Diffuse large B cell lymphoma medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Treatment
Chemotherapy
- Standard treatment is CHOP-R,[1] also referred to as R-CHOP, an improved form of CHOP with the addition of rituximab (Rituxan),[2] which has increased the rates of complete responses for Diffuse large B cell lymphoma patients, particularly elderly patients.
- R-CHOP is a combination of one monoclonal antibody, 3 chemotherapy drugs, and one steroid:
- rituximab (Rituxan),
- cyclophosphamide (Cytoxan)
- doxorubicin (Hydroxydaunorubicin)
- vincristine (Oncovin)
- prednisone.[3]
- Chemotherapy is administered intravenously and is most effective when it is administered multiple times over a period of months (e.g. every 3 weeks, over 6 to 8 cycles). The number of cycles of chemotherapy given depends on the stage of the disease.
- Patients with limited stage disease receive 3 cycles of therapy
- Patients with extensive disease 6 or 8 cycles of chemotherapy. In the United States, 6 cycles is the preferred approach rather than 8 cycles.
A new development is obtaining a PET scan after completing two cycles of chemotherapy, to help make further decisions after chemotherapy.
Older people
Older people are not able to tolerate therapy well. Multiple lower intensity regimens have been attempted in this age group.[4]
People receiving chemotherapy commonly have a (Peripherally inserted central catheter) in their arm near the elbow or a surgically implanted medical port.
Radiation therapy
Radiation is often added in the treatment. It is used commonly after completing 3 cycles of treatment in limited stage disease. In extensive disease, radiation can be used at the end of the treatment, after 6-8 cycles of chemotherapy, to areas of bulky involvement. Radiation therapy alone is not an effective treatment for this disease.
Drug Regimen
Chemotherapy is based on staging of the disease[5]
- 1 Non-bulky(<10cm) stage I or II disease
- 2 Bulky disease(>10cm)
- 3 Advanced stage disease
- 3.1 Preferred regimen: R-CHOP (category 1) OR comparable anthracycline-based regimens
- 3.2 Preferred regimen: RT to bulky sites (category 2B)
- 3.3 Alternative regimen: Dose-adjusted EPOCH(EtoposideAND PrednisoneAND VincristineAND CyclophosphamideAND Doxorubicin) PLUS Rituximab (category 2B) ORDose dense R-CHOP-14 (category 3)
Special Conditions
- 1 Frail patients or with poor left ventricular function
- 1.1 Preferred regimen: R-miniCHOP (frial patients >80 years)
- 1.2 Preferred regimen: CEPP (Cyclophosphamide AND Etoposide AND Prednisone AND Procarbazine) PLUS Rituximab
- 1.3 Preferred regimen: CDOP (Cyclophosphamide AND Liposomal doxorubicin AND Vincristine AND Prednisone) PLUS Rituximab
- 1.4 Preferred regimen: CNOP (Cyclophosphamide AND Mitoxantrone AND Vincristine AND Prednisone) PLUS Rituximab
- 1.5 Preferred regimen: Dose adjusted EPOCH (Etoposide AND Prednisone AND Vincristine AND Cyclophosphamide AND Doxorubicin) PLUS Rituximab
- 1.6 Preferred regimen: CEOP (Cyclophosphamide AND Etoposide AND Vincristine AND Prednisone) PLUS Rituximab
- 2 Bulky disease or Impaired renal function
- 2.1 Monitoring and prophylaxis for tumor lysis syndrome
- 3 CNS relapse with involvement of the paranasal sinus, testes, bone marrow with large cell lymphoma or 2 or more extranodal sites with elevated LDH
- 3.1 Preferred regimen: 4 to 8 doses of intrathecal Methotrexate AND/OR Cytarabine
- 3.2 Preferred regimen: (3-3.5 g/m2)systemic Methotrexate
- 4 Concurrent presentation of parenchymal involvement of CNS
- 4.1 Preferred regimen: (3-8 g/m2)systemic Methotrexate
- 5 Concurrent Leptomeningeal disease
- 5.1 Preferred regimen: 4 to 8 doses of intrathecal Methotrexate AND/OR Liposomal cytarabine AND/OR (3-3.5 g/m2)systemic Methotrexate
- 6 High dose methotrexate
- 6.1 Pre-treated with hydration and alkalinization.
- 6.2 Leucovorin rescue after 24 hours of infusion.
- 6.3 Monitor renal and hepatic function.
- 6.4 Confirm full recovery of blood counts before starting next cycle of R-CHOP.
References
- ↑ http://cornell-lymphoma.com/tag/dlbcl/[full citation needed]
- ↑ Sehn, L. H.; Berry, B.; Chhanabhai, M.; Fitzgerald, C.; Gill, K.; Hoskins, P.; Klasa, R.; Savage, K. J.; Shenkier, T.; Sutherland, J.; Gascoyne, R. D.; Connors, J. M. (2007). "The revised International Prognostic Index (R-IPI) is a better predictor of outcome than the standard IPI for patients with diffuse large B-cell lymphoma treated with R-CHOP". Blood. 109 (5): 1857–61. doi:10.1182/blood-2006-08-038257. PMID 17105812.
- ↑ Farber, Charles M.; Axelrod, Randy C. (2011). "The Clinical and Economic Value of Rituximab for the Treatment of Hematologic Malignancies". Contemporary Oncology. 3 (1).
- ↑ Zaja, F.; Tomadini, V.; Zaccaria, A.; Lenoci, M.; Battista, M.; Molinari, A. L.; Fabbri, A.; Battista, R.; Cabras, M. G.; Gallamini, A.; Fanin, R. (2006). "CHOP-rituximab with pegylated liposomal doxorubicin for the treatment of elderly patients with diffuse large B-cell lymphoma". Leukemia & Lymphoma. 47 (10): 2174–80. doi:10.1080/10428190600799946. PMID 17071492.
- ↑ "Non-Hodgkin's Lymphomas (NCCN.org)" (PDF).