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Non-Hodgkin's Lymphoma

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Indolent NHL

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    Interferon-alpha also shows activity in this disease, in contrast to poor responses in patients with multiple myeloma.[44] Myeloablative therapy with autologous or allogeneic hematopoietic stem cell support is under clinical evaluation.[45,46,47,48] Candidates for this approach should avoid long-term use of alkylating agents or purine nucleoside analogs, which can deplete hematopoietic stem cells or predispose patients to myelodysplasia or acute leukemia.[32,49] After relapse from alkylating-agent therapy, 92 patients with lymphoplasmacytic lymphoma were randomly assigned to either fludarabine or cyclophosphamide, doxorubicin, and prednisone. Although relapse-free survival favored fludarabine (median duration of 19 months vs. 3 months, P < .01), no difference was observed in OS.[50][Level of evidence: 1iiDii] Among patients with concomitant hepatitis C virus (HCV) infection, some will attain a complete or partial remission after loss of detectable HCV RNA with treatment using interferon-alpha with or without ribavirin.[51][Level of evidence: 3iiiDiv]

    Marginal Zone Lymphoma

    Marginal zone lymphomas were previously included among the diffuse small lymphocytic lymphomas. When marginal zone lymphomas involve the nodes, they are called monocytoid B-cell lymphomas or nodal marginal zone B-cell lymphomas, and when they involve extranodal sites (e.g., gastrointestinal tract, thyroid, lung, breast, orbit, and skin), they are called mucosa-associated lymphatic tissue (MALT) lymphomas.[52,53,54,55,56,57,58,59,60]

    Gastric MALT

    Many patients have a history of autoimmune disease, such as Hashimoto thyroiditis or Sjögren syndrome, or of Helicobactergastritis. Most patients present with stage I or stage II extranodal disease, which is most often in the stomach. Treatment of Helicobacter pylori infection may resolve most cases of localized gastric involvement.[61,62] After standard antibiotic regimens, 50% of patients show resolution of gastric MALT by endoscopy after 3 months. Other patients may show resolution after 12 to 18 months of observation. Of the patients who attain complete remission, 30% demonstrate monoclonality by immunoglobulin heavy chain rearrangement on stomach biopsies with a 5-year median follow-up.[63] The clinical implication of this finding is unknown. Translocation t(11;18) in patients with gastric MALT predicts for poor response to antibiotic therapy, for H. pylori –negative testing, and for poor response to oral alkylator chemotherapy.[64,65,66] Stable asymptomatic patients with persistently positive biopsies have been successfully followed on a watchful waiting approach until disease progression.[62] Patients who progress are treated with radiation therapy,[67,68,69,70] rituximab,[71] surgery (total gastrectomy or partial gastrectomy plus radiation therapy),[72] chemotherapy,[58] or combined–modality therapy.[73] The use of endoscopic ultrasonography may help clinicians to follow responses in these patients.[74] Three small case series (two retrospective and one prospective) reported durable complete remissions after treatment of H. pylori in patients with aggressive lymphoma (complete remission rate of 35%–88% and a median duration of 21–60 months).[75,76,77]

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