Treatment of high grade

See also Treatment of Low grade

Most people will have chemotherapy as their main treatment but they may have surgery and radiotherapy as well. Treatment needed will depend on how advanced disease is at presentation and the type of lymphoma.

Surgery

Most people will have minor surgery to remove a lymph node for diagnosis of Non-Hodgkin lymphoma. Recovery from this type of surgery takes on average 2-7 days. Very rarely people may have their spleen removed ( a ‘splenectomy’) – this can be done laparoscopically in which case the recovery time is up to 2 weeks or as an open operation – the recovery time is up to 6 weeks.

Chemotherapy

Treatment guidance is divided into two sections these are:

• First line treatment early disease(stage I)
• First line treatments for advanced disease (stage II b to IV) or Relapsed disease

First line treatment for early disease (non bulky stage I) and advanced disease (stage II b to IV)

The standard treatment is R-CHOP – (rituximab and cyclophosphamide, doxorubicin, vincristine and prednisolone) given over 3-8 cycles (around 3-6 months of treatment). Other variations of this treatment may be given and some people may also receive short courses of radiotherapy over 2.5 to 4.5 weeks to affected areas. 5 year survival without recurrence is as in the region of 30-70% in people under 60 years of age.

Relapsed disease some time after this treatment is common. Second line treatment options will depend on whether a person is fit enough to have more aggressive treatment. Most people under 60-65 will be fit enough, most people over this age will not. The two options for second line treatment are below:

Second line treatment - for people under 60-65 years of age who are fit - this group are likely to be offered ‘salvage’ combination chemotherapy followed by high dose chemotherapy and bone marrow transplant.

The following salvage chemotherapies are commonly used for relapsed disease:

• DHAP+/-R (dexamethasone, cytarabine, cisplatin)
• ESHAP+/-R (etoposide, methylprednisolone, cytarabine and cisplatin)
• IVE (ifosfamide, etoposide and epirubicin)
• ICE (ifosfamide, carboplatin and etoposide)
• RICE– (rituximab, ifosfamide, carboplatin and etoposide)

If disease responds to salvage chemotherapy they will be offered a stem cell transplant. The chance of success after a stem cell transplant is about 60%. People who do not respond to salvage chemotherapy will probably die within the next few months

Second line treatment - for people over 60-65 or younger people who are not fit enough for aggressive treatment

They will generally be offered some further chemotherapy with one of the following-:

• PMitCEBO+/-R
• CHOP+/_-R
• Vincristine and steroids
• Vincristine and bleomycin
• Radiotherapy

Disease is likely to relapse or progress within a few months though some may remain in remission for a few years.

Methotrexate – is a chemotherapy drug which may be used in addition to other chemotherapy treatments either as an intrathecal injection (injection into the cerebrospinal fluid around the spinal cord) or intravenous injection to prevent or treat lymphoma in the brain, so called Central Nervous System (CNS) involvement.

Relapsed disease

People of working age whose Non-Hodgkin lymphoma has relapsed some time after successful treatment are likely to go on to have high dose chemotherapy and Peripheral Blood Stem Cell Transplant (PBSCT) or bone marrow transplant especially if they are fit. Results from this treatment are good. If disease returns again it can often be kept under control for some time with further chemotherapy and or radiotherapy. As people have more treatments over time they are likely to develop disabling effects related to both the disease and its treatment. In young patients under 60 five year median relapse free survival is approximately 60%, over 60 relapse free survival rates drop to 50%

Long term side effects of chemotherapy treatment

These are of note because Non-Hodgkin Lymphoma affects young people the long term effects of treatment are particularly likely to affect this group and are summarised here-:

• Infertility
• Secondary cancers
• Lung damage e.g. pulmonary fibrosis
• Heart disease
• Thyroid disorders

Those who do not respond to standard chemotherapy during the first course of chemotherapy treatment or whose lymphoma relapses after treatment are likely to go on to have high dose chemotherapy and PBSCT or bone marrow transplant treatment. The side effects of this treatment can be severe.

Radiotherapy

Radiotherapy may be used in advanced Non-Hodgkin Lymphoma after chemotherapy for residual disease or symptom control.

Side effects

These are of note because Non-Hodgkin Lymphoma affects young people the long term effects of treatment are particularly likely to affect this group and are summarised here-:

• Skin damage/pigmentation to treated area
• Lung damage
• Heart disease
• Secondary cancers
• Thyroid disorders

Steroid drugs

These include prednisolone, methylprednisolone and dexamethasone. These drugs are used in short bursts during chemotherapy treatment. In general side effects are minimal. However if used for prolonged periods the following side effects are very common – significant weight gain, osteoporosis and diabetes mellitus. Rarer side effects include psychiatric problems ranging from depression and anxiety to major psychotic episodes.

• Side effects of chemotherapy
• Radiotherapy and Brachytherapy
• Bone marrow transplant
• Problems in adults who had cancer treatment as children
• Stages

Amended February 2009