Although localized presentations are uncommon in non-Hodgkin lymphoma (NHL), the goal of treatment should be to cure the disease in patients who are shown to have truly localized occurrence after undergoing appropriate staging procedures.
Standard Treatment Options for Indolent, Stage I and Contiguous Stage II Adult NHL
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Other therapies as designated for patients with advanced-stage disease.
The National Lymphocare Study identified 471 patients with stage I follicular lymphoma. Of those patients, 206 were rigorously staged with a bone marrow aspirate and biopsy, and computed tomography (CT) scans or positive-emission tomography (PET-CT) scans. Nonrandomized treatments included radiation therapy (27%), rituximab-chemotherapy (R-chemotherapy) (28%), watchful waiting (17%), R-chemotherapy plus radiation therapy (13%), and rituximab alone (12%), although more than one-third of the patients started with expectant therapy. With a median follow-up of 57 months, progression-free survival favored R-chemotherapy or R-chemotherapy plus radiation therapy, but overall survival was nearly identical, all over 90%.[Level of evidence: 3iiiD] Clinical trials are required to answer questions such as:
If the PET-CT scan is clear after excisional biopsy, is watchful waiting or radiation therapy preferred?
Should rituximab be added to radiation therapy for stage I follicular lymphoma?
Is there any role for R-chemotherapy plus radiation therapy?
Long-term disease control within radiation fields can be achieved in a significant number of patients with indolent stage I or stage II NHL by using dosages of radiation that usually range from 25 Gy to 40 Gy to involved sites or to extended fields that cover adjacent nodal sites.[3,4,5,6,7] Almost half of all patients treated with radiation therapy alone will relapse out-of-field within 10 years.
Rituximab with or without chemotherapy
For symptomatic patients who require therapy, when radiation therapy is contraindicated or when an alternative treatment is preferred, rituximab with or without chemotherapy can be employed (as outlined below for more advanced-stage patients). The value of adjuvant treatment with radiation to decrease relapse, plus rituximab (an anti-CD20 monoclonal antibody) either alone or in combination with chemotherapy, has been extrapolated from trials of patients with advanced-stage disease and has not been confirmed.[9,10]