Prognosis
Prognosis depends on the patient’s age, performance status, serum LDH,
clinical disease stage and presence or absence of extranodal site involvement. More
than 2 prognostic factors increase the chances for recurrence and decrease
overall survival. A positron emission tomography (PET) scan is only indicated
in patients suspected of disease relapse and not as routine surveillance scan.
Patients undergoing Alemtuzumab treatment should be monitored for CMV
reactivation using quantitative PCR assay every 2-3 weeks during therapy and
for 2 months after completion of treatment.
Non-Hodgkins Lymphoma_Follow UpLugano Response Criteria for NHL
A positron emission tomography should be done simultaneously or separately with contrast-enhanced diagnostic CT in patients suspected of disease relapse.
Complete Response (CR)
PET-CT score of 1, 2, or 3 with or without a residual mass on 5-point scale (5-PS), with no evidence of FDG-avid disease in bone marrow or on CT, target nodes/nodal masses must regress to ≤1.5 cm in the longest transverse diameter of a lesion (LDi) with no extralymphatic sites of disease, organ enlargement must regress to normal and with normal morphology of the bone marrow.
Partial Response (PR)
PET-CT score of 4 or 5 with reduced uptake compared with baseline, no new progressive lesions and residual uptake higher than uptake in normal marrow but reduced compared to baseline or on CT ≥50% decrease in sum of the product of the perpendicular diameters for multiple lesions (SPD) of up to 6 target measurable nodes and extranodal sites, absent or no increase in non-measured lesion and regression of spleen length by >50% beyond normal.
No Response or Stable Disease (SD)
PET-CT score of 4 or 5 with no significant change in FDG uptake from baseline at interim or end-of-treatment, no new or progressive lesions and no change in bone marrow from baseline or on CT <50% decrease in SPD from baseline of up to 6 dominant measurable nodes and extranodal sites, without evidence consistent with progression.
Progressive Disease (PD)
PET-CT score of 4 or 5 with an increase in intensity of uptake from baseline and/or new FDG-avid foci consistent with lymphoma at interim or end-of-treatment assessment or
On CT will have ≥1 of the following:
- An individual node/lesion must be abnormal with LDi >1.5 cm and increase by ≥50% from cross product of the LDi and perpendicular diameter (PPD) nadir and an increase in LDi or shortest axis perpendicular to the LDi (SDi) from nadir of 0.5 cm for lesions ≤2 cm or 1.0 cm for lesions >2 cm
- Splenic length in the setting of splenomegaly must increase by >50% of the extent of its prior increase beyond baseline or if without prior splenomegaly, must increase by ≥2 cm from baseline
- Recurrent or new splenomegaly
- New or clear progression of preexisting non-measured lesions
- Regrowth of previously resolved lesions, a new node >1.5 cm in any axis or if <1.0 cm in any axis, its presence must be unequivocal and must be attributable to lymphoma or assessable disease of any size unequivocably attributable to lymphoma, and/or
- New or recurrent involvement of the bone marrow
PET 5-Point Scale (5-PS)
PET 5-Point Scale (5-PS) is based on visual
assessment of FDG uptake in the involved sites relative to that of the liver and
mediastinum:
| 1 | No uptake above background |
| 2 | Uptake ≤ mediastinum |
| 3 | Uptake > mediastinum but ≤ liver |
| 4 | Uptake moderately > liver |
| 5 | Uptake markedly higher than liver and/or new lesions |
| X | New areas of uptake unlikely to be related to lymphoma |
Histologic Transformation
Histologic transformation to DLBCL can occur with FL or MZL. Histologic
transformation of FL or MZL to DLBCL after minimal or without previous therapy
may be treated with anthracycline-based chemotherapy regimens recommended for
first-line therapy of DLBCL unless contraindicated with or without ISRT.
Patients with FL or nodal MZL with minimal or without previous therapy and with
histological transformation to DLBCL may be observed or enrolled in a clinical
trial if with complete response from initial therapy or may be treated with
second-line therapy if with partial or no response from initial therapy.
Patients with FL or nodal MZL with histological transformation to DLBCL
after multiple lines of prior therapies including ≥2 chemoimmunotherapy
regimens for indolent or transformed disease have the following therapeutic options:
- Enrollment in a clinical trial or
- Treatment
with systemic therapy regimens choice of which is individualized depending on
the presence or absence of intention to proceed to transplant and previous
treatment history, with or without ISRT: or
- With intention to proceed to transplant: RCHOP, DHA, GDP, ICE
- Without intention to proceed to transplant: RCHOP, Polatuzumab vedotin ± Bendamustine ±Rituximab, Tafasitamab + Lenalomide, CEOP, GDP ± Rituximab, GemOx ± Rituximab, Loncastuximab tesirine, Selinexor
- CAR T-cell therapy (eg Axicabtagene ciloleucel, Lisocabtagene maraleucel, Tisagenlecleucel) or
- Bispecific antibody therapy or
- ISRT for localized presentations, bulky disease and/or limited osseous disease or
- Managed with best supportive care