Non-Hodgkin lymphoma medical therapy: Difference between revisions

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__NOTOC__
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{{Non-Hodgkin lymphoma}}  
{{Non-Hodgkin lymphoma}}  
{{CMG}}
{{CMG}}; {{AE}} {{Preeti}}; {{AS}}
 
== Overview ==
== Overview ==
Treatment for non-Hodgkin's lymphoma depends on the stage of the disease, the type of cells involved, whether they are indolent or aggressive, and the age and general health of the patient.
The predominant therapy for non-Hodgkin lymphoma is chemotherapy. Adjunctive [[radiation]], [[immunotherapy]], and [[stem cell transplantation]] may be required.


Non-Hodgkin's lymphoma is often treated by a team of specialists that may include a [[hematologist]], medical oncologist, and/or radiation oncologist. Non-Hodgkin's lymphoma is usually treated with [[chemotherapy]], [[radiation therapy]], or a combination of these treatments. In some cases, [[bone marrow transplantation]], biological therapies, or surgery may be options. For indolent lymphomas, the doctor may decide to wait until the disease causes symptoms before starting treatment. Often, this approach is called "watchful waiting."
==Medical Therapy==
*The optimal therapy for non-Hodgkin lymphoma depends on:<ref name="pmid28332735">{{cite journal| author=Intragumtornchai T, Bunworasate U, Wudhikarn K, Lekhakula A, Julamanee J, Chansung K et al.| title=Non-Hodgkin lymphoma in South East Asia: An analysis of the histopathology, clinical features, and survival from Thailand. | journal=Hematol Oncol | year= 2018 | volume= 36 | issue= 1 | pages= 28-36 | pmid=28332735 | doi=10.1002/hon.2392 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28332735  }} </ref><ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
:*Age
:*The type of non-Hodgkin lymphoma
:*The stage of non-Hodgkin lymphoma
:*Growth of the tumor, slow growing (indolent) or fast growing (aggressive)
:*Prognostic factors
:*Other medical conditions that may interfere with treatment
:*Previous treatment


Taking part in a clinical trial (research study) to evaluate promising new ways to treat non-Hodgkin's lymphoma is an important option for many people with this disease.
{| style="border: 0px; font-size: 90%; margin: 3px;" align="center"
 
|+ '''Medical therapy for non-Hodgkin lymphoma'''
==Medical Therapy==
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+ '''Medical therapy for Non-Hodgkin lymphoma'''
! style="background: #4479BA; color:#FFF;" | Stage
! style="background: #4479BA; color:#FFF;" | Stage
! style="background: #4479BA; color:#FFF;" | Watchful waiting  
! style="background: #4479BA; color:#FFF;" | Watchful waiting  
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! style="background: #4479BA; color:#FFF;" | Stem cell transplant
! style="background: #4479BA; color:#FFF;" | Stem cell transplant
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" colspan=6 | '''Indolent Lymphoma'''
| colspan="6" style="padding: 5px 5px; background: #DCDCDC;" | '''Indolent Lymphoma'''
|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Limited stage  
| style="padding: 5px 5px; background: #F5F5F5;" | Limited stage  
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*External beam radiation therapy is used most often
*External beam radiation therapy is used most often
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*May be offered along with chemotherapy<BR>
*May be offered along with chemotherapy  
*Rituximab is used most often<BR>
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ---------
*Only used for B-cell lymphomas
| style="padding: 5px 5px; background: #F5F5F5;" | ---------
|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Advanced stage  
| style="padding: 5px 5px; background: #F5F5F5;" | Advanced stage  
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| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
* May be offered
* May be offered
| style="padding: 5px 5px; background: #F5F5F5;" | ---------
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ---------
|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Recurrent  
| style="padding: 5px 5px; background: #F5F5F5;" | Recurrent  
| style="padding: 5px 5px; background: #F5F5F5;" | ---------
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ---------
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Single Drug Regimen:
*Single Drug Regimen:
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*May be offered
*May be offered
|-
|-
| style="padding: 5px 5px; background: #DCDCDC;" colspan=6 | '''Aggressive Lymphoma'''
| colspan="6" style="padding: 5px 5px; background: #DCDCDC;" | '''Aggressive Lymphoma'''
|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Limited stage  
| style="padding: 5px 5px; background: #F5F5F5;" | Limited stage  
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*Used if the lymphoma is localized in one area of the body
*Used if the lymphoma is localized in one area of the body
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Rituximab is used most often
*Used in combination with chemotherapy
*Used in combination with chemotherapy
| style="padding: 5px 5px; background: #F5F5F5;" | ----------
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ----------
|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Advanced stage  
| style="padding: 5px 5px; background: #F5F5F5;" | Advanced stage  
| style="padding: 5px 5px; background: #F5F5F5;" | ----------
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ----------
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
*Combination Drug Regimen:
*Combination Drug Regimen:
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:*Drug Regimen (Intrathecal or Intravenously):  
:*Drug Regimen (Intrathecal or Intravenously):  
::* [[Methotrexate]] {{or}} [[Cytarabine]]  
::* [[Methotrexate]] {{or}} [[Cytarabine]]  
:* To treat primary CNS lymphoma
:* As preventive for lymphomas that tend to spread to the CNS:
::*Lymphoma that involves paranasal sinuses or the testicles
::*Very aggressive lymphomas, such as [[Burkitt lymphoma]] or lymphoblastic lymphomas
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*May be offered
*May be offered
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|-
|-
| style="padding: 5px 5px; background: #F5F5F5;" | Recurrent  
| style="padding: 5px 5px; background: #F5F5F5;" | Recurrent  
| style="padding: 5px 5px; background: #F5F5F5;" | ---------
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ---------
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="padding: 5px 5px; background: #F5F5F5;" |
*Combination Drug Regimen:  
*Combination Drug Regimen:  
:*(DHAP) [[Dexamethasone]] {{and}} [[Cytarabine]] {{and}} [[Cisplatin]]  
:*(DHAP) [[Dexamethasone]] {{and}} [[Cytarabine]] {{and}} [[Cisplatin]]  
Line 114: Line 109:
:*(ICE) [[Ifosfamide]] {{and}} [[Cisplatin]] {{and}} [[Etoposide]]
:*(ICE) [[Ifosfamide]] {{and}} [[Cisplatin]] {{and}} [[Etoposide]]
:*(mini-BEAM) [[Carmustine]] {{and}} [[Etoposide]] {{and}} [[Cytarabine]] {{and}} [[Melphalan]]  
:*(mini-BEAM) [[Carmustine]] {{and}} [[Etoposide]] {{and}} [[Cytarabine]] {{and}} [[Melphalan]]  
| style="padding: 5px 5px; background: #F5F5F5;" |
| style="text-align: center; padding: 5px 5px; background: #F5F5F5;" | ---------
| style="padding: 5px 5px; background: #F5F5F5;" |  
*May be offered
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |  
| style="padding: 5px 5px; background: #F5F5F5;" |
*May be recommended
|-
|}
|}
===Chemotherapy and Radiation therapy===
===Watchful waiting===
[[Chemotherapy]] and [[radiation therapy]] are the most common treatments for non-Hodgkin's lymphoma, although bone marrow transplantation, biological therapies, or surgery are sometimes used. [[CHOP]], with [[rituximab]] added in certain circumstances, is the most commonly used combination of chemotherapy.
* May be a treatment option for some people with asymptomatic lymphomas and patients with slow-growing (indolent) non-Hodgkin lymphoma (NHL) who are otherwise healthy.<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
* Patients have regular checkups and follow-up with their doctor during this time.
* Treatment is given when the signs and symptoms of the lymphoma appear or change or the lymphoma looks like it is progressing.


[[Rituximab]] is an antibody-based therapy. Zevalin and Bexxar are government-approved options, requiring a Nuclear Medicine facility, but only two shots 1 week apart. There is mounting evidence that more patients have long-term remission if they use radioimmunotherapy first.
===Chemotherapy===
* Chemotherapy may be used:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
:* As the primary treatment, with or without [[radiation therapy]], to destroy cancer cells
::* Alone or along with biological therapy or radiation therapy, depending on the type and stage of non-Hodgkin lymphoma
::* Early stage, slow-growing (indolent) lymphomas may be treated with radiation therapy by itself or with chemotherapy or biological therapy, if the person has symptoms
::* Aggressive lymphomas are usually treated immediately with combination chemotherapy and biological therapy with or without radiation therapy. This treatment offers the best chance of success.
:* In people with a lymphoma that tends to spread to the brain and spinal cord.
:* In combination with biological therapy or radiation therapy to treat recurrent or relapsed lymphoma.
:* To relieve pain or to control the symptoms of advanced non-Hodgkin lymphoma.


Radiation therapy (also called radiotherapy) is the use of high-energy rays to kill cancer cells. Treatment with radiation may be given alone or with chemotherapy. Radiation therapy is local treatment; it affects cancer cells only in the treated area. Radiation therapy for Non Hodgkin's lymphoma comes from a machine that aims the high-energy rays at a specific area of the body. There is no radioactivity in the body when the treatment is over.
====CNS Prophylaxis====
:* To treat primary CNS lymphoma
:* As preventive for lymphomas that tend to spread to the CNS:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
::*Lymphoma that involves paranasal sinuses or the testicles
::*Very aggressive lymphomas, such as [[Burkitt lymphoma]] or lymphoblastic lymphomas


Sometimes patients are given chemotherapy and/or radiation therapy to kill undetected cancer cells that may be present in the central nervous system (CNS). In this treatment, called central nervous system prophylaxis, the doctor injects anticancer drugs directly into the cerebrospinal fluid.
===Radiation therapy===
Radiation may be used for non-Hodgkin lymphoma:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
:* As the main treatment for early stage (stage I or sometimes stage II) indolent non-Hodgkin lymphoma
::* Radiation therapy may be used when non-Hodgkin lymphoma is in 1 or 2 lymph node areas in the same part of the body
::* Early stage non-Hodgkin lymphoma often responds very well to radiation therapy
:* With chemotherapy to destroy lymphoma cells
::* Radiation therapy is often given with chemotherapy, either after or along with chemotherapy, to help destroy lymphoma cells and to reduce the risk of the cancer recurring
::* Radiation therapy to certain areas is usually combined with chemotherapy to treat aggressive lymphomas or for large tumors
:* To relieve pain or to control the symptoms of advanced lymphoma (palliative radiation therapy)
::* Radiation can be used to shrink tumors that are pressing on or spreading into other organs or structures
::* It can also be used to shrink enlarged [[lymph nodes]] and relieve symptoms caused by tumors
 
====External beam radiation therapy====
* Radiation therapy treatment is usually given each day for 5 days a week.
* The dose and schedule for the radiation therapy is determined by:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
:* The type of non-Hodgkin lymphoma
:* The extent of the disease
:* Whether the treatment is being given to cure the lymphoma or relieve symptoms.
 
====Radiation fields====
* Radiation treatments are given to different areas of the body when treating non-Hodgkin lymphoma. The radiation field is the part of the body that receives the radiation. Some of the fields where radiation is given for treating lymphoma are:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
* Involved field – most commonly used
:* Radiation is given to only 1 or a few lymph node areas known to contain lymphoma and is used for localized, early stage non-Hodgkin lymphoma. Involved field radiation therapy is also called IFRT. When radiation is given to a larger area to cover nearby or the next level of lymph node sites, this may be called extended field radiation therapy (EFRT).
* Mantle field
:* Radiation is given to the lymph nodes in the neck, chest, and underarms
* Upper abdominal field
:* Radiation is given to lymph nodes around the [[heart]] and [[aorta]] (para-aortic area) and possibly the [[spleen]] (unless it has been removed)
* Pelvic field
:* Radiation is given to lymph nodes in the [[pelvis]] and [[groin]]
:* A large amount of [[bone marrow]] is also radiated because the hip bones, which contain the most bone marrow, are in this field
* Inverted (upside down) Y field
:* Radiation is given to lymph nodes in the upper [[abdominal]] and [[pelvic]] fields


===Hematopoietic stem cell transplantation===
===Hematopoietic stem cell transplantation===
* Stem cell transplants may be considered for people with non-Hodgkin lymphoma in the following cases:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
:* To treat people with high-grade or aggressive non-Hodgkin lymphoma that has recurred or relapsed, depending on the type of lymphoma.
:* High-dose chemotherapy and a stem cell transplant may be useful, especially if the lymphoma was sensitive or responded to chemotherapy in the past.
:* Used in some cases when the person's lymphoma is not responding to other treatments or standard treatment has failed to work.
:* Occasionally considered to treat people with non-Hodgkin lymphoma who are in remission, but have a high risk of the lymphoma recurring.


[[Hematopoietic stem cell transplantation]] (HSCT), or [[Bone marrow transplantation]] (BMT) may also be a treatment option, especially for patients whose non-Hodgkin's lymphoma has recurred (come back). BMT provides the patient with healthy stem cells (very immature cells, found in the marrow, that produce blood cells), the function of which is to replace white blood cells that are damaged or destroyed by treatment with very high doses of chemotherapy and/or radiation therapy. The healthy bone marrow may come from a donor, or it may be "autologous" (marrow that was removed from the patient, stored, and then given back to the person following the high-dose treatment). Autologous transplants are preferred, as the recipient is less likely to reject the cells, the origins of which were the same entity. However, in order for an autologous transplant to be performed, certain physiological conditions must be optimal within the patient. If these conditions are not present, transplanted stem cells can come from other donors. Until the transplanted bone marrow begins to produce enough white blood cells, patients have to be carefully protected from infection due to the virtual elimination of the auto-immune system resulting from the high-intensity treatment. Without the introduction of the stem cells following the high dose treatment, the patient will not survive as the body will be unable to produce infection-fighting white blood cells. Patients usually stay in the hospital for several weeks and will be monitored for transplant rejection and overall health.
===Immunotherapy===
Biological therapy (also called [[immunotherapy]]) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen the side effects that can be caused by some cancer treatments. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. This approach is under close investigation. Biological therapy is sometimes also called biological response modifier therapy.
* Biological therapy may be used:<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
:* To treat advanced indolent non-Hodgkin lymphoma or aggressive non-Hodgkin lymphoma.
:* To treat recurrent or relapsed non-Hodgkin lymphoma.
:* In certain cases when chemotherapy no longer seems to be working.
:* To treat B-cell lymphomas.


===Immunotherapy===
* The most common biological therapy drugs used to treat non-Hodgkin lymphoma are:
:* [[Rituximab]]
:* [[Ibritumomab]]
:* [[Alemtuzumab]]
:* Interferon alfa


Biological therapy (also called [[immunotherapy]]) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen the side effects that can be caused by some cancer treatments. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. This approach is under close investigation. Biological therapy is sometimes also called biological response modifier therapy.
===Chimeric antigen receptor T (CAR-T) cell therapy===
*Chimeric antigen receptor T (CAR-T) cell therapy has recently been approved by the Food and Drug Administration for the treatment of non-Hodgkin lymphoma (specifically diffuse large B cell lymphoma) in the second- or third-line settings.<ref name="pmid28395545">{{cite journal| author=Jiang M, Bennani NN, Feldman AL| title=Lymphoma classification update: B-cell non-Hodgkin lymphomas. | journal=Expert Rev Hematol | year= 2017 | volume= 10 | issue= 5 | pages= 405-415 | pmid=28395545 | doi=10.1080/17474086.2017.1318053 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28395545  }} </ref>
*This form of therapy involves the engineering of a patient's own T lymphocytes to create genetically engineered cells that have anti-tumor immune responses.
*The process of CAR-T construction involves first performing leukapheresis to collect peripheral blood mononuclear cells, which contain the T cell population.
*The T cells are stimulated to proliferated via treatment with interleukin-2 (IL-2) or anti-CD3 agonist antibody.
*A lentivirus or retrovirus is transfected into the T cells, and this lentivirus contains the DNA sequence that encodes for the CAR gene.
*The final CAR-T cell product is usually composed of 3 components: a single-chain variable fragment, a transmembrane domain, and an intracellular signal transduction domain.  
*This structure allows for antigen recognition that parallels B lymphocyte activity and effector function that parallels T lymphocyte activity, hence the name "chimeric."
*CAR-T cells are a combination of T cells and antibodies and are thus sometimes known as "T-bodies."
*In non-Hodgkin lymphoma, the specific tumor antigen against which CAR-T cells are engineered is CD19, which is a B cell marker.
*The current FDA-approved products are tisagenleclucel and axicabtagene ciloleucel.


===Measuring response to treatment===
===Measuring response to treatment===
 
After treatment for non-Hodgkin's lymphoma, the response is classified as follows:<ref name="pmid28378140">{{cite journal| author=Thacker N, Bakhshi S, Chinnaswamy G, Vora T, Prasad M, Bansal D et al.| title=Management of Non-Hodgkin Lymphoma: ICMR Consensus Document. | journal=Indian J Pediatr | year= 2017 | volume= 84 | issue= 5 | pages= 382-392 | pmid=28378140 | doi=10.1007/s12098-017-2318-0 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28378140  }} </ref>
After treatment for non-Hodgkin's lymphoma, the response is classified as follows:
:*''Complete Response (CR)''. This indicates the disappearance of all detectable disease.
:*''Complete Response (CR)''. This indicates the disappearance of all detectable disease.
:*''Partial Response (PR)''. A reduction in the bulk of disease by at least 50%, but with some remaining disease.
:*''Partial Response (PR)''. A reduction in the bulk of disease by at least 50%, but with some remaining disease.
:*''Stable Disease''. Less than a partial remission, but no progression of disease and no new sites of disease.
:*''Stable Disease''. Less than a partial remission, but no progression of disease and no new sites of disease.
:*''Progressive Disease''. Growth in bulk of disease by >50%, or the appearance of new sites of disease.
:*''Progressive Disease''. Growth in bulk of disease by >50%, or the appearance of new sites of disease.
*If a complete remission is achieved, the patient is watched closely for any evidence of recurrent disease. Standard guidelines dictate that a patient be monitored for relapse every three months in the first year following a complete remission, every six months in the second year, and finally once annually in the third and later years.
*Diffuse large b-cell lymphoma is the most common type of lymphoma that is considered curable.
*Currently, if a patient maintains a complete remission for 3 years, the patient is considered cured.
*Generally most relapses of [[diffuse large b-cell lymphoma]] occur within the first year after a complete remission is obtained.
*Recurences after 3 years are rare but they do occur.
*The effect of Rituximab on relapse rates for diffuse large b-cell lymphoma is still largely unknown, though initial relapse rates since 2003 have been much lower than expected.
*Patients with [[follicular lymphoma]] are generally not considered cured. Instead, they are categorized as in ongoing complete remission. Relapses occur steadily over time. Relapse rates are estimated to be 33%, 66%, and 100% for follicular lymphoma's Grades I, II, and III respectively.
*Research has indicated that relapse rates can be lowered on patients with follicular lymphoma by giving supplemental radiation therapy, however, it is known that this additional therapy increases the chances of a second malignancy of unknown type later in life.
*If the response to treatment falls short of a complete response, more treatment may be administered (using a different [[chemotherapy]] regimen), or watchful waiting may be utilized, depending on the goals of treatment.


If a complete remission is achieved, the patient is watched closely for any evidence of recurrent disease. Standard guidelines dictate that a patient be monitored for relapse every three months in the first year following a complete remission, every six months in the second year, and finally once annually in the third and later years. Diffuse large b-cell lymphoma is the most common type of lymphoma that is considered curable. Currently, if a patient maintains a complete remission for 3 years, the patient is considered cured. Generally most relapses of diffuse large b-cell lymphoma occur within the first year after a complete remission is obtained. Reoccurences after 3 years are rare but they do occur. The effect of Rituximab on relapse rates for diffuse large b-cell lymphoma is still largely unknown, though initial relapse rates since 2003 have been much lower than expected.
Patients with follicular lymphoma are generally not considered cured. Instead, they are categorized as in ongoing complete remission. Relapses occur steadily over time. Relapse rates are estimated to be 33%, 66%, and 100% for follicular lymphoma's Grades I, II, and III respectively.
Research has indicated that relapse rates can be lowered on patients with follicular lymphoma by giving supplemental radiation therapy, however, it is known that this additional therapy increases the chances of a second malignancy of unknown type later in life.
If the response to treatment falls short of a complete response, more treatment may be administered (using a different[[chemotherapy]] regimen), or watchful waiting may be utilized, depending on the goals of treatment.
===Nutrition during treatment===
Eating well during cancer treatment means getting enough [[food energy]] and [[protein]] to help prevent weight loss and regain strength. Good nutrition often helps people feel better and have more energy.
Some people with cancer find it hard to eat a balanced diet because they may lose their appetite. In addition, common side effects of treatment, such as nausea, vomiting, or mouth sores, can make eating difficult. Often, foods may taste or smell different. Also, people being treated for cancer may not feel like eating when they are uncomfortable or tired.
Doctors, nurses, and dietitians can offer advice on how to get enough food energy and protein during cancer treatment. Patients and their families also may want to read the [[National Cancer Institute]] (USA) booklet ''Eating Hints for Cancer Patients'', which contains many useful suggestions.<ref> {{cite web|url=http://www.cancer.gov/cancertopics/eatinghints |title=Eating Hints for Cancer Patients: Before, During, and After Treatment |accessdate=2007-07-15 |publisher=National Cancer Institute }}</ref>
== Followup care ==
People who have had non-Hodgkin's lymphoma should have regular followup examinations after their treatment is over. Followup care is an important part of the overall treatment plan, and people should not hesitate to discuss it with their health care provider. Regular followup care ensures that patients are carefully monitored, any changes in health are discussed, and new or recurrent cancer can be detected and treated as soon as possible. Between followup appointments, people who have had Non Hodgkin's lymphoma should report any health problems as soon as they appear.


==References==
==References==
{{reflist|2}}
{{reflist|2}}


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Latest revision as of 21:43, 20 January 2019

Non-Hodgkin lymphoma Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Preeti Singh, M.B.B.S.[2]; Sowminya Arikapudi, M.B,B.S. [3]

Overview

The predominant therapy for non-Hodgkin lymphoma is chemotherapy. Adjunctive radiation, immunotherapy, and stem cell transplantation may be required.

Medical Therapy

  • The optimal therapy for non-Hodgkin lymphoma depends on:[1][2]
  • Age
  • The type of non-Hodgkin lymphoma
  • The stage of non-Hodgkin lymphoma
  • Growth of the tumor, slow growing (indolent) or fast growing (aggressive)
  • Prognostic factors
  • Other medical conditions that may interfere with treatment
  • Previous treatment
Medical therapy for non-Hodgkin lymphoma
Stage Watchful waiting Chemotherapy Radiotherapy Biological therapy Stem cell transplant
Indolent Lymphoma
Limited stage
  • Offered to patients who do not have symptoms
  • Offered if patients cannot have radiation therapy
  • If lymphoma is causing symptoms
  • External beam radiation therapy is used most often
  • May be offered along with chemotherapy
---------
Advanced stage
  • Offered to patients who do not have symptoms
  • Offered to patients who have symptoms
  • Single Drug Regimen:
  • Combination Drug Regimen:
  • May also be given to specific areas to control symptoms
  • May be offered
---------
Recurrent ---------
  • Single Drug Regimen:
  • Combination Drug Regimen:
  • May be given to relieve pain or to control the symptoms
  • May be offered
  • May be offered
Aggressive Lymphoma
Limited stage ----------
  • Chemotherapy is usually the main treatment
  • Combination Drug Regimen:
  • Radiation therapy is usually given after chemotherapy
  • Used if the lymphoma is localized in one area of the body
  • Used in combination with chemotherapy
----------
Advanced stage ----------
  • Combination Drug Regimen:
  • CNS Prophylaxis:
  • Drug Regimen (Intrathecal or Intravenously):
  • May be offered
  • May be offered
  • May be considered
Recurrent ---------
  • Combination Drug Regimen:
---------
  • May be offered
  • May be recommended

Watchful waiting

  • May be a treatment option for some people with asymptomatic lymphomas and patients with slow-growing (indolent) non-Hodgkin lymphoma (NHL) who are otherwise healthy.[2]
  • Patients have regular checkups and follow-up with their doctor during this time.
  • Treatment is given when the signs and symptoms of the lymphoma appear or change or the lymphoma looks like it is progressing.

Chemotherapy

  • Chemotherapy may be used:[2]
  • Alone or along with biological therapy or radiation therapy, depending on the type and stage of non-Hodgkin lymphoma
  • Early stage, slow-growing (indolent) lymphomas may be treated with radiation therapy by itself or with chemotherapy or biological therapy, if the person has symptoms
  • Aggressive lymphomas are usually treated immediately with combination chemotherapy and biological therapy with or without radiation therapy. This treatment offers the best chance of success.
  • In people with a lymphoma that tends to spread to the brain and spinal cord.
  • In combination with biological therapy or radiation therapy to treat recurrent or relapsed lymphoma.
  • To relieve pain or to control the symptoms of advanced non-Hodgkin lymphoma.

CNS Prophylaxis

  • To treat primary CNS lymphoma
  • As preventive for lymphomas that tend to spread to the CNS:[2]
  • Lymphoma that involves paranasal sinuses or the testicles
  • Very aggressive lymphomas, such as Burkitt lymphoma or lymphoblastic lymphomas

Radiation therapy

Radiation may be used for non-Hodgkin lymphoma:[2]

  • As the main treatment for early stage (stage I or sometimes stage II) indolent non-Hodgkin lymphoma
  • Radiation therapy may be used when non-Hodgkin lymphoma is in 1 or 2 lymph node areas in the same part of the body
  • Early stage non-Hodgkin lymphoma often responds very well to radiation therapy
  • With chemotherapy to destroy lymphoma cells
  • Radiation therapy is often given with chemotherapy, either after or along with chemotherapy, to help destroy lymphoma cells and to reduce the risk of the cancer recurring
  • Radiation therapy to certain areas is usually combined with chemotherapy to treat aggressive lymphomas or for large tumors
  • To relieve pain or to control the symptoms of advanced lymphoma (palliative radiation therapy)
  • Radiation can be used to shrink tumors that are pressing on or spreading into other organs or structures
  • It can also be used to shrink enlarged lymph nodes and relieve symptoms caused by tumors

External beam radiation therapy

  • Radiation therapy treatment is usually given each day for 5 days a week.
  • The dose and schedule for the radiation therapy is determined by:[2]
  • The type of non-Hodgkin lymphoma
  • The extent of the disease
  • Whether the treatment is being given to cure the lymphoma or relieve symptoms.

Radiation fields

  • Radiation treatments are given to different areas of the body when treating non-Hodgkin lymphoma. The radiation field is the part of the body that receives the radiation. Some of the fields where radiation is given for treating lymphoma are:[2]
  • Involved field – most commonly used
  • Radiation is given to only 1 or a few lymph node areas known to contain lymphoma and is used for localized, early stage non-Hodgkin lymphoma. Involved field radiation therapy is also called IFRT. When radiation is given to a larger area to cover nearby or the next level of lymph node sites, this may be called extended field radiation therapy (EFRT).
  • Mantle field
  • Radiation is given to the lymph nodes in the neck, chest, and underarms
  • Upper abdominal field
  • Radiation is given to lymph nodes around the heart and aorta (para-aortic area) and possibly the spleen (unless it has been removed)
  • Pelvic field
  • Radiation is given to lymph nodes in the pelvis and groin
  • A large amount of bone marrow is also radiated because the hip bones, which contain the most bone marrow, are in this field
  • Inverted (upside down) Y field

Hematopoietic stem cell transplantation

  • Stem cell transplants may be considered for people with non-Hodgkin lymphoma in the following cases:[2]
  • To treat people with high-grade or aggressive non-Hodgkin lymphoma that has recurred or relapsed, depending on the type of lymphoma.
  • High-dose chemotherapy and a stem cell transplant may be useful, especially if the lymphoma was sensitive or responded to chemotherapy in the past.
  • Used in some cases when the person's lymphoma is not responding to other treatments or standard treatment has failed to work.
  • Occasionally considered to treat people with non-Hodgkin lymphoma who are in remission, but have a high risk of the lymphoma recurring.

Immunotherapy

Biological therapy (also called immunotherapy) is a form of treatment that uses the body's immune system, either directly or indirectly, to fight cancer or to lessen the side effects that can be caused by some cancer treatments. It uses materials made by the body or made in a laboratory to boost, direct, or restore the body's natural defenses against disease. This approach is under close investigation. Biological therapy is sometimes also called biological response modifier therapy.

  • Biological therapy may be used:[2]
  • To treat advanced indolent non-Hodgkin lymphoma or aggressive non-Hodgkin lymphoma.
  • To treat recurrent or relapsed non-Hodgkin lymphoma.
  • In certain cases when chemotherapy no longer seems to be working.
  • To treat B-cell lymphomas.
  • The most common biological therapy drugs used to treat non-Hodgkin lymphoma are:

Chimeric antigen receptor T (CAR-T) cell therapy

  • Chimeric antigen receptor T (CAR-T) cell therapy has recently been approved by the Food and Drug Administration for the treatment of non-Hodgkin lymphoma (specifically diffuse large B cell lymphoma) in the second- or third-line settings.[2]
  • This form of therapy involves the engineering of a patient's own T lymphocytes to create genetically engineered cells that have anti-tumor immune responses.
  • The process of CAR-T construction involves first performing leukapheresis to collect peripheral blood mononuclear cells, which contain the T cell population.
  • The T cells are stimulated to proliferated via treatment with interleukin-2 (IL-2) or anti-CD3 agonist antibody.
  • A lentivirus or retrovirus is transfected into the T cells, and this lentivirus contains the DNA sequence that encodes for the CAR gene.
  • The final CAR-T cell product is usually composed of 3 components: a single-chain variable fragment, a transmembrane domain, and an intracellular signal transduction domain.
  • This structure allows for antigen recognition that parallels B lymphocyte activity and effector function that parallels T lymphocyte activity, hence the name "chimeric."
  • CAR-T cells are a combination of T cells and antibodies and are thus sometimes known as "T-bodies."
  • In non-Hodgkin lymphoma, the specific tumor antigen against which CAR-T cells are engineered is CD19, which is a B cell marker.
  • The current FDA-approved products are tisagenleclucel and axicabtagene ciloleucel.

Measuring response to treatment

After treatment for non-Hodgkin's lymphoma, the response is classified as follows:[3]

  • Complete Response (CR). This indicates the disappearance of all detectable disease.
  • Partial Response (PR). A reduction in the bulk of disease by at least 50%, but with some remaining disease.
  • Stable Disease. Less than a partial remission, but no progression of disease and no new sites of disease.
  • Progressive Disease. Growth in bulk of disease by >50%, or the appearance of new sites of disease.
  • If a complete remission is achieved, the patient is watched closely for any evidence of recurrent disease. Standard guidelines dictate that a patient be monitored for relapse every three months in the first year following a complete remission, every six months in the second year, and finally once annually in the third and later years.
  • Diffuse large b-cell lymphoma is the most common type of lymphoma that is considered curable.
  • Currently, if a patient maintains a complete remission for 3 years, the patient is considered cured.
  • Generally most relapses of diffuse large b-cell lymphoma occur within the first year after a complete remission is obtained.
  • Recurences after 3 years are rare but they do occur.
  • The effect of Rituximab on relapse rates for diffuse large b-cell lymphoma is still largely unknown, though initial relapse rates since 2003 have been much lower than expected.
  • Patients with follicular lymphoma are generally not considered cured. Instead, they are categorized as in ongoing complete remission. Relapses occur steadily over time. Relapse rates are estimated to be 33%, 66%, and 100% for follicular lymphoma's Grades I, II, and III respectively.
  • Research has indicated that relapse rates can be lowered on patients with follicular lymphoma by giving supplemental radiation therapy, however, it is known that this additional therapy increases the chances of a second malignancy of unknown type later in life.
  • If the response to treatment falls short of a complete response, more treatment may be administered (using a different chemotherapy regimen), or watchful waiting may be utilized, depending on the goals of treatment.


References

  1. Intragumtornchai T, Bunworasate U, Wudhikarn K, Lekhakula A, Julamanee J, Chansung K; et al. (2018). "Non-Hodgkin lymphoma in South East Asia: An analysis of the histopathology, clinical features, and survival from Thailand". Hematol Oncol. 36 (1): 28–36. doi:10.1002/hon.2392. PMID 28332735.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Jiang M, Bennani NN, Feldman AL (2017). "Lymphoma classification update: B-cell non-Hodgkin lymphomas". Expert Rev Hematol. 10 (5): 405–415. doi:10.1080/17474086.2017.1318053. PMID 28395545.
  3. Thacker N, Bakhshi S, Chinnaswamy G, Vora T, Prasad M, Bansal D; et al. (2017). "Management of Non-Hodgkin Lymphoma: ICMR Consensus Document". Indian J Pediatr. 84 (5): 382–392. doi:10.1007/s12098-017-2318-0. PMID 28378140.