Sections

Treatment

Approach Considerations

The treatment of non-Hodgkin lymphoma (NHL) varies greatly, depending on the following factors:

Tumor stage
Phenotype (B-cell, T-cell or natural killer [NK] cell/null-cell)
Histology (ie, low, intermediate, or high grade)
Symptoms
Performance status
Patient age
Comorbidities

Most of the chemotherapy for NHL, whether combination or single-drug, can be administered in an outpatient setting, at an infusion clinic. In the infusion clinic, specially trained oncology nurses, who are supervised by oncologists, administer the chemotherapy. Growth factor support (eg, granulocyte-colony stimulating factor [GCSF], granulocyte macrophage–colony stimulating factor [GM-CSF], erythropoietin) is also administered in an outpatient treatment setting.

Infusional chemotherapy (eg, infusional cyclophosphamide, doxorubicin, and etoposide [CDE], which should be administered continuously for 4 days) should be administered as inpatient treatment. High-dose chemotherapy and bone marrow and/or stem cell transplantation are administered in an inpatient setting of a tertiary hospital with an approved transplant center.

For the initial treatment of patients with intermediate- or high-grade lymphoma and patients with bulky disease, an inpatient setting is recommended in order to monitor for tumor lysis syndrome and to manage appropriately.

Admit patients with NHL for complications of disease progression (eg, pain control for intractable pain) or adverse effects from chemotherapy (eg, dehydration secondary to diarrhea, vomiting requiring IV hydration, severe mucositis). Patients with fever during neutropenia should be admitted for broad-spectrum antibiotic therapy.

Ensure that patients understand their diagnosis, treatment options, and prognosis and complications of therapy, which, in rare occasions, may result in a fatal event (eg, death secondary to severe infection unresponsive to antimicrobial therapy, in a patient with severe neutropenia). Start the treatment only after the patient has signed an informed consent form.

Management of Indolent NHL

Follicular lymphoma (grade I-IIIa) comprises 70% of this group. Other entities in this group include small lymphocytic lymphoma (SLL), lymphoplasmacytoid lymphoma, and marginal zone lymphomas (MZL, nodal or extranodal).

Indolent stage I and contiguous stage II NHL

Standard management consists of radiotherapy alone. Forty percent of patients with limited-stage disease remained disease-free at 10 years after radiation in a study done by Mac Manus and Hoppe.^[22]No randomized study has shown combined chemotherapy and radiation to be better than radiation alone.

A study by Rossier et al found that low-dose involved-field radiotherapy is effective in treating patients with recurrent low-grade lymphoma.^[23]

Radiation therapy (2500-4000 cGy) produces a 10-year failure-free survival (FFS) rate of 50-60%, with an overall survival (OS) rate of 60-80%. Offering adjuvant chemotherapy to selected patients with stage I-II NHL who have unfavorable prognostic factors (eg, B symptoms, >2 nodal sites), and to those with follicular mixed histology is not unreasonable. Early treatment in asymptomatic patients has not been shown to improve survival.

Rituximab is another treatment option for symptomatic patients for whom radiation therapy is contraindicated or who prefer an alternative treatment.^[3]The use of rituximab—a monoclonal antibody that targets the CD20 antigen, which is present in benign and malignant B-cells—in combination with systemic chemotherapy, has resulted in an improved duration of remission and survival for patients with indolent B-cell lymphomas, compared with chemotherapy alone. Prospective studies and two meta-analyses suggest that rituximab-chemotherapy, also known as chemo-immunotherapy, may change the natural progression of indolent lymphomas.

Indolent noncontiguous stage II, III, and IV NHL

The treatment of indolent B-cell lymphomas continues to evolve as new therapies with potent antitumor activity and limited toxicity are becoming available. Monoclonal antibodies are changing the treatment paradigm of patients with B-cell lymphomas. However, controversies persist regarding the best treatment strategy and the best time to initiate treatment.

The disease course of indolent lymphomas is characterized by a continuous decrease in the quality and the duration of response with each subsequent treatment or treatments. This effect is primarily due to the acquisition of chemotherapy resistance.

Advanced indolent lymphomas have been accepted to be not curable with currently available therapies. However, sustained complete remissions can be achieved with various treatment modalities.

Asymptomatic patients, especially older patients and patients with concomitant medical problems, deferred therapy with careful observation is an option. Early intervention in asymptomatic patients does not appear to prolong survival. The median time to progression is 4-6 years, and OS is 6-10 years.

The treatment of symptomatic patients with indolent lymphomas should focus on achieving the best possible quality of response without producing excessive toxicity. Single-agent treatment with chlorambucil or cyclophosphamide (with or without prednisone) is useful in elderly patients with significant comorbidities. However, only a few achieve remission; most achieve palliation.

A study by Gaulard et al found that rituximab plus low-dose CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) (R-miniCHOP) offered a good compromise between efficacy and safety in patients older than 80 years. The authors concluded that R-miniCHOP should be considered the new standard of treatment in these patients.^[24]

Combination chemotherapies are used in younger patients with the goal of achieving a complete remission. Bendamustine plus rituximab has demonstrated efficacy for the first-line treatment of advanced follicular, indolent, and mantle cell lymphomas.^[25] Current NCCN guidelines list the following as preferred first-line regimens for follicular lymphoma^[26]:

Bendamustine plus obinutuzumab or rituximab
CHOP plus obinutuzumab or rituximab
CVP (cyclophosphamide, vincristine, prednisone) plus obinutuzumab or rituximab
Lenalidomide plus rituximab

Combination agents are useful in bulky and rapidly progressive disease and have higher response rates than single agents, but there is no improvement in overall survival.^{[27, 28, 29]}

A study by Watanabe et al found that a denser-dose R-CHOP strategy was not associated with improved progression-free survival in patients with untreated indolent B-cell lymphoma.^[30]

Randomized trials have shown that adding rituximab to chemotherapy regimens results in higher response rates, longer time to progression, and longer survival than chemotherapy. For example, Czuczman et al reported a 95% overall response rate and increase in time to progression with addition of rituximab to CHOP chemotherapy (R-CHOP).^[31] Rituximab as a single agent is also useful in patients who are unable to tolerate chemotherapy or those patients who elect to undergo treatment in the absence of high tumor burden.

Subcutaneous rituximab/hyaluronidase (Rituxan Hycela) may be substituted for rituximab after patients have received the first dose of rituximab by IV infusion. FDA-approved biosimilar rituximab may also be used as a substitute for rituximab.

Maintenance therapy with rituximab after induction chemotherapy has been reported to prolong progression-free survival (PFS) in comparison with observation alone in patients with indolent lymphoma. However, long-term follow-up in a randomized phase 3 study found that weekly rituximab every 6 months for 2 years did not influence overall survival, although the PFS benefit was maintained. These researchers concluded that maintenance rituximab should be considered optional for patients with indolent B-cell lymphoma.^[32]

In patients with indolent NHL that is refractory to rituximab, obinutuzumab plus bendamustine followed by obinutuzumab maintenance has improved efficacy over bendamustine monotherapy, with manageable toxicity. A phase 3 trial by Sehn et al reported significantly longer PFS with obinutuzumab plus bendamustine (median not reached) than with bendamustine monotherapy (14.9 months; P=0.0001).^[33]

Management of Aggressive NHL

Diffuse large B-cell lymphoma is the most common type of NHL. Other distinct entities in this group include immunoblastic, anaplastic, lymphoblastic, large-cell, Burkitt, and Burkitt-like lymphomas (high-grade lymphomas). Mantle cell lymphomas also behave aggressively.

Aggressive stage I and contiguous stage II (nonbulky or < 10 cm) NHL

Based on 2 large randomized trials (ie, Southwest Oncology Group [SWOG], Eastern Cooperative Oncology Group [ECOG]), the preferred treatment option for patients with intermediate-grade NHL is combination chemotherapy (3 cycles of CHOP) plus involved-field radiation therapy.

According to SWOG data, patients who are treated with chemotherapy and involved-field radiation therapy have significantly better progression-free survival rates (ie, 77% versus 66%) and 5-year overall survival (OS) rates (ie, 82% versus 72%) compared with patients surviving 8 cycles of chemotherapy (ie, CHOP) alone. Patients with high-grade disease should be strongly considered for treatment with more aggressive regimens beyond CHOP.

Aggressive noncontiguous stage II, III, and IV NHL

Approximately 40-50% of these patients are cured with standard therapy, approximately 35-40% will respond but ultimately progress or relapse, and the remainder will be have disease that is refractory to primary treatment. Scoring systems such the IPI score have been developed and validated to estimate the response rate or survival rate of a given patient with aggressive lymphomas.

For many years, the treatment of aggressive lymphomas consisted of chemotherapy regimens using multiple drugs. Initial clinical studies were focused on investigating the use of more toxic regimens (higher doses or more drugs).

A prospective randomized trial in patients with diffuse large-cell lymphoma showed no difference in response rate (RR), OS, or time to treatment failure (TTF) at 3 years with any of the following regimens^[34]:

CHOP
Prednisone, methotrexate, leucovorin, doxorubicin, cyclophosphamide, and etoposide—cyclophosphamide, etoposide, Adriamycin, cytarabine, bleomycin, Oncovin, methotrexate, leucovorin, and prednisone (ProMACE-CytaBOM)
Methotrexate, bleomycin, doxorubicin (Adriamycin), cyclophosphamide, Oncovin, and dexamethasone (m-BACOD)
Methotrexate-leucovorin, Adriamycin, cyclophosphamide, Oncovin, prednisone, and bleomycin (MACOP-B)
Hyper-CVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone, alternating with methotrexate and cytarabine) plus rituximab has been shown to achieve a high rate of durable remission in patients with mantle cell lymphoma. It is a toxic regimen and is typically used in patients with good performance status, who can tolerate it; otherwise, R-CHOP is used.^[35]
Bendamustine and rituximab combination has been successfully used in patients with mantle cell lymphoma in the first and second-line setting.^[36]A study by Weidmann et al found that bendamustine in combination with rituximab may be an alternative treatment for aggressive lymphomas in elderly patients who are not eligible for R-CHOP because of its efficacy and low toxicity.^[37]

Bortezomib has also been used in patients with relapsed or refractory mantle cell lymphoma.^[38]

ProMACE-CytaBOM, m-BACOD, and MACOP-B all proved more toxic than CHOP. However, non-CHOP regimens such as MACOP-B are used as first-line therapies in some subtypes of NHL such as primary mediastinal large B-cell NHL.

After more than 2 decades of scientific investigations, the treatment of aggressive lymphomas was changed by the clinical development of rituximab. Currently, 6-8 cycles of CHOP chemotherapy in combination with rituximab is the standard of care in patients with advanced disease.

The GELA (Groupe d'Etude des Lymphomes de l'Adulte) study was the first phase III trial to demonstrate the efficacy of combining rituximab with standard doses of CHOP chemotherapy for elderly (older than 60 y) patients with diffuse large B-cell lymphoma. At 5-year follow-up, OS was 58% with rituximab and CHOP versus 46% with CHOP alone.^[39]The results of this study were further validated by other international randomized studies favoring the use of rituximab and chemotherapy in elderly patients with aggressive B-cell lymphomas.

Studies in younger patients also showed the benefit of combining rituximab and CHOP chemotherapy. A large international study, the MabThera International Trial (MInT,) supported the role of rituximab-chemotherapy in young patients with aggressive B-cell lymphomas.^[40]The study, which has been presented only in an abstract form, was a phase III trial in which 823 patients (ages 18-60 y) with diffuse large B-cell, CD20⁺ NHL (DLBCL).

These patients were randomized to receive either rituximab plus a standard anthracycline-containing chemotherapy regimen (standard chemotherapy) or standard chemotherapy alone as induction therapy. The rituximab plus standard chemotherapy regimens increased 2-year overall survival (OS) from 86% to 95% compared with standard chemotherapy alone and resulted in significant improvement in time to treatment failure and projected overall survival.^[40]

Ongoing research is being focused on identifying patients at risk for treatment failure and developing tailored treatment for patients with aggressive lymphoma based on clinical scores (IPI score) or gene profiles. Patients at high risk of relapse (IPI intermediate or poor risk groups) might have an improved 5-year event-free survival/overall survival from autologous and allogeneic bone marrow or peripheral stem cell transplantation following chemotherapy.

CNS prophylaxis, usually with 4-6 injections of methotrexate intrathecally, is recommended for patients with paranasal sinus or testicular involvement, diffuse small noncleaved cell or Burkitt lymphoma, or lymphoblastic lymphoma. CNS prophylaxis for bone marrow involvement is controversial.

Treatment of acute lymphoblastic lymphoma, a very aggressive form of NHL, is usually patterned after acute lymphoblastic leukemia (ALL) therapy. Other subtypes of high-grade lymphomas are usually treated with more aggressive variations of CHOP chemotherapy, including the addition of high-dose methotrexate or other chemotherapy drugs and higher doses of cyclophosphamide.

Management of Indolent Recurrent NHL

In general, treatment with standard agents rarely produces a cure in patients who have relapsed. Sustained remissions after relapse can often be obtained in patients with indolent lymphomas, but relapse usually ensues. Favorable survival after relapse has been associated with age younger than 60 years, prior complete remission rather than partial remission, and duration of response longer than 1 year. For relapse that remains low grade, the following are possible treatment options:

Single alkylating agents (chlorambucil or bendamustine)
Novel biological agents and small molecule inhibitors showing promising results in patients with indolent lymphomas include ofatumumab, lenalidomide, and temsirolimus^[41]
Combination chemotherapy - CVP, CHOP, and others
Purine analogues - Fludarabine, 2-CDA
Rituximab (results in a 40-50% RR in patients with relapsed/refractory indolent B-cell lymphomas) in standard or extended schedules of administration
Radioimmunotherapy

¹³¹Iodine-rituximab radioimmunotherapy of relapsed or refractory indolent NHL achieves high overall response rates and complete response rates with minimal toxicity.^[42]Tositumomab (a murine IgG2a lambda monoclonal antibody directed against CD20 antigen) plus ¹³¹I (Bexxar) has been approved by the US Food and Drug Administration (FDA) for relapsed or refractory, low-grade, follicular, or transformed NHL.^{[43, 44]}

Ibritumomab tiuxetan plus ⁹⁰yttrium (Zevalin) also has been approved for use in relapsed indolent lymphoma. These radioimmunotherapy agents typically are used only in patients with less than 25% bone marrow involvement with lymphoma and in patients refractory to rituximab.

Local relapse can be treated with radiotherapy. High-dose chemotherapy plus stem cell transplantation is being investigated to determine whether it can produce significantly better survival rates compared with conventional chemotherapy.^[45]

In 2019, the FDA approved lenalidomide in combination with a rituximab product for the treatment of previously treated follicular lymphoma or marginal zone lymphoma, the first nonchemotherapeutic regimen approved for those conditions. Approval was based on the AUGMENT study, in which patients were randomized to receive either lenalidomide or placebo for 12 cycles plus rituximab once per week for 4 weeks in cycle 1 and day 1 of cycles 2 through 5. The objective response was 80% in the lenalidomide plus rituximab arm compared with 55% in the control arm. Progression-free survival improved for lenalidomide plus rituximab arm versus control arm, with median duration of 39.4 months versus 14.1 months.^[46]

Current NCCN guidelines recommend phosphoinositide 3-kinase (PI3K) inhibitors for relapsed or refractory indolent NHL that has failed to respond to 2 prior therapies. PI3K inhibitors include idelalisib, copanlisib, and duvelisib.^[26]

Idelalisib (Zydelig) is the first PI3K inhibitor to receive accelerated approval from the FDA for relapsed follicular B-cell NHL and small lymphocytic lymphoma in patients who have received at least two prior systemic therapies. In this single-group, phase II, open-label study, patients received idelalisib 150 mg PO BID until disease progression or study withdrawal. The response rate was 57% (71 of 125 patients), with 6% meeting the criteria for a complete response. The median time to a response was 1.9 months, the median duration of response was 12.5 months, and the median progression-free survival was 11 months. ^[47]

Copanlisib and duvelisib were also FDA-approved for follicular lymphoma in patients who failed to respond to two prior therapies. For copanlisib, approval was based on a phase II trial that reported an objective response rate was 59%, with 12% complete responses. The median duration of response (DoR) was 22.6 months. The median progression-free survival was 11.2 months, with the median overall survival not yet reached.^[48]

Duvelisib is a selective oral small molecule inhibitor of PI3K-delta and PI3K-gamma. The open label, global, phase II DYNAMO trial reported an overall response rate (ORR) of 47.3%. The estimated median DoR was 10 months, and the estimated median progression-free survival was 9.5 months.^[49]

Although PI3K inhibitors provide therapeutic benefits, there have been concerns of severe adverse reactions, including severe infections (eg, Pneumocystis jirovecii pneumonia [PJP]) and long-term immune-related toxicities. Therefore, concomitant PJP prophylaxis is strongly recommended for patients receiving treatment with idelalisib and should be considered in those receiving copanlisib or duvelisib.

Umbralisib is a dual inhibitor of PI3K-delta and casein kinase (CK1) 1-epsilon expressed on malignant B cells. It was granted accelerated approval for or refractory MZL who have received at least 1 prior anti-CD20-based regimen and for relapsed or FL who have received at least 3 prior lines of systemic therapy.

Approval was based on two single-arm cohorts of an open-label, multicenter trial, in patients with MZL who received at least 1 prior therapy and in patients with FL after at least 2 prior systemic therapies. Patients received umbralisib 800 mg PO once daily until disease progression or unacceptable toxicity. For patients with MZL, the overall response rate was 49% (95% CI: 37.0, 61.6) with 16% achieving complete responses. Median DOR was not reached (95% CI: 9.3, NE) in these patients. For patients with FL, the ORR was 43% (95% CI: 33.6, 52.2) with 3% achieving complete responses. Median DOR was 11.1 months (8.3, 16.4). ^[50]

Management of Aggressive Recurrent Adult NHL

High-dose chemotherapy plus stem-cell transplantation is the treatment of choice for patients who have recurrent aggressive lymphomas. Preliminary studies indicate that approximately 20-40% of patients have a long-term disease-free status, but the precise percentage depends on patient selection and specific treatment used.

In 2019, polatuzumab vedotin, a CD79b-directed antibody-drug conjugate, gained accelerated approval from the FDA for use in combination with bendamustine and a rituximab product for adults with relapsed or recurrent DLBCL who have received at least 2 prior therapies and are not candidates for transplantation. FDA approval was based on a study in which the addition of polatuzumab vedotin to bendamustine plus rituximab led to increased rates of complete and objective responses and prolonged progression-free and overall survival, with manageable toxicity.^[51]

Second-line chemotherapy regimens such as ICE (ifosfamide, carboplatin, etoposide), DHAP (dexamethasone, high-dose cytarabine, cisplatin), or EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, prednisone) are usually used with rituximab if the tumor is CD20 positive. A retrospective study by Tixier et al concluded that regimens combining dexamethasone and high-dose cytarabine with oxaliplatin (DHAOX) or carboplatin (DHAC) have more favorable toxicity profiles than DHAP; in particular, they are far less likely to cause renal toxicity.^[52]

Gemcitabine and navelbine are also being attempted in these relapsed patients. Chemotherapy is usually followed by stem-cell transplantation.

In the PARMA trial, patients with relapsed NHL who were randomized to autologous bone marrow transplantation followed by involved-field radiation therapy did better than those randomized to conventional chemotherapy and involved-field radiation therapy.^{[53, 54]}After a 5-year median follow-up study, the event-free survival (EFS) rate was significantly better with transplantation (46% versus 12%), and the overall survival (OS) rate was also better (53% versus 32%).

Allogeneic transplants have lower relapse rates but higher transplant-related mortality than autologous transplants.^[55]

In general, patients who respond to initial therapy and who respond to conventional salvage therapy prior to bone marrow transplantation have better survival outcomes. Patients who relapse late (> 12 mo after diagnosis) have better OS than patients who relapse earlier. Patients who are not candidates for transplantation can be treated with chemotherapy with or without monoclonal antibodies. If possible, these patients should be enrolled into clinical trials.

Chimeric antigen receptor T-cell therapy

Chimeric antigen receptor (CAR) T-cell therapy is approved for use in adult patients with relapsed or refractory large B-cell lymphoma, after two or more lines of systemic therapy. The following CAR T-cell therapies have FDA approval:

Axicabtagene ciloleucel (Yescarta) - Indications include diffuse large B-cell lymphoma (DLBCL) not otherwise specified, primary mediastinal large B-cell lymphoma, high-grade B-cell lymphoma, and DLBCL arising from follicular lymphoma.
Tisagenlecleucel (Kymriah) - Indications include DLBCL not otherwise specified, high-grade B-cell lymphoma, and DLBCL arising from follicular lymphoma.
Lisocabtagene maraleucel (Breyanzi) - Indicated for DLBCL not otherwise specified (including DLBCL arising from indolent lymphoma), high-grade B-cell lymphoma, primary mediastinal large B-cell lymphoma, and follicular lymphoma grade 3B. It is not indicated for primary CNS lymphoma.

For full discussion, see Cancer Immunotherapy with Chimeric Antigen Receptor (CAR) T Cells.

Management of T-cell Lymphomas

The treatment of T-cell lymphomas continues to be challenging. T-cell lymphomas are divided into 2 subgroups: cutaneous or systemic T-cell disorders. Typically, cutaneous T-cell lymphomas (CTCL) are managed with topical agents and oral disease modifiers during the early stage of the disease. See Cutaneous T-Cell Lymphoma for more information on this topic. Systemic chemotherapy is usually incorporated late in the course of the disease, with modest activity. Systemic T-cell lymphomas represent a challenge to the practicing oncologist.

The complexity of each subtype of T-cell lymphomas, the low incidence, and poor response to standard therapies are important factors that contribute to the poor clinical outcomes of this group of neoplasms. Most patients with T-cell lymphomas are better served by participating in clinical trials exploring dose-intense regimens, early bone marrow transplantation, and/or novel chemotherapeutic agents. Treatment options for T-cell lymphoma can be categorized as follows:

Combination chemotherapy regimens - CHOP, CHOP plus etoposide, gemcitabine-based regimens
Single chemotherapy agents - Pralatrexate
Monoclonal antibodies - Alemtuzumab (effective in prolymphocytic T-cell leukemia and hepatosplenic gamma-delta T-cell lymphoma)
Immunotoxin - Denileukin diftitox (discontinued January 2014)
Novel biological agents and small molecule inhibitors - Histone deacetylase inhibitors (vorinostat, panobinostat, romidepsin, belinostat), lenalidomide, and bortezomib

The US Food and Drug Administration (FDA) granted accelerated approval for pralatrexate injection (Folotyn) as a single agent for the treatment of patients with relapsed or refractory peripheral T-cell lymphoma (PTCL).^[56]

In 2011, the FDA granted accelerated approval for romidepsin (Istodax) for treatment of PTCL in patients who have received at least one prior therapy.^[57] However, a subsequent confirmatory phase III trial study evaluating romidepsin plus CHOP versus CHOP in first-line PTCL patients failed to meet the primary efficacy endpoint of progression-free survival, so in August 2021 the manufacturer voluntarily withdrew this indication in the US.^[58]

In 2014, the FDA approved the histone deacetylase inhibitor belinostat (Beleodaq) for treatment of relapsed or refractory PTCL. Approval was based on the results of a multicenter, single-arm, nonrandomized trial of 120 patients with refractory or relapsed PTCL and included patients with baseline platelet levels below 100,000/μL. The overall complete and partial response rates were 10.8% and 15.0%, respectively. The median response duration (first date of response to disease progression or death) was 8.4 months.^{[59, 60]}

Jacobsen et al concluded that hematopoietic stem cell transplantation (HSCT) can result in long-term remissions in patients with relapsed or refractory T-cell lymphoma, especially those with nodal histologies.^[61]

Surgical Care

The role of surgery in the treatment of patients with NHL is limited. Surgery is useful in selected situations (eg, GI lymphoma), particularly if the disease is localized or if risk of perforation, obstruction, and massive bleeding is present. Orchiectomy is part of the initial management of testicular lymphoma.

Complications of Therapy

Potential chemotherapy and other treatment-related complications include the following:

Cytopenias (ie, neutropenia, anemia, thrombocytopenia)
Nausea or vomiting
Infection
Fatigue
Neuropathy
Dehydration after diarrhea or vomiting
Cardiac toxicity from doxorubicin
Catheter-related sepsis
Catheter-related thrombosis
Secondary malignancies
Tumor lysis syndrome
Atherosclerosis

Tumor lysis syndrome

This syndrome commonly occurs after treatment of high-grade bulky NHLs because of their exquisite sensitivity to therapy, which is caused by their high proliferative capacity. Tumor lysis syndrome is characterized by hyperuricemia, hyperkalemia, hyperphosphatemia, hypocalcemia, and renal failure. Death from cardiac asystole can occur from hyperkalemia.

Measures to prevent this complication include aggressive hydration, allopurinol administration, and urine alkalinization. Frequent monitoring of input and output, electrolytes, uric acid, and creatinine is necessary. Dialysis is sometimes required.

Atherosclerosis

In a 3-year study, Bilora et al found evidence that patients receiving radiotherapy and chemotherapy for lymphoma (either NHL or Hodgkin lymphoma) are predisposed to early development of atherosclerosis.^[62]In 96 patients, the investigators found increased intima-media thickness at 1-year follow-up; thickness had decreased at 3-year follow-up, but reduction in flow-mediated dilatation measured in the patients at 1 year had not improved by the 3-year examination.^[62]

Dietary Modification

Usually, a regular diet is adequate, except when the patient is neutropenic. Patients with neutropenia should not eat raw fruits or vegetables.

Transplant patients who have severe mucositis, decreasing albumin levels, or both may be administered total parenteral nutrition (TPN) until they can tolerate oral feedings.

Activity Restriction

The following restrictions apply to patients who are neutropenic, thrombocytopenic, or both:

Avoid exposure to or contact with other patients with communicable or infectious diseases
Use a soft toothbrush during episodes of neutropenia and thrombocytopenia
Do not shave with a razor

Ideally, patients with neutropenia should be admitted directly to a private room and should not stay long in the emergency department for evaluation. All medical personnel should wash hands before and after examining these patients

Children

Pediatric patients with NHL are best treated by pediatric oncologists.

Pregnant women

NHL during pregnancy is uncommon, but it presents an ethical dilemma. Remission may be obtained with chemotherapy, but chemotherapy has potentially harmful effects to the fetus. Consider fetal exposure to transplacental chemotherapy when evaluating therapy options and carefully evaluate the timing of delivery.

For patients diagnosed with NHL during the second or third trimester of pregnancy, few literature reports suggest that they can be treated with chemotherapy without significant toxicity to the fetus. If possible, alkylating agents should be avoided. If the fetus can be delivered safely prior to administration of chemotherapy and a short wait will not affect the treatment outcome and prognosis of the patient, starting the treatment after the birth of the baby is better.

If the patient has high-grade NHL (eg, Burkitt or lymphoblastic lymphoma) diagnosed during the first trimester of pregnancy, immediate institution of therapy is necessary; otherwise, the condition could be fatal. Discuss at length with the patient and family that chemotherapy treatment at this period of pregnancy is very risky for the fetus, and whether therapeutic termination of pregnancy should be performed before the patient is treated should be decided. Consultation with the ethical committee of the hospital should be obtained in these very difficult situations.

CAR T-cell Therapy

Chimeric antigen receptor (CAR) T-cell therapy utilizes each patient’s own T cells, extracted by leukapheresis. The T cells are sent to a processing facility, where they are genetically engineered with CD19 receptors that seek out cancer cells; the T-cell population is then expanded and infused back into the patient, who has undergone conditioning chemotherapy in preparation for the infusion.

In October 2017, FDA approved axicabtagene ciloleucel (Yescarta) for treatment of large B-cell lymphoma after at least two other kinds of therapy have failed. Approved uses include diffuse large B-cell lymphoma (DLBCL), primary mediastinal large B-cell lymphoma, high-grade B-cell lymphoma, and DLBCL arising from follicular lymphoma. Axicabtagene ciloleucel is not indicated for the treatment of patients with primary central nervous system lymphoma.^[63]

Approval was based on the primary results from the ZUMA-1 study, an open-label, multicenter trial enrolling 111 patients from 22 institutions. Patients in ZUMA-1 received the target dose of axicabtagene ciloleucel (2 x 10⁶ cells/kg) after low-dose conditioning with cyclophosphamide and fludarabine for 3 days. Two-year follow-up data from ZUMA-1 included the following^[64]:

Objective responses were seen in 83% of patients; complete responses were seen in 58%.
Median duration of response was 11.1 months (4.2months to not estimable).
Median overall survival was not reached; median progression-free survival was 5.9 months.
Grade 3 or worse serious adverse events occurred in 48% of patients, including grade 3 or worse cytokine release syndrome occurred in 11% and grade 3 or worse neurological events in 32%.

For more information, see Cancer Immunotherapy with Chimeric Antigen Receptor (CAR) T-Cells

Consultations

A hematologist-oncologist should treat patients with NHL.

Consult a radiation oncologist for treatment of patients with localized or limited-stage low-grade lymphoma and for palliative radiation therapy (eg, for treatment of SVC syndrome, treatment of painful metastases [especially to bone] as an adjunctive treatment for CNS lymphomas).

Consult an infectious disease specialist for the management of patients with neutropenic fever who are not responding to the usual broad-spectrum antibiotics.

Surgical consultation is needed for lymph node biopsy, palliative procedures, or placement of a venous access device (eg, Port-a-Cath, Hickman catheter) for blood drawing and chemotherapy access.

Long-Term Monitoring

Treatment and follow-up care of patients with NHL are usually performed on an outpatient basis. Monitoring patients’ blood cell counts while they are receiving chemotherapy (eg, prior to each treatment cycle and 10-14 d after each treatment cycle) is important.

Monitor adverse effects of chemotherapy with a detailed patient history, an examination, a CBC, and serum chemistries (especially liver function tests, electrolytes, lactate dehydrogenase, and blood urea nitrogen [BUN]/creatinine).

Treat symptomatic adverse effects such as nausea, vomiting, diarrhea, mucositis, anorexia, pain, and fatigue. Administer packed red blood cell (PRBC) transfusions for patients with symptomatic anemia and provide platelet transfusions for patients with a platelet count less than 10,000- 20,000/mm³. Provide growth factor (eg, granulocyte colony-stimulating factor [GCSF], granulocyte-macrophage colony-stimulating factor [GM-CSF], erythropoietin) support as necessary.

Perform a disease and response to treatment evaluation by obtaining patient history, physical examination (at intervals q2-3mo), and imaging studies (eg, CT scans at intervals q4-12mo).

Provide psychosocial support for the patient and family.

Guidelines

Zhang QY, Foucar K. Bone marrow involvement by Hodgkin and non-Hodgkin lymphomas. Hematol Oncol Clin North Am. 2009 Aug. 23(4):873-902. [QxMD MEDLINE Link].
Hsia CC, Howson-Jan K, Rizkalla KS. Hodgkin lymphoma with cutaneous involvement. Dermatol Online J. 2009 May 15. 15(5):5. [QxMD MEDLINE Link].
PDQ Adult Treatment Editorial Board. Adult Non-Hodgkin Lymphoma Treatment (PDQ®): Health Professional Version. January 20, 2021. [QxMD MEDLINE Link]. [Full Text].
Shustik J, Quinn M, Connors JM, et al. Follicular non-Hodgkin lymphoma grades 3A and 3B have a similar outcome and appear incurable with anthracycline-based therapy. Ann Oncol. 2011 May. 22(5):1164-9. [QxMD MEDLINE Link].
Martí-Carvajal AJ, Cardona AF, Lawrence A. Interventions for previously untreated patients with AIDS-associated non-Hodgkin's lymphoma. Cochrane Database Syst Rev. 2009 Jul 8. CD005419. [QxMD MEDLINE Link].
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Media Gallery

Posteroanterior (PA) chest radiograph in a man with thoracic non-Hodgkin lymphoma (NHL) shows mediastinal widening due to grossly enlarged right paratracheal and left paratracheal nodes.
Posteroanterior (PA) chest radiograph in a 16-year-old male adolescent with thoracic non-Hodgkin lymphoma (NHL) shows subtle enlargement of the lower paratracheal lymph nodes.
Nonenhanced CT scan through the mediastinum shows multiple enlarged lymph nodes in the prevascular space, in the right and left paratracheal region. Nodes in the left paratracheal region cause the trachea to be indented and narrowed on the left side. Note the small, bilateral pleural effusion
Nonenhanced CT scan through the mediastinum at the level of the carina shows enlarged tracheobronchial and subcarinal nodes. Note the small bilateral pleural effusion.
Contrast-enhanced axial CT scan in a child shows hypoattenuating, enlarged, subcarinal lymph nodes with splaying of the tracheal bifurcation.
Posteroanterior (PA) chest radiograph shows a large mass in the right parahilar region extending into the right upper and middle zones, with silhouetting of the right pulmonary artery. Smaller mass is seen in the periphery of the right lower zone. The masses did not respond to a trial of antibiotics. Core-needle biopsy of the larger lesion revealed NHL deposits in the lung.
Lateral image shows a large mass in the anterior aspect of the right upper lobe of the lung.
Posterior bone scan shows no abnormally increased uptake in the thoracic vertebrae. Image shows an unusual pattern of non-Hodgkin lymphoma (NHL) of the upper thoracic vertebra.
This 28-year-old man was being evaluated for fever of unknown origin. Gallium-67 study shows extensive uptake in the mediastinal lymph nodes due to non-Hodgkin lymphoma (NHL).
T1-weighted coronal MRI of the thorax in a 55-year-old woman with lower dorsal pain. Note the signal-intensity changes in the body of D12; these are associated with a right-sided, large, paravertebral soft-tissue mass involving the psoas muscle. Biopsy confirmed non-Hodgkin lymphoma (NHL).
T1-weighted coronal MRI of the thorax in a 55-year-old woman with lower dorsal pain (same patient as in the previous image). Note the signal-intensity changes in the body of D12; these are associated with a right-sided, large, paravertebral soft-tissue mass involving the psoas muscle. Biopsy confirmed non-Hodgkin lymphoma (NHL).
Positron emission tomography (PET) CT in an 80-year-old woman with diffuse, large B-cell NHL of the skin and subcutaneous tissues that recently transformed from previous low-grade non-Hodgkin lymphoma (NHL). PET shows high level of uptake in the anterior subcutaneous nodule in the chest (white arrows). CT scan of similar nodules (arrowheads) on the anterior left chest does not show PET uptake; these may represent regions of lower-grade NHL. PET image of posterior lesions shows only mild uptake (gray arrow).
Non-Hodgkin lymphoma of the terminal ileum. Note the doughnut sign, ie, intraluminal contrast material surrounded by a grossly thickened bowel wall. This appearance is highly suggestive of small noncleaved cell lymphoma (Burkitt type).
Computed tomography of the throat in highly-malignant non-hodgkin lymphoma present as lymph node swelling in a child (transverse section with contrast). DE: Computertomographie des Halses bei einem hoch-malignen Non-Hodgkin
Malignant lymphoma high grade_B_cell
Ultrasound throat lymphadenopathy non-hodgkin-lymphoma

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Table 1. Non-Hodgkin lymphoma staging.

Stage		Area of Involvement	Extranodal (E) Status
I	Single node or adjacent group of nodes		Single extranodal lesions without nodal involvement
II	Multiple lymph node groups on same side of diaphragm		Stage I or II by nodal extent with limited contiguous extranodal involvement
II bulky*	Multiple lymph node groups on same side of diaphragm with “bulky disease”		N/A
III	Multiple lymph node groups on both sides of diaphragm; nodes above the diaphragm with spleen involvement		N/A
IV	Multiple noncontiguous extranodal sites		N/A

Table 2. Comparison of Lugano and Paris staging systems

Lugano Staging System		Paris Staging System
Stage	Area of Involvement	TNM	Tumor extension
I_E1	Confined to GI tract—mucosa, submucosa	T1m N0 M0 T1sm N0 M0	Mucosa Submucosa
I_E2	Confined to GI tract—muscularis propria, serosa	T2 N0 M0 T3 N0 M0	Muscularis propria Serosa
II_E1	Extending into abdomen—local nodal involvement	T1-3 N1 M0	Perigastric lymph nodes
II_E2	Extending into abdomen—distant nodal involvement	T1-3 N2 M0	More distant regional nodes
II_E	Penetration of serosa to involve adjacent organs or tissues	T4 N0 M0	Invasion of adjacent structures
IV	T1-4 N3 M0 T1-4 N0-3 M1	Lymph nodes on both sides of the diaphragm/distant metastases (eg, bone marrow or additional extranodal sites)

Table 3. International Society for Cutaneous Lymphoma/European Organization for Research and Treatment of Cancer tumor-node-metastasis classification for cutaneous B-cell lymphoma

Tumor	Involvement	Node	Involvement	Metastatic Spread	Involvement
T1	Solitary skin involvement T1a: ≤5 cm diameter T1b: >5 cm diameter	N0	No lymph node involvement	M0	No evidence of extracutaneous non-lymph node disease
T2	Multiple lesions limited to one body region or two contiguous body regions T2a: all-disease in a < 15-cm diameter T2b: all-disease in a >15- and < 30-cm diameter T2c: all-disease in a >30-cm diameter	N1	Involvement of one peripheral lymph node region	M1	Evidence of extracutaneous non-lymph node disease
T3	Generalized skin involvement T3a: multiple lesions involving two noncontiguous body regions T3b: multiple lesions involving three body regions	N2	Involvement of two or more peripheral lymph node regions or involvement of any lymph node region that does not drain an area of current or prior skin involvement
		N3	Central lymph nodes involvement

Table 4. International Society for Cutaneous Lymphoma/European Organization for Research and Treatment of Cancer tumor-node-metastasis-blood revised classification for mycosis fungoides and Sezary syndrome

Skin	Involvement	Node	Involvement	Viscera	Involvement
T1	Patchy or plaquelike skin disease involving ≤10% of the skin surface area	N0	No abnormal lymph nodes	M0	No visceral organ involvement
T2	Patchy or plaquelike skin disease involving ≥10% of the skin surface area	N1	Histopathology Dutch Gr 1 or NCI LN 0-2	M1	Visceral organ involvement
T3	Tumors are present ≥1 cm in diameter	N2	Histopathology Dutch Gr 2 or NCI LN 3	MX	Abnormal visceral site; no histologic confirmation
T4	Erythroderma ≥80% of body area	N3	Histopathology Dutch Gr 3-4 or NCI LN 4	Blood	Involvement
		Nx	Abnormal lymph nodes; no histologic confirmation	B0	≤5% of peripheral blood lymphocytes are Sezary cells
				B1	>5% of peripheral blood lymphocytes are Sezary cells but do met B2 criteria
				B2	≥1000/mcL Sezary cells or CD4/CD8 ≥10 or ≥40% CD4+/CD7- or ≥30% CD4+/CD26- cells

Table 5. Staging classifications for mycosis fungoides and Sezary syndrome

Clinical Stage	5-year Survival ^[87]	TNM (B) Stage
IA	96-100%	T₁N₀M₀B₀	T₁N₀M₀B₁
IB	73-86%	T₂N₀M₀B₀	T₂N₀M₀B₁
IIA	49-73%	T₁N₁M₀B₀	T₁N₁M₀B₁	T₁N₂M₀B₀	T₁N₂M₀B₁
IIA		T₂N₁M₀B₀	T₂N₁M₀B₁	T₂N₂M₀B₀	T₂N₂M₀B₁
IIB	40-65%	T₃N₀M₀B₀	T₃N₀M₀B₁	T₃N₁M₀B₀	T₃N₁M₀B₁
IIB		T₃N₂M₀B₀	T₃N₂M₀B₁
IIIA	50-57%	T₄N₀M₀B₀	T₄N₁M₀B₀	T₄N₂M₀B₀
IIIB	50-57%	T₄N₀M₀B₁	T₄N₁M₀B₁	T₄N₂M₀B₁
IVA	15-40%	T₁N₀M₀B₂	T₂N₀M₀B₂	T₃N₀M₀B₂	T₄N₀M₀B₂
		T₁N₁M₀B₂	T₂N₁M₀B₂	T₃N₁M₀B₂	T₄N₁M₀B₂
		T₁N₂M₀B₂	T₂N₂M₀B₂	T₃N₂M₀B₂	T₄N₂M₀B₂
		T₁N₃M₀B₀	T₂N₃M₀B₀	T₃N₃M₀B₀	T₄N₃M₀B₀
		T₁N₃M₀B₁	T₂N₃M₀B₁	T₃N₃M₀B₁	T₄N₃M₀B₁
		T₁N₃M₀B₂	T₂N₃M₀B₂	T₃N₃M₀B₂	T₄N₃M₀B₂
IVB	0-15%	T₁N₀M₁B₀	T₂N₀M₁B₀	T₃N₀M₁B₀	T₄N₀M₁B₀
		T₁N₁M₁B₁	T₂N₁M₁B₁	T₃N₁M₁B₁	T₄N₁M₁B₁
		T₁N₂M₁B₂	T₂N₂M₁B₂	T₃N₂M₁B₂	T₄N₂M₁B₂
		T₁N₃M₁B₃	T₂N₃M₁B₃	T₃N₃M₁B₃	T₄N₃M₁B₃

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Author

Sanjay Vinjamaram, MD, MPH Physician in Hematology/Oncology, Essentia/Innovis Health Cancer Center

Sanjay Vinjamaram, MD, MPH is a member of the following medical societies: American Association for the Advancement of Science, Sigma Xi, The Scientific Research Honor Society, American Society for Cell Biology

Disclosure: Nothing to disclose.

Coauthor(s)

Dolores A Estrada-Garcia, MD Consulting Staff in Hematology-Oncology, Cancer Care Specialists of Central Illinois

Dolores A Estrada-Garcia, MD is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology

Disclosure: Nothing to disclose.

Francisco J Hernandez-Ilizaliturri, MD Professor of Medicine, Department of Medical Oncology, Associate Professor of Immunology, Department of Immunology, Chief, Lymphoma and Myeloma Section, Director, The Lymphoma Translational Research Program, Roswell Park Cancer Institute, University of Buffalo State University of New York School of Medicine and Biomedical Sciences

Francisco J Hernandez-Ilizaliturri, MD is a member of the following medical societies: American Association for Cancer Research, American Society of Hematology

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Acknowledgements

Koyamangalath Krishnan, MD, FRCP, FACP Paul Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine and Chief of Hematology-Oncology, James H Quillen College of Medicine at East Tennessee State University

Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, and Royal College of Physicians

Disclosure: Nothing to disclose.

Lakshmi Rajdev, MD Site Director, Jacobi Medical Center; Assistant Professor, Department of Radiation Oncology, Albert Einstein College of Medicine

Disclosure: Nothing to disclose.

Joseph A Sparano, MD Professor of Medicine, Albert Einstein College of Medicine/Cancer Center; Program Director, Director of Breast Medical Oncology, Department of Internal Medicine, Division of Oncology, Montefiore Medical Center

Joseph A Sparano, MD is a member of the following medical societies: American Association for Cancer Research, American College of Physicians, and American Society of Hematology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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