Non-Hodgkins Lymphoma
Staging system as per HD
IPSS for high grade lymphoma
Age60 2 or more RF’s gives <50% 5yr RFS
PS 0-1 PS2+
Normal LDH LDH elevated
Stage 1,2 Stage 3,4
Nodal disease Extranodal disease
Low grade lymphomas
Follicular, MALT, Lymphoplasmacytic, Splenic marginal zone, Mycosis
No treatments are curative. Treat on symptoms.
Stage 1,2 Low grade lymphoma
Excision and involved field radiotherapy. BNLI VIII trial of 24Gy in 12# vs 40Gy in
20#
No value in adjuvant chemotherapy
Stage 3,4 Low grade lymphoma
Observation
Chlorambucil 10mg daily 2 weeks on 2 weeks off, or 0.1mg/kg continuously
Relapse
Rechallenge with chlorambucil
Fludarabine 40mg/m2 oral 5 days every 4 weeks
Cyclophosphamide 50mg daily
CVP (Cyclophosphamide 1000mg/m2 d1, Vincristine 1.4mg/m2 d1 max 2mg,
Prednisolone 100mg daily 5 days) q21 days or q28 days in elderly
2 x 2Gy local irradiation
High grade lymphomas
Diffuse large B cell, Anaplastic Large cell, Most T cell types including enteropathy
assoc. Mantle Cell
Offer curative treatment
Stage 1,2 High Grade lymphoma
CHOP x 3 followed by IFRT 30-40Gy in 15-20 fractions (SWOG study showed
equivalence with 8 cycles of CHOP. Bulky disease, extranodal disease does better
with more chemo)
Young patients, give accelerated CHOP (2 weekly with GCSF) as per German study
Stage 3,4 High grade lymphoma
CHOP x 6-8 cycles or to CR+2 cycles. No other regime shown to be better
GELA study showed superiority of CHOP Rituximab vs CHOP in over 60’s
German accelerated CHOP with GCSF better in young patients
Elderly patients tolerate PMITCEBO better than CHOP. Get to see them more
regularly during treatment as well. Prednisolone taken continuously first 4 weeks,
then every other day next 4 weeks.
o Week 1 Mitoxantrone, Cyclophasphamide, Etoposide
o Week 2 Bleomycin, Vincristine
Relapsed high grade lymphoma
Bone marrow transplantation is treatment of choice in under 60. 25-40% will get long
term disease free period
Special sites
Paranasal and testicular lymphomas need CNS prophylaxis – 4-6 does of IT
methotrexate
Pregnancy : Use MRI & USS for staging. Usually aggressive lymphomas so can’t
nd rd
delay treatment. Doxorubicin based chemo safe in 2 3 trimester
st
Consider TOP if in 1 trimester
If indolent, consider waiting until term to treat
GI lymphomas arising in bowel wall at risk of perforation when treated. Best to admit
for first cycle of chemotherapy
Primary cerebral lymphoma
o Standard staging + LP and slit lamp exam (high incidence ocular
involvement), HIV test
o Under 60 and good PS, get CHOD-BVAM then whole brain RT 40Gy in 20#
o Under 60 and/or poor PS, get RT 20 in 5 or supportive treatment only