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Lymphoma

Conventional Treatment

Hodgkin Lymphoma

HL is treated typically with radiation and chemotherapy. The types of chemotherapy drugs used depend on the type and stage (I-IV) of the cancer. There are 4 chemotherapy regimens that are usually considered first-line treatments for HL (Townsend 2012; Lash 2013):

  • MOPP (mechlorethamine, vincristine, procarbazine, prednisone)
  • ABVD (Adriamycin® [doxorubicin], bleomycin, vinblastine, dacarbazine)
  • Stanford V (doxorubicin, vinblastine, mustard, bleomycin, vincristine, etoposide, prednisone)
  • BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone)

Unfortunately, HL treatment regimens are associated with considerable long-term side effects in many cases; in fact, for patients who survive more than 10-years following therapy, treatment-related long-term side effects are a major cause of death (Townsend 2012). Therefore, an important treatment consideration is to give the patient enough therapy to control their cancer, but not so much as to increase their risk of long-term side effects (Lash 2013).

Generally, HL has a relatively high cure rate, but the disease does relapse sometimes. In these cases, more powerful, higher-dose treatment regimens may be administered, and hematopoietic stem cell transplantation may be utilized to help rescue the patient’s blood-cell-producing system (Lash 2013; Townsend 2012).

Non-Hodgkin Lymphoma

The treatment of NHL varies greatly and depends on the type and stage of the cancer. Treatment options for patients with lymphoma range from a "watch and wait" strategy to hematopoietic stem cell transplantation (Luminari 2012).

The chemotherapy regimen R-CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone, plus rituximab) is commonly used to treat NHLs, including DLBCL and follicular lymphomas. The role of radiation therapy for early-stage lymphoma is still a matter of debate among experts in the field (MSKCC 2013; Tomita 2013; Campbell 2013).

There is a very limited role for surgery in the treatment of lymphoma. However, surgery is an effective management option in the treatment of primary cutaneous B-cell lymphoma (PCBCL) (Parbhakar 2011). Surgery no longer plays a role in the treatment of gastric MALT lymphoma except for very rare complications such as perforation or bleeding that cannot be controlled endoscopically (Fischbach 2013; NCI 2013).

Patients whose lymphoma returns despite standard treatment (ie, relapsed disease) typically receive a different treatment regimen (eg, chemotherapy, chemoimmunotherapy, radioimmunotherapy, or participate in an investigative clinical trial) (Nastoupil 2012; Ujjani 2013; Otte 2009).

Rituximab

Rituximab is a drug that makes it easier for the body to destroy cancerous B cells. It works by binding to a specialized protein on the surface of most B cells. When rituximab binds to a B cell, it causes changes in the arrangement of structures on the cell’s surface; these changes make it easier for the immune system to kill cancerous B cells (Rudnicka 2013; Marcus 2007).

Rituximab has become an important part of lymphoma treatment and is often administered in conjunction with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). The combination of all 5 agents is referred to as “R-CHOP.” One comprehensive review found that adding rituximab to CHOP led to a 3-fold higher complete remission rate over CHOP in NHL (Hou 2011). Several studies have shown that treatment with rituximab can prolong remission of follicular and diffuse large B-cell lymphomas (Marcus 2007). Addition of rituximab to chemotherapy has been shown to improve complete response and overall survival among HIV-positive individuals with NHL as well (Castillo 2012). Rituximab has also been shown to confer a survival benefit when administered as maintenance therapy in people with treatment-resistant or relapsed follicular lymphoma (Vidal 2011).

Rituximab weakens the immune system and can increase susceptibility to viral infections such hepatitis B, cytomegalovirus infection, and varicella-zoster virus infection (Aksoy 2007; Sisson 2013).

Hematopoietic Stem Cell Transplantation

Standard chemotherapy and/or radiation therapy regimens sometimes fail to eradicate lymphoma, resulting in refractory or relapsing disease. In these cases, doctors may administer higher dosages of chemotherapy or radiotherapy in an attempt to destroy the cancer. However, an unfortunate side effect of high-dose chemotherapy and radiation is destruction of bone marrow, which is where blood cell production takes place. This leads to insufficient blood cell synthesis (ACS 2013; Holmberg 2011).

An important strategy for overcoming this treatment barrier is hematopoietic stem cell transplantation. This involves infusing the patient with hematopoietic stem cells following chemotherapy or radiotherapy. Hematopoietic stem cells help rebuild the blood-cell-generating system within the bone marrow. This helps ensure that the patient is able to continue generating sufficient numbers of blood cells following cancer treatment (ACS 2013).

Stem cells can either be derived from the patient or from someone else whose tissue characteristics match the patient’s. When stem cells are derived from the patient, the procedure is referred to as autologous stem cell transplantation; when they are derived from someone else, the procedure is called allogeneic stem cell transplantation (ACS 2013).

Not all lymphoma patients will be good candidates for stem cell transplantation, and some types of lymphoma are more amenable to this approach than others. For example, high-dose chemotherapy along with autologous stem cell transplantation is used quite often for refractory diffuse large B cell lymphoma and HL (Rancea 2013; Gavrilina 2013; ACS 2013).

Antimicrobial Treatment: H. pylori Eradication to Treat Gastric MALT

MALT lymphomas are usually not aggressive and have a good long-term outcome in most cases (Alshemmari 2013). Many patients with gastric MALT lymphomas who are infected with H. pylori can achieve remission and symptom improvement with antibiotic therapy to eradicate the pathogen.

In one study, in which MALT lymphoma was treated exclusively by eradicating H. pylori, there was complete remission in 62% of patients, minimal residual disease in 18%, partial remission in 12%, no change in 4%, and progressive disease in only 2% at an average 44- month follow up (Fischbach 2004). Patients with more advanced disease, or those unresponsive to H. pylori antibiotic therapy, may be treated with a single agent (eg, chlorambucil), combination chemotherapy (eg, rituximab with fludarabine), or radiation therapy (Sisson 2013; ACS 2013).