eMedicine Specialties > Hematology > Stem Cells and Disorders

Lymphoma, Diffuse Mixed: Follow-up

Author: Clifford H Pemberton, MD, Instructor in Medicine, Jefferson Medical College; Medical Director, Jefferson Hospice and Palliative Care Program; Consulting Staff, Department of Medicine, Division of Hematology/Oncology, Lankenau Hospital
Coauthor(s): Asher A Chanan-Khan, MD, Assistant Professor, Department of Medicine, Division of Lymphoma and Bone Marrow Transplantation, Roswell Park Cancer Institute, State University of New York at Buffalo
Contributor Information and Disclosures

Updated: Dec 18, 2008

Follow-up

Further Inpatient Care

  • Hospitalization may be necessary for patients with the following diffuse large B-cell lymphomas (diffuse mixed lymphomas) disease- or therapy-associated complications:
    • Neutropenic fever: Patients are usually expected to be neutropenic approximately 10-14 days after a dose of chemotherapy, and individuals are most susceptible to infections at this point. If febrile, they should be admitted to the hospital and treated with intravenous antibiotics.
    • Anemia and thrombocytopenia: Transfusions (red blood cells or platelets) should be administered as clinically indicated for anemia and thrombocytopenia.

Further Outpatient Care

  • Growth factor support: Patients with a previous episode of febrile neutropenia should be treated with growth factor (ie, GM-CSF, G-CSF) during subsequent cycles.
  • Anemia: Patients with persistently low hemoglobin values due to disease or chemotherapy may require red blood cell transfusions or erythropoietin or darbepoetin alfa (Aranesp) injections.

Inpatient & Outpatient Medications

  • Antiemetics are administered as required for control of nausea and vomiting.
    • The 5-hydroxytriptamine 3 (5-HT3) antagonists such as granisetron (1 mg PO q12h) or ondansetron (8 mg PO q8h) for severe chemotherapy-induced nausea and vomiting
    • Lorazepam (1 mg PO/SL q4-6h)
    • Metoclopramide (0.5-2 mg/kg PO q3-4h)
    • Prochlorperazine (10 mg PO q4-6h)
  • For patients with anemia, consider erythropoietin or epoetin alfa (Procrit) at 40,000-60,000 U subcutaneously [SC] once per week, or darbepoetin alfa 300 mcg SC weekly.

Transfer

  • Patients whose conditions relapse after multiple regimens or who have poor performance status are thus not candidates for further chemotherapy and should be considered for palliative management and hospice care. The following services can be sought in appropriate clinical situations:
    • Pain management service
    • Nursing home
    • Terminal care facility (hospice)
    • Home care with specialized nursing support for pain management
    • Rehabilitative centers

Deterrence/Prevention

  • Patients who administer growth factors to themselves should be carefully advised on sterile techniques.
  • Fevers during periods of neutropenia should be immediately brought to the attention of the treating physician.

Complications

  • Chemotherapy-associated complications
    • Cardiomyopathy (related to anthracycline)
    • Infections (during neutropenia, postchemotherapy)
    • Gonadal dysfunction (sterility related to chemotherapy)
    • Secondary leukemias (exposure to alkylating agents)
    • Alopecia
    • Neuropathy
    • Related to bone marrow transplantation

Prognosis

  • The 5-year relapse-free survival rate for low-risk patients is 70%, and the 5-year OS rate is 73%. For the high-risk group, the 5-year relapse-free survival rate is 40% and the 5-year OS rate is 26%.
  • The IPI uses 5 pretreatment characteristics to identify the various risk groups, which are as follows:
    • Age ( <60 y vs >60 y)
    • Number of extranodal sites of involvement ( <1 vs >1)
    • Tumor stage I or II (localized) versus III or IV (advanced)
    • Patient performance status (0 or 1 vs >2)
    • Serum LDH level (normal vs abnormal)
  • Based on the 5 IPI characteristics, patients are classified into 4 categories:
    • High risk: Four or 5 adverse factors
    • High-intermediate risk: Three adverse factors
    • Low-intermediate risk: Two adverse factors
    • Low risk: No or 1 adverse factor

Patient Education

  • Patients with diffuse large B-cell lymphomas (diffuse mixed lymphomas) should be educated about the following:
    • Febrile neutropenia
    • Postchemotherapy thrombocytopenia and the tendency to bleed with minimal trauma
    • Chemotherapy-associated alopecia
    • Avoidance of pregnancy in reproductive-aged women
    • Chemotherapy-induced nausea and vomiting
    • Chemotherapy-associated menstrual dysregulation (females) and the possibility of sexual dysfunction
    • Fatigue
    • Sperm banking and risk of sterility for males

Miscellaneous

Medicolegal Pitfalls

  • Failure to inform patients with diffuse large B-cell lymphomas (diffuse mixed lymphomas) about the long-term sequelae of chemotherapeutic agents, which include the following:
    • Infertility
    • Secondary leukemias
    • Myelodysplastic syndrome
    • Possible anaphylactic reactions
    • Serious and potentially fatal infections
  • Failure to clearly explain transfusions (both red blood cells and platelets) and associated complications
  • Failure to inform patients who require HDC and ASCT that long-term complications of higher doses of chemoradiotherapy and mortality rates as high as 3-5% from the conditioning regimen are possible
  • Cardiomyopathy

Special Concerns

  • The pathology findings in patients with possible diffuse, mixed cell non-Hodgkin lymphoma should be reviewed by an experienced hematopathologist.
  • Patients with induction-failure non-Hodgkin lymphoma (ie, those with chemosensitive disease who do not achieve CR with primary therapy) or recurrent non-Hodgkin lymphoma should be carefully selected for bone marrow transplantation. Only patients with chemosensitive disease should be considered for HDC and ASCT.
 


More on Lymphoma, Diffuse Mixed

Overview: Lymphoma, Diffuse Mixed
Differential Diagnoses & Workup: Lymphoma, Diffuse Mixed
Treatment & Medication: Lymphoma, Diffuse Mixed
Follow-up: Lymphoma, Diffuse Mixed
Multimedia: Lymphoma, Diffuse Mixed
References
Further Reading
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References

  1. Sweetenham JW. Diffuse large B-cell lymphoma: risk stratification and management of relapsed disease. Hematology Am Soc Hematol Educ Program. 2005;252-9. [Medline]. [Full Text].

  2. International Non-Hodgkin's Lymphoma Prognostic Factors Project. A predictive model for aggressive non-Hodgkin's lymphoma. N Engl J Med. Sep 30 1993;329(14):987-94. [Medline]. [Full Text].

  3. Vose JM, Link BK, Grossbard ML, et al. Phase II study of rituximab in combination with CHOP chemotherapy in patients with previously untreated, aggressive non-Hodgkin's lymphoma. J Clin Oncol. Jan 15 2001;19(2):389-97. [Medline]. [Full Text].

  4. Pfreundschuh M, Truemper L, Gill D, et al. First analysis of the completed Mabthera International (Mint) Trial in young patients with low-risk diffuse large B-cell lymphoma (DLBCL): addition of rituximab to a CHOP-like regimen significantly improves outcome of all patients with the identification of a very favorable subgroup with IPI=O and no bulky disease [abstract 157]. Blood. 2004;104:48a:[Full Text].

  5. Sehn LH, Donaldson J, Chhanabhai M, et al. Introduction of combined CHOP plus rituximab therapy dramatically improved outcome of diffuse large B-cell lymphoma in British Columbia. J Clin Oncol. Aug 1 2005;23(22):5027-33. [Medline]. [Full Text].

  6. Philip T, Chauvin F, Armitage J, et al. Parma international protocol: pilot study of DHAP followed by involved-field radiotherapy and BEAC with autologous bone marrow transplantation. Blood. Apr 1 1991;77(7):1587-92. [Medline]. [Full Text].

  7. Glass B, Kloess M, Bentz M, et al. Dose-escalated CHOP plus etoposide (MegaCHOEP) followed by repeated stem cell transplantation for primary treatment of aggressive high-risk non-Hodgkin lymphoma. Blood. Apr 15 2006;107(8):3058-64. [Medline]. [Full Text].

  8. Leonard JP, Furman RR, Cheung YKK, et al. Phase I/II trial of bortezomib + CHOP-rituximab in diffuse large B cell (DLBCL) and mantle cell lymphoma (MCL): phase I results [abstract]. Blood. 2005;106:491a:[Full Text].

  9. Fillet G, Bonnet C, Mounier N, et al. No role for chemoradiotherapy when compared with chemotherapy alone in elderly patients with localized low risk aggressive lymphoma: final results of the LNH93-4 GELA study [abstract 15]. Blood. 2005;106:9a:[Full Text].

  10. Kunkel L, Wong A, Maneatis T, et al. Optimizing the use of rituximab for treatment of B-cell non-Hodgkin's lymphoma: a benefit-risk update. Semin Oncol. Dec 2000;27(6 suppl 12):53-61. [Medline].

  11. Link MP, Donaldson SS, Berard CW, Shuster JJ, Murphy SB. Results of treatment of childhood localized non-Hodgkin's lymphoma with combination chemotherapy with or without radiotherapy. N Engl J Med. Apr 26 1990;322(17):1169-74. [Medline].

  12. Martin-Subero JI, Kreuz M, Bibikova M, et al. New insights into the biology and origin of mature aggressive B-cell lymphomas by combined epigenomic, genomic and transcriptional profiling. Blood. Dec 15 2008;epub ahead of print. [Medline].

  13. Philip T, Guglielmi C, Hagenbeek A, et al. Autologous bone marrow transplantation as compared with salvage chemotherapy in relapses of chemotherapy-sensitive non-Hodgkin's lymphoma. N Engl J Med. Dec 7 1995;333(23):1540-5. [Medline]. [Full Text].

  14. Rodriguez MA, Cabanillas FC, Velasquez W, et al. Results of a salvage treatment program for relapsing lymphoma: MINE consolidated with ESHAP. J Clin Oncol. Jul 1995;13(7):1734-41. [Medline].

  15. Tondini C, Zanini M, Lombardi F, et al. Combined modality treatment with primary CHOP chemotherapy followed by locoregional irradiation in stage I or II histologically aggressive non-Hodgkin's lymphomas. J Clin Oncol. Apr 1993;11(4):720-5. [Medline].

  16. Vose JM, Zhang MJ, Rowlings PA, et al. Autologous transplantation for diffuse aggressive non-Hodgkin's lymphoma in patients never achieving remission: a report from the Autologous Blood and Marrow Transplant Registry. J Clin Oncol. Jan 15 2001;19(2):406-13. [Medline]. [Full Text].

  17. Zainuddin N, Berglund M, Wanders A, et al. TP53 mutations predict for poor survival in de novo diffuse large B-cell lymphoma of germinal center subtype. Leuk Res. Jan 2009;33(1):60-6. [Medline].

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Further Reading

Related eMedicine Topics

Suggested Reading

  • Griffin TC, Weitzman S, Weinstein H, et al, and the Children's Oncology Group. A study of rituximab and ifosfamide, carboplatin, and etoposide chemotherapy in children with recurrent/refractory B-cell (CD20+) non-Hodgkin lymphoma and mature B-cell acute lymphoblastic leukemia: A report from the Children's Oncology Group. Pediatr Blood Cancer. 2009 Feb;52(2):177-81. [Medline].

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Keywords

diffuse mixed lymphoma, diffuse mixed-cell lymphoma, diffuse mixed small and large cell lymphoma, diffuse undifferentiated lymphoma, intermediate grade lymphoma, diffuse small and large cell lymphoma, malignant lymphoma, diffuse mixed type, intermediate-grade lymphoma, mixed histiocytic-lymphocytic malignant lymphoma, mixed small and large cell lymphoma, diffuse mixed lymphomas, cancer, malignant histiocytes, malignant lymphocytes, lymphatic sarcoma, mixed lymphocytic-histiocytic

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Contributor Information and Disclosures

Author

Clifford H Pemberton, MD, Instructor in Medicine, Jefferson Medical College; Medical Director, Jefferson Hospice and Palliative Care Program; Consulting Staff, Department of Medicine, Division of Hematology/Oncology, Lankenau Hospital
Clifford H Pemberton, MD is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American College of Physicians, American Medical Association, American Society of Hematology, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Asher A Chanan-Khan, MD, Assistant Professor, Department of Medicine, Division of Lymphoma and Bone Marrow Transplantation, Roswell Park Cancer Institute, State University of New York at Buffalo
Asher A Chanan-Khan, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Society of Hematology
Disclosure: Nothing to disclose.

Medical Editor

Michael Paul Kosty, MD, Associate Director, Associate Professor, Department of Internal Medicine, Divisions of Supportive Care Services and Hematology and Oncology, Ida M and Cecil H Green Cancer Center, Scripps Clinic
Michael Paul Kosty, MD is a member of the following medical societies: American College of Physicians, American Society of Hematology, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Wendy Hu, MD, Consulting Staff, Department of Hematology/Oncology and Bone Marrow Transplantation, Huntington Memorial Medical Center
Wendy Hu, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

CME Editor

Rajalaxmi McKenna, MD, FACP, Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems
Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis
Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD, Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Thomas Jefferson University
Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, and New York Academy of Sciences
Disclosure: Nothing to disclose.

 
 
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