Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)
In general, treatment with standard agents rarely produces a cure in patients whose disease has relapsed. Sustained remissions after relapse can often be obtained in patients with indolent lymphomas, but relapse will usually ensue. Favorable survival after relapse has been associated with an age younger than 60 years, complete remission rather than partial remission, and duration of response longer than 1 year. Even the most favorable subset, however, has a tenfold greater mortality compared with age-adjusted U.S. population rates. Patients who experience a relapse with indolent lymphoma can often have their disease controlled with palliative radiation therapy, chemotherapy, or rituximab, an anti-CD20 monoclonal antibody.[2,3] Long-term freedom from second relapse, however, is uncommon and multiple relapses will usually occur. Significant activity for fludarabine and 2-chlorodeoxyadenosine has been demonstrated in relapsed low-grade lymphomas, both as single agents and in combination with other drugs.[4,5,6,7,8,9] Rituximab results in a 40% to 50% response rate in patients who relapse with indolent B-cell lymphomas.[10,11,12,13] Rituximab can also be combined with combination chemotherapy. Responses of 20% to 30% have been reported for lenalidomide, especially for follicular lymphoma and small lymphocytic lymphoma.[Level of evidence: 3iiiDiv] Durable responses to radiolabeled monoclonal antibodies, such as yttrium-90 ibritumomab (commercially available) and iodine-131 tositumomab, have also been reported; subsequent chemotherapy regimens can be delivered at the time of relapse following radioimmunotherapy.[16,17,18,19,20,21] In two randomized prospective studies involving previously treated patients with relapsed indolent lymphoma, patients were randomly assigned to rituximab maintenance after retreatment with combination chemotherapy (with or without rituximab during induction); both trials showed prolongation of response duration,[22,23] and one trial demonstrated improvement in median progression-free survival (52 months vs. 15 months, P < .001) and overall survival (OS) (85% vs. 77%, P = .01) at 3 years with a median follow-up of 39 months favoring maintenance rituximab.[Level of evidence: 1iiA]
Symptoms of non-Hodgkin lymphoma may include:
Painless swelling, of one or more lymph nodes, with no recent infection. The lymph node swelling may be intermittent.
Swelling, fluid accumulation, or pain in the abdomen.
Shortness of breath, wheezing, or coughing.
Bloody stool or vomit.
Swelling of the face, neck, and arms.
Blockage of urine flow.
Unexplained weight loss amounting to 10% of body weight over six months.
Fever lasting for at least 14 consecutive...
In many institutions, autologous or allogeneic stem cell transplantations are being used for patients whose disease has relapsed. Such an approach is still under evaluation but should be considered in the context of a clinical trial.[24,25,26,27,28] The German Low-Grade Lymphoma Study Group treated 307 patients with follicular lymphoma with two cycles of CHOP-like induction chemotherapy and then randomly assigned them to autologous stem cell transplantation versus interferon maintenance. With a median follow-up of 4.2 years, the 5-year progression-free survival was 65% for transplantation versus 33% for interferon (P < .001), but with no difference in OS.[Level of evidence: 1iiDiii]