Current approaches to the treatment of non-Hodgkin's lymphoma

Abstract

Chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) has long been a standard treatment for lymphoma. Improvements to the efficacy of this regimen can be made by increasing the doses of doxorubicin and cyclophosphamide, as in the chemotherapeutic regimen of doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (ACVBP), and by reducing the standard dosing interval, as seen with the CHOP-14 regimen. Adding the immunotherapeutic agent rituximab (R) to either CHOP or ACVBP has been shown to improve outcomes significantly, such that six cycles of R-CHOP plus two cycles of ritux-imab are as effective as eight cycles of R-CHOP, and R-CHOP-21 appears to be at least as effective as the more dose-intense R-CHOP-14. In patients who have several adverse prognostic factors, R-ACVBP plus autologous stem-cell transplantation has been shown to produce good treatment outcomes. The use of positron emission tomography scanning before and early in treatment should allow prediction of long-term outcomes, and therefore the adaptation of treatment to individual prognosis and treatment needs. In patients with follicular lymphoma, rituximab has been shown to improve the efficacy of conventional chemotherapies. In addition, rituximab alone or yttrium-90-ibritumomab tiuxetan are effective maintenance therapies in this condition.

Figure 1

Progression-free survival (PFS) in 208 hard-to-treat patients (with an International Prognostic Index of 2–3) with diffuse large B-cell lymphoma, who were given four cycles of rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycin, and prednisone (R-ACVBP), followed by carmustine, etoposide, cytarabine, and melphalan (BEAM) and autologous stem-cell transplantation (unpublished data). Intention-to-treat population.

Figure 2

Examples of sequential [18F]fluoro-2-deoxy-D-glucose positron emission tomography (PET) findings in two patients. Panels A–C show scans from a patient with truly negative early PET, predicting complete response. Panels D–F show scans from a patient with truly positive early PET, predicting relapse. Arrows show hilar foci after two (panel E) and four (panel F) cycles of chemotherapy. The Kaplan-Meier plot shows 2-year estimates of event-free survival (EFS) according to early PET status after two cycles of chemotherapy. From Haioun C et al.[18F]fluoro-2-deoxy-D-glucose positron emission tomography (FDG-PET) in aggressive lymphoma: an early prognostic tool for predicting patient outcome. Blood 2005;106:1376-81. Reprinted with permission from the American Society of Hematology via the Copyright Clearance Center and the authors.