Treatment approaches for malignant lymphomas are complex. In this module, we examine treatment approaches for NHL only.
A treatment plan needs to be developed by a MDT in conjunction with the individual affected, who is informed of their options and the aims of treatment. The aims may be defined in terms of potentially curative treatment or palliative management plan. The effects of the disease and its management, the need for long-term follow up, and the potential for late complications of treatment need to be discussed.15
Treatment plans for NHL can include:7
- watch and wait
- systemic combined antineoplastic agent regimens with or without immunotherapy
- haematopoietic stem cell transplantation (HSCT).
Treatment approaches vary depending on the type and stage of NHL, the person's overall clinical presentation and their response to treatment. The principles associated with treating the different grades of NHL are outlined below.
Low grade lymphoma:6, 15
- the highest priority of treatment is to maximise the individual's overall survival, maintain quality of life and avoid treatment-related morbidity
- treatment recommendations are discussed using 'surrogate endpoints' including overall response rates, complete remission rates, and 'molecular' complete remission rates
- treatment options may include radiotherapy, antineoplastic agents, monoclonal antibody therapy, watch and wait approach and HSCT.
Aggressive (Intermediate) grade lymphoma:15
- the treatment intent, where feasible, is cure, as these lymphomas are very chemosensitive
- the main treatment modality is antineoplastic agents and monoclonal antibody therapy
- in some individuals radiation therapy provides additional benefit, particularly where there is bulky local disease
- surgery has little role in this disease, other than in diagnosis.
High grade lymphoma:15
- due to the complexities associated with the disease and its management, individuals with newly diagnosed high grade lymphoma should ideally be managed in specialist units experienced in treating these disorders
- treatment approaches involve intensive antineoplastic agent regimens and include central nervous system (CNS) prophylaxis
- radiotherapy has little role in this disease.
Access the NCCN Guidelines – Non-Hodgkin’s Lymphomas3(a free resource, but you must register and then click 'Remember me' to bypass the login page in future), and outline the current treatment options recommended for DLBCL.
Summarise the evidence for and against dose reduction of antineoplastic agents in the older person diagnosed with DLBCL.
Adjuvant treatment approaches for NHL
The application of immunotherapy, a therapy which boosts the immune system, in the management of NHL has focused on the use of Interferon. Typically used as a maintenance therapy, Interferon is used to treat low grade lymphomas in those who can tolerate it. The use of Interferon in Australia may be considered on an individual basis.15
Further use of immunotherapy in the treatment of NHL is under investigation with the implementation of clinical trials in which a vaccine derived from healthy B cells is administered.7
The addition of radioisotopes to anti-CD20 antibodies is also known as systemic targeted radiation or STAR. This therapy inflicts collateral damage to adjacent tumour cells as a result of the cytotoxicity of the beta particles emitted by the radionucleotide which is attached to the antibody.33 Normal tissues are also potentially damaged by the emissions of the radioisotope; thus, care is taken when determining appropriate radioisotopes to use in radioimmunotherapy.33
Two radioimmunotherapy agents used in the treatment of NHL are iodine 131 or tositumomab (Bexxar) and ibritumomabtiuxetan (Zevalin). The agents are administered as an outpatient usually one week apart. The most common and major toxicity associated with both agents is myelosuppression.7
A new class of drugs for the treatment of NHL is proteasome inhibitors. Proteasomes are responsible for maintaining protein concentrations in cells and are able to interrupt an abnormal accumulation of disease related proteins. Bortezomib (Velcade) has been reported as the most commonly used proteasome inhibitor.7
Haematopoietic stem cell transplantation
Options for transplantation in individuals with NHL vary according to sub-type and are only usually considered once standard therapy has failed.7 In Australia an allogeneic stem cell transplant is recommended as a treatment option for immunodeficiency associated lymphomas. However, its application in other sub-types is recommended as a last resort for those who have failed all other treatments and do not present with a high risk of transplant related complications.15
Outline the information and supportive care which would be provided to an individual receiving treatment with radioimmunotherapy as an outpatient.
Access a current text and / or research and summarise the role of proteasome inhibitors in the management of NHL.
Access a current text and / or research and summarise the role of haematopoietic stem cell transplantation in the management of NHL.
Arthur’s story 2: Arthur’s treatment
Access the following resources to respond to the activities below:
- NCCN Guidelines – Non-Hodgkin’s Lymphomas3
- NCCN Clinical practice guidelines for oncology - senior adult oncology32
Note: both NCCN resources are free to access, but you must register and then click 'Remember me' to bypass the login page in future.
Develop a care plan to address Arthur's information needs at this time.
Identify factors you would encourage Arthur to consider when making his decision about treatment.
Plan in detail how you would support Arthur in the process of making treatment decisions.
Identify issues the MDT may discuss to ensure Arthur receives the optimal approach to treatment.