Guidelines on Diagnosis and Treatment of Malignant Lymphomas

Prognostic Factors / Index:
i. Early stage disease (I – IIA)
ii.
Adverse factors:
Advanced stage disease (IIB – IV)
Adverse factors:
(International
Prognostic score)
Age > 50 years
ESR > 50 mm /hr or > 30 mm /hr
with B symptoms
Four or more separate nodal
sites involved
Mediastinial mass ratio > 1/3
Age > 45 years
Male sex
Stage IV
Haemoglobin < 10.5 g/dl
Albumin < 40 g/l
Lymphocytes < 0.6 x 10 9 /l or < 8%
White blood count > 15 x 10 9 /l
Potential Pitfalls
i. Failure to differentiate between NLPHL and CHL
ii. Confusion with DLBCL and its variants
iii. Incorrect stage
Treatment of nodular lymphocyte
predominant HL
The treatment of NLPHL is undergoing review. Where there is
stage I disease and no B symptoms or adverse clinical risk
factors, the patient may be treated with involved field radiation
therapy (IFRT) 30Gy or may be observed following nodal excision
in the absence of residual disease. Rituximab may be used as an
alternative or in addition to radiotherapy. Patients with extensive
or relapsed disease can be treated with Rituximab containing
CHOP or ABVD.
Treatment of classical HL
Early stage disease
Clinical stage IA or IIA
Treatment:
ABVD x 4 cycles and involved field radiation
therapy (IFRT) 20-30Gy
Or
ABVD x 6 cycles
The use of radiotherapy in stage I and II disease is associated
with a lower risk of relapse, and this has to be off set by
concerns about long term morbidity following radiotherapy.
Advanced Stage Disease
Clinical stages IIB to IV
Standard treatment is with ABVD x6-8 cycles or escalated
BEACOPP. A rational approach using the known prognostic value
of PET scanning after 2 courses of ABVD may be to intensify
treatment to escalated or dose-dense BEACOPP if the PET scan is
deemed positive at this stage. This approach is currently being
tested in the RATHL study sponsored by the British NCRN group.
Little consensus exists on the role of radiation in advanced
stage disease. Ideally all patients should be reviewed in an
MDT setting at the beginning and end of therapy to review the
indication for radiotherapy
Response Evaluation
Patients should have careful clinical evaluation with each cycle of
chemotherapy and treatment delays should be avoided. ABVD
can be safely administered on schedule in the presence of
moderate neutropenia without GCSF support
Response evaluation with repeat radiology of abnormal sites at
presentation is traditionally undertaken after four cycles of therapy,
however if F18DG-PET/CT scanning is used this evaluation is most
usefully carried out after two courses of chemotherapy
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