Question: Dr. Chiragbhai, thank you for explaining in last part about Non Hodgkin’s Lymphoma importance of IHC in diagnosis and treatment, staging, and prognostic tools. We learnt a very important lesson that diagnosis of lymphoma is not sufficient, subtyping is important, for prognosis and some important treatment decisions. Now, can you tell us about the treatment options for NHL?
Answer: As there are many subtypes of NHL, treatments also differ. Broadly, one can classify as below:
- Low grade lymphomas – mostly non curative, but very slow to progress. Hence goal of treatment is to keep patient symptom free. Patients of follicular lymphoma, if asymptomatic, are not treated and just regularly monitored. Same is true for CLL. Some low grade lymphomas however are treated even if asymptomatic, as they have a good chance for cure, such as MALT lymphoma involving stomach, intestine, lung and other sites. Stomach MALT in very early stages are frequently associated with H. pylori infection. H. pylori treatment with antibiotic course is curative in many cases of stage I MALT lymphoma.
- Intermediate grade lymphomas: commonest subtype of NHL is DLBCL – diffuse large B cell lymphoma, and is treated with the most famous treatment for NHL i.e. CHOP chemotherapy regimen. CHOP includes cyclophosphamide, doxorubicin, vincristine, and prednisone. On an average, about 50% patients are cured with this regimen. These lymphomas progress over several weeks and are fatal if untreated. They mostly present with enlarged lymph nodes, and in many cases with fever, weight loss, and night sweats, the so called typical B symptoms. Mantle cell lymphoma is another lymphoma, but it overlaps low grade and intermediate grade.
Rituximab is a targeted therapy against CD 20 antigen on surface of many lymphomas. Addition of rituximab to CHOP and other regimens improves survival and cure rates substantially i.e. from 50% with CHOP alone to about 60-65% with added rituximab. Rituximab is not a chemotherapy, and by itself does not cause typical side effects of chemotherapy like hair loss, nausea, low blood counts, skin changes etc. It is associated with severe infusion reactions during first dose, in many cases, hence needs careful monitoring and a specific administration schedule to avoid serious outcome. Subsequent doses are generally well tolerated. For CD 20 positive lymphomas, addition of rituximab is a standard of care, and must be done if cost is not an issue. Drug cost of CHOP chemotherapy is about Rs 5,000 per cycle. Drug cost of rituximab is about additional Rs 30-50,000 per cycle (depending on the manufacturer). Thus cost becomes an important factor in decision making in India while choosing regimen.
- High grade lymphomas: typically present with rapid progression over days to weeks, rapidly fatal if untreated, but very high cure rates if treated in time (in the range of 70-90%), require specialized centers as regimens are complex and aggressive. Commonest varieties are lymphoblastic lymphoma, burkitt’s lymphoma. Treatment has to focus on supportive care such as prevention of tumor lysis syndrome as well.
Next time we will talk about some the common subtypes of low grade NHL.
Dr. Chirag A. Shah; M.D. Oncology/Hematology (USA), 079 26754001. Diplomate American Board of Oncology and Hematology. Ahmedabad. firstname.lastname@example.org
Shyam Hem-Onc Clinic. 402 Galaxy, Near Shivranjani, Opp Jhansi ki Rani BRTS, Ahmedabad. www.shyamhemoncclinic.com