Guidelines on Diagnosis and Treatment of Malignant Lymphomas

Patients with primary refractory disease or partial response to
therapy will need to have treatment intensified. Switching to
BEACOPP-14 is recommended in patients with positive PET after
2 cycles of ABVD. If PET is negative after 4 cycles consolidate
with 2 further cycles of BEACOPP-14. If PET remains positive
salvage treatment followed by autologous stem cell transplantion
should be considered.
Follow-Up
Clinical:
History and physical examination every three months for one year,
every six months for three years, then yearly.
Laboratory:
FBC and biochemistry along with clinical evaluations for up to two
years. Thyroid function to be assessed at one year then yearly for
life in patients who have had neck or mediastinal irradiation.
Diagnostic imaging:
Chest radiographs, along with clinical evaluations up to two years.
Then as indicated. CT scan to define initial remission status and
then, if necessary, to monitor residual abnormalities if chest
radiograph does not suffice. PET scan is not needed at the end of
treatment if interim scan is negative.
Mammography or other suitable screening should be offered in a
structured fashion to young women given chest irradiation before
age 25 years.
Treatment at Relapse
Salvage chemotherapy (eg ICE) followed by autologous
transplant should be considered standard therapy for all patients
with an adequate performance status previously treated with
chemotherapy including those with late relapse. Early referral to a
centre with the capacity to deliver such therapy is mandatory.
Patients should be scheduled for harvest after 2 cycles of salvage
chemotherapy. A further course of salvage chemotherapy is then
administered prior to high dose chemotherapy and autologous
stem cell rescue.
Repeat CT scan post 2 cycles of salvage chemotherapy and PET
scan after third and final cycle. CT scan after second cycle is to
confirm responsive disease and PET scan after third cycle is to
confirm CR. Patients who are PET positive at this stage should be
considered for further salvage therapy with Gemcitabine based
treatment or allogeneic transplantation.
In patients unfit for transplant palliative chemotherapy and
radiotherapy can be administered as required. Rituximab may
be a useful adjunct in CD20 positive cases.
Selected References:
PET for response adapted in advanced Hodgkin’s Lymphoma
(RATHL) – NCRI
VEPEMB in elderly Hodgkin’s lymphoma patients. Results from
Intergruppo Italiano Linfomi (IIL) study. Levis,A et al. Annals of
Oncology 15: 123-128, 2004.
G-CSF is not necessary to maintain over 99% dose-intensity
with ABVD in treatment of Hodgkin Lymphoma: low toxicity and
excellent outcome in a 10-year analysis. Evens AM et al. British
Journal of Haematology 2007 137, 545-552.
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