Lymphoma Treatment Approaches
Treatments vary depending on the specific type of lymphoma, and other factors such as the patient’s age, overall health and prior therapy.

 
Surgery

Because lymphoma spreads throughout the lymph system,  surgery plays a minimal role.  However, in primary extranodal tumors, such as those arising in the spleen or stomach, surgical removal may be useful. In localized lymphomas of the skin, surgical excision is usually the first-line treatment.
 
 
Chemotherapy

Chemotherapy is often an essential component of lymphoma treatment, because a systemic approach is necessary to kill cells circulating throughout the lymphatic system. Chemotherapy is usually given in cycles, starting with treatment over several days. It is then followed by a few weeks without treatment so that the patient can recover from side effects, particularly anemia and low counts of white blood cells. The sequence is then repeated until the disease is in remission, and then continued to extend remission.
 
Chemotherapy drugs used for lymphoma may include combinations of the following:
 
  • bleomycin (Blenoxane®)
  • cyclophosphamide (Cytoxan®)
  • dacarbazine (DTIC-Dome®)
  • daunorubicin doxorubicin (Adriamycin®)
  • etoposide (VP-16, VePesid®)
  • mechlorethamine (Mustargen®, a.k.a. nitrogen mustard)
  • prednisone
  • procarbazine (Matulane®) 
  • vinblastine (Velban®)
  • vincristine (Oncovin®)

Hodgkin lymphoma
The following combination chemotherapy protocols are used widely in Hodgkin lymphoma:
 
  • ABVD: doxorubicin, bleomycin , vinblastine and dacarbazine
  • BEACOPP: bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine and prednisone
  • MOPP: mechlorethamine, vincristine, procarbazine and prednisone
     
ABVD and MOPP are long-established; BEACOPP is a newer regimen. BEACOPP, with its seven different components, may have increased side effects, but has also shown favorable treatment outcomes versus other protocols, particularly in later-stage disease.
 
Brentuximab vedotin is FDA approved for the treatment of relapsed/refractory Hodgkin lymphoma. It is an antibody drug conjugate that is used as an immunotherapy treatment, but has a chemotherapy drug as well. Brentuximab vedotin delivers a potent cytotoxic molecule (MMAE) directly into tumor cells expressing CD30.  Almost all Hodgkin lymphoma cells express CD30.  This drug has high efficacy and a favorable toxicity profile.
 
Non-Hodgkin Lymphoma
Perhaps the most common combination chemotherapy protocol for non-Hodgkin lymphoma is CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone). However, there are numerous other combination protocols. Because there are many varieties of non-Hodgkin lymphoma, there may be specific treatments applicable to a particular type.
 
City of Hope’s Lymphoma  Specialized Program of Research Excellence (SPORE) program is focused on developing translational studies to improve the detection and therapy of Hodgkin and non-Hodgkin lymphoma. The studies are aimed at creating lymphoma therapies that will reduce toxicities associated with current treatment regimens. Those new therapies can then be translated for use in older patient populations.
 
Immunotherapy

Some patients with non-Hodgkin lymphoma, especially B cell lymphoma, are treated with antibodies that have specific activity against the tumor. These antibodies can work alone or can be given in combination with drugs to enhance the efficacy of chemotherapy. Common monoclonal antibody treatments include:
  • Rituxan® (rituximab)
  • Bexxar® (tositumomab)
  • Zevalin® (ibritumomab tiuxetan)
Radioimmunotherapy
City of Hope has developed novel ways of delivering radiation utilizing monoclonal antibodies, part of the immune system, that have been combined with small amounts of radioactive substances. These radio-labeled antibodies allow doctors to target lymphoma cells directly while minimizing damage to normal tissues. City of Hope was one of the first programs to use radioimmunotherapy as part of a transplant regimen to improve the safety and efficacy of the treatment.
 
Adoptive T Cell Therapy
T cells are a powerful part of the immune system. A new approach being studied at City of Hope involves redirecting T cells to recognize cancer cells specific to lymphoma. Researchers are taking T cells from patients with lymphoma and genetically modifying them to target and destroy the malignant T cells. Studies are focusing on patients with recurrent diffuse large cell lymphoma who are undergoing autologous stem cell transplantation.
 
Stem Cell Transplantation

Hematopoietic Cell Transplantation (HCT) and Peripheral Blood Stem Cell Transplantation (PBSCT) use stem cells (immature blood cells) to treat a patient's malignancy or to repair diseased or defective bone marrow. Transplants are sometimes performed early in the course of treatment to improve long-term results.  In some patients, it is utilized when other treatments are not working.
 
Transplant procedures include intensive chemotherapy, with or without radiation therapy, to destroy (ablate) the cancerous cells, followed by an infusion of healthy new cells.
 
Autologous Stem Cell Transplantation (ASCT)
In autologous transplants, a patient donates and receives back his or her own stem cells, typically collected from peripheral (circulating) blood. The greatest concern for patients with lymphoma is the chance that the disease will return. City of Hope’s Department of Hematology and Hematopoietic Cell Transplantation pioneered the use of early autologous stem cell transplantation (ASCT) in patients with poor-risk, aggressive non-Hodgkin lymphoma to avoid relapse after initial treatment. ASCT is also the most effective treatment for most patients who suffer a recurrence of their lymphoma or Hodgkin disease.
 
ASCT in AIDS-related Lymphoma and Hodgkin Lymphoma
At City of Hope, patients with AIDS-related lymphoma and Hodgkin lymphoma are sometimes candidates for ASCT, and results have been excellent. We are also conducting studies of autologous stem cells that have been genetically engineered to provide additional resistance to HIV infection in patients undergoing ASCT. This approach is being studied at City of Hope to help improve the control of the virus after transplant.
 
Allogeneic Stem Cell Transplantation
In certain situations, a patient’s lymphoma is very advanced, and the blood or bone marrow is extensively involved. In these cases, an allogeneic transplant strategy is preferred, using stem cells from a matched donor or cord blood.
 
In allogeneic transplants, the donor is preferably a sibling. Alternatively, a matched unrelated donor (MUD) who has a similar genetic type may be used. In fact, 45 percent of all allogeneic transplants at City of Hope come from volunteer donors who are unrelated to the patient.
 
Researchers now understand that the response from the immune system carried in transplanted donor stem cells helps fight the cancer. This is known as a graft versus tumor effect.
 
Efforts to decrease allogeneic transplant-related complications are being explored, including the use of less intensive nonmyeloablative transplant conditioning regimens (also called “mini-HCT”), which have a reduced risk of side effects and can be used to treat older patients with lymphoma, leukemia and myeloma.
 
Nonmyeloablative (Mini) Transplants
Our nationally recognized stem cell transplantation program specializes in “mini” hematopoietic cell transplants.  Nonmyeloablative transplants have allowed patients who could not tolerate the traditional pre-transplant regiments to become candidates for the procedure. Originally, pre-transplant protocols required high-dose chemotherapy and/or high-dose whole-body irradiation. For elderly patients or patients with other diseases, these protocols were too demanding and often excluded them from transplants.
 
In order to improve both the safety of transplantation and its applicability to a larger number of patients, City of Hope developed an approach in 1998 for a “mini” transplant. These transplants rely less on the heavy doses of chemotherapy and radiation and more on the antitumor effects of the graft itself (known as a graft-versus-tumor effect). This novel approach has allowed for transplants in patients who are older, including patients in their 70s, who would previously not have been eligible for a transplant. These patients, with conditions such as leukemia, myeloma, lymphoma and myelodysplasia, have been significantly helped – even cured – by mini transplants.

 
Radiation therapy

Radiation therapy uses high-energy X-rays or other types of radiation to kill cancer cells or keep them from growing. Traditional lymphoma treatment had required the use of whole-body irradiation, which unnecessarily exposes healthy tissues. City of Hope was the first in the western United States to treat lymphoma using the more effective  Helical TomoTherapy System®, which reduces the unwanted exposure of normal tissues and reduces potential complications. The system combines radiation delivery with real-time imaging, allowing doctors to create a higher dose of energy more precisely focused on the target.