Canterbury DHB

Context

Management of Non-Trial Patients

There are many guidelines and expert reviews for management and treatment of non-Hodgkin’s lymphoma which often describe approaches using newer drugs that may not necessarily be available or funded in NZ.

For expert reviews, see:

In This Section

Assessment of Response

CNS Directed Therapy

Treatment of Lymphoma

Chemotherapy for Diffuse Large B-cell NHL

Primary CNS Lymphoma

Salvage Protocols

Chemotherapy Schedules for Burkitt's and Burkitt-like tumours

Chemotherapy Schedules for Indolent NHL

Management of elderly patients with lymphoma

Assessment of Response

See Cheson, B. D., et al. (2014). "Recommendations for Initial Evaluation, Staging, and Response Assessment of Hodgkin and Non-Hodgkin Lymphoma: The Lugano Classification." Journal of Clinical Oncology 32(27): 3059-3067 and Cheson, B.D., Ansell, S. (2016). "Refinement of the Lugano Classification lymphoma response criteria in the era of immunomodulatory therapy." Blood 128: 2489.

Re-assessment is often performed after 3-4 cycles of therapy to confirm a response. All patients will be systematically re-evaluated to assess response 3-4 weeks following final chemotherapy administration.

Re-evaluation Investigations

  1. Full history and physical examination.
  2. FBC, biochemical profile, LDH level.
  3. Repeat CT of all sites found to be abnormal pre-chemotherapy.
  4. Bone marrow trephine + aspirate, if abnormal pre-chemotherapy.

PET and PET/CT

Positron emission tomography using 18F-fluorodeoxyglucose when combined with CT scanning can improve the detection of lymphoma and measure disease activity. It may be used for staging, early therapy response, and end of treatment evaluation. It is helpful in determining the nature of residual masses after therapy. PET/CT is available at Christchurch Radiology Group for the following DHB-Approved indications in lymphoma:

LY1

Staging of early stage non Hodgkin’s lymphoma to guide indication for radiation and appropriate treatment fields.

LY2

Staging of Hodgkin’s disease.

LY3

Re-staging of residual mass in Hodgkin’s and non Hodgkin’s lymphoma following definitive treatment.

LY4

Re-staging of Hodgkin’s lymphoma after 2-4 cycles of chemotherapy to inform management options for paediatric patients.

LY5

Assessment of response to salvage chemotherapy in patients who are candidates for stem cell transplantation.

Complete both sides of the PET/CT Imaging Request Form and give the form to Anne Quick, Clerical Supervisor (ext 80399).

Suggested Follow-Up

There is no standardised follow-up for patients who have completed therapy. This will depend on the:

In practice it is reasonable to follow patients 2-3 monthly for the first 6 months after treatment has finished, then less often, and to consider discharge after 3-5 years.

CNS Directed Therapy

Secondary CNS involvement occurs more commonly in high grade than low grade lymphoma. Relapse in the CNS may occur following complete remission and the prognosis is extremely poor. Risk factors for CNS involvement include:

There is no consensus about which patients should receive prophylactic CNS-directed therapy or which regime is the most effective. However, a valuable and practical approach is based on risk assessment and use of intravenous methotrexate after systemic chemotherapy (usually RCHOP) in high risk patients with DLBCL. See:

Here is the Christchurch Hospital algorithm for selecting which patients with DLBCL should receive CNS prophylaxis. It is based on the German NHL CNS study group international prognostic index.

Christchurch Hospital algorithm for selecting which patients with DLBCL should receive CNS prophylaxis

Christchurch Hospital algorithm for selecting which patients with DLBCL should receive CNS prophylaxis

Treatment of Lymphoma

It goes without saying that wherever possible patients should be offered treatment in any studies for which they may be eligible.

There are many very promising new drugs at an advanced stage of development for the treatment of all subtypes of lymphoma. In some cases these are licensed in NZ and more generally overseas. None is funded in NZ as of 2018. Patients may wish to purchase these drugs at their own expense.

Some treatment studies available in Christchurch may include some of these newer agents.

These drugs include:

All treatments below are available in NZ. Some require special authority (rituximab, bendamustine, vinorelbine, gemcitabine, GCSF, and pegfilgrastim) which may be limited to use in certain NHL or to particular stages of disease.

About this Canterbury DHB document (5949):

Document Owner:

Peter Ganly (see Who's Who)

Issue Date:

November 2018

Next Review:

November 2021

Keywords:

Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer

Topic Code: 5949