Non-Hodgkin's Lymphoma - Staging and Treatment Guidelines

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Advanced Stage Lymphomas (Stage III and IV)

In stage III, lymphoma is found in lymph node areas on both sides of the diaphragm (for instance, in both the chest and the abdomen). The lymphoma may also have spread to the spleen. In stage IV, lymphoma has spread via the bloodstream to organs outside the lymph system, such as the bone marrow or brain. Lymphoma cells may or may not be in the lymph nodes near these organs.

Advanced Stage Indolent (Low-Grade Lymphomas). Treatment options are controversial because of the low-cure rate and yet slow-growing nature of these lymphomas. Patients without symptoms are often managed by watchful waiting, in which the disease is monitored closely for development of symptoms or bulky tumor masses, particularly if they threaten major organs. At such times, treatment is started. Treatment may include:

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• Chemotherapy combinations (CHOP, CVP, C[M]OPP)
• Nucleoside analogs (for example, fludarabine) alone or with chemotherapy
• Oral alkylating chemotherapy drugs such as cyclophosphamide or chlorambucil with or without steroids
• Monoclonal antibodies (MAbs) such as rituximab alone or in combinations with CHOP or nucleoside analogs
• Chemotherapy plus interferon
• Clinical trials involving intensive chemotherapy and radiation followed by bone marrow or stem cell transplantation

Advanced Stage Aggressive (Intermediate- to High-Grade) Lymphomas. Treatment options may include:

• Doxorubicin-based combination chemotherapy with or without rituximab
• Chemotherapy plus radiation therapy
• Immunotherapies with or without chemotherapy
• Treatments to prevent disease from spreading to central nervous system in high-risk patients
• Clinical trials for patients at high risk for relapse that involve intensive chemotherapy, high dose chemotherapy, and bone marrow or stem cell transplantation

Relapsed or Refractory (Nonresponsive to Treatment) Non-Hodgkin's Lymphoma

Indolent-Lymphomas Relapses. Nearly all patients with indolent lymphomas relapse after initial treatment, with duration of remissions after a first treatment averaging 18 - 50 months. Successful retreatment is often possible, but disease-free periods become increasingly shorter with each subsequent treatment.

Older patients may choose watchful waiting. Other treatment options may include: