Patients should be referred to a medical hematologist or oncologist for treatment.
Medication
The mainstay of therapy consists of combination chemotherapy. Regimens are complex, and doses vary depending on a patient's weight and body surface area. They usually contain corticosteroids, an anthracycline, an alkylating agent, and a vinca alkaloid. The introduction of rituximab (a monoclonal anti-CD20 agent) has improved the outcome for patients with large B-cell lymphoma. The standard front-line regimen is R-CHOP, although other intensified regimens including DA-EPOCH-R and MACOP-B have been successfully utilized in small series of patients. Patients should be referred to a medical hematologist or oncologist for treatment.
Radiation to the mediastinum is often used as consolidation therapy. Others have recommended high-dose chemotherapy with stem cell support (autologous stem cell transplantation).
Some patients are young women who may be pregnant at the time of diagnosis. The management of malignancy during pregnancy raises specific and complex issues. Concern for the patient's health needs to be balanced with the potential teratogenicity of the chemotherapy and the radiation administered for diagnostic examinations or as part of treatment. Termination of pregnancy is often recommended if the diagnosis is made in the first trimester. However, this is not acceptable to all patients. In cases in which pregnancy is continued, the administration of chemotherapy drugs without undue teratogenicity is often possible. Staging and restaging examinations are minimized. Radiography is avoided, and MRI or ultrasonography procedures are used instead. The administration of corticosteroids may exacerbate problems such as preeclampsia or glucose intolerance. Close collaboration with an obstetrician is required.
The chemotherapeutic drugs used for the management of lymphoma have numerous adverse effects. Nausea and vomiting are common but can be avoided with the use of appropriate antiemetics. Hair loss occurs in most patients but is completely reversible after the completion of treatment.
Myelosuppression (bone marrow suppression) and moderate pancytopenia occur after every treatment cycle. Blood counts typically reach their nadir approximately 10 days after the completion of a treatment cycle. Fatigue is common. Approximately 10-20% of patients develop excessive neutropenia or an infectious complication. In such patients, treatment with recombinant cytokines such as filgrastim (Neupogen), pegfilgrastim (Neulasta), or sargramostim (Leukine) is recommended. These cytokines hasten the recovery of blood counts and may allow the timely administration of treatment cycles.
Recent evidence suggests that routine administration of cytokines may permit more rapid and intense administration of chemotherapy (eg, cyclophosphamide, doxorubicin [Adriamycin], vincristine, and prednisone combined with rituximab [CHOP-R] q2wk or etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin and rituximab [EPOCH-R]) and may improve cure rates. Cardiac toxicity from anthracyclines is dose dependent and rare in the typical young patient with primary mediastinal B-cell lymphoma (PMBL). Serial monitoring with echocardiograms or multiple gated acquisition (MUGA) scans may be necessary in individual cases. The use of cardioprotectant agents may allow the administration of higher doses of anthracyclines, but these cardioprotectant agents might affect the efficacy of chemotherapy. Therefore, cardioprotectant agents are not routinely recommended. Quinolone antibiotics such as levofloxacin or moxifloxacin are sometimes administered to prevent infections. Their usefulness remains somewhatcontroversial.
Rituximab is generally safe. It can cause fever and chills, particularly during the first administration. Rare cases of anaphylactic reaction have been reported. Recently, cases of hepatitis B virus (HBV) reactivation that have resulted in fulminant hepatitis and death have been reported. Persons at high risk of HBV infection should be screened before the initiation of rituximab (Rituxan). Carriers of HBV should be closely monitored for clinical and laboratory signs of active HBV infection and for signs of hepatitis during and up to several months after Rituxan therapy.
Acute adverse effects of radiation are usually limited and include erythema of the skin and, sometimes, radiation pneumonitis.
High-dose chemotherapy and autologous transplantation are complex procedures that involve the collection of stem cells, the administration of high doses of chemotherapy, and the reinfusion of the stem cells. The procedure usually requires admission to the hospital and support with transfusions, cytokines, and antibiotics. This procedure causes considerable, but transient, morbidity. However, because of advances in supportive care, the mortality associated with this procedure is minimal.
More on Lymphoma, Mediastinal |
| Overview: Lymphoma, Mediastinal |
| Differential Diagnoses & Workup: Lymphoma, Mediastinal |
 Treatment & Medication: Lymphoma, Mediastinal |
| Follow-up: Lymphoma, Mediastinal |
| Multimedia: Lymphoma, Mediastinal |
| References |
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References
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Further Reading
Keywords
primary mediastinal B-cell lymphoma, PMBL, B-cell neoplasm
