National Comprehensive Cancer Network

Non-Hodgkin’s lymphomas (NHLs) are a heterogeneous group of lymphoproliferative disorders originating in B-lymphocytes, T-lymphocytes, or natural killer lymphocytes. An estimated 65,980 new cases of NHL were diagnosed and 19,500 patients died of the disease in 2009. The median age of individuals with NHL has risen in the past 2 decades, resulting in a patient population that may also have significant comorbid conditions, complicating treatment options. These guidelines reflect significant updates, including the addition of a new guideline for adult T-cell leukemia/lymphoma, modifications to several treatment options for various lymphomas, and the inclusion of new therapies that recently received FDA approval.

Special Feature

Does Adjuvant Bisphosphonate in Early Breast Cancer Modify the Natural Course of the Disease? A Meta-Analysis of Randomized Controlled Trials
Davide Mauri, MD; Antonis Valachis, MD; Nikolaos P. Polyzos, MD; Lamprini Tsali, MD; Dimitris Mavroudis, MD, PhD; Vassilis Georgoulias, MD, PhD; and Giovanni Casazza, PhD

Many randomized controlled trials have evaluated the role of bisphosphonates in the adjuvant setting of breast cancer and have shown a beneficial effect on bone loss prevention.9 However, the overall clinical impact of bisphosphonates on the disease status of patients with early breast cancer is still unclear and controversial. To address whether bisphosphonate use in the adjuvant setting of breast cancer might affect the natural disease course, a meta-analysis was conducted of published and unpublished randomized controlled trials found in PubMed, Cochrane Central Register of Controlled Trials, ISI Web of Knowledge, and abstracts of major international conferences up to January 2009. All trials that randomized patients with primary breast cancer to undergo adjuvant treatment with any bisphosphonate versus non-use were considered eligible. Analysis included data from 13 eligible trials involving 6886 patients randomized to treatment with bisphosphonates (n = 3414) or either placebo or no treatment (n = 3472). Most specifically, this study investigated for any beneficial effects on overall survival, prevention of disease recurrences, and occurrence of bone metastases.

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The Role of Hematopoietic Stem Cell Transplant in Follicular Lymphoma
Edward A. Faber Jr., DO, MS, and Julie M. Vose, MD

Substantial progress has been made in the clinical management of patients with follicular lymphoma over the past 2 decades. However, the role of autologous and allogeneic stem cell transplantation in these patients remains controversial. Myeloablative chemotherapy or radioimmunotherapy supported by autologous hematopoietic cell transplantation has been shown to lead to a longer progression-free survival and, in some studies, improved survival over standard therapy. However, in the era of rituximab-based therapies used as part of induction or salvage, these historical trials may not be representative. Allogeneic stem cell transplantation offers the advantages of a tumor-free graft and some immunologic graft-versus-lymphoma effects. However, fully myeloablative transplants have high morbidity and mortality rates. Dose-reduced conditioning regimens followed by allogeneic hematopoietic cell transplantation have substantially reduced treatment-related mortality and may produce better outcomes long-term. This article outlines some historical information regarding stem cell transplantation for follicular lymphoma and discusses recent modifications that may improve outcomes, such as adding radioimmunotherapy to autologous stem cell transplantation or using alternative dose-reduced regimens that could benefit patients with reduced toxicities.

An Update on the Role of Interim Restaging FDG-PET in Patients With Diffuse Large B-Cell Lymphoma and Hodgkin Lymphoma
Craig H. Moskowitz, MD; Andrew Zelenetz, MD, PhD; and Heiko Schoder, MD

A significant amount of literature is available on treatment monitoring and response assessment in lymphoma using FDG-PET, yet confusion exists concerning the potential and limitations of FDG-PET for determining the presence of residual disease during chemotherapy (interim FDG-PET). This article reviews the role of interim FDG-PET in 3 important scenarios: untreated diffuse large B-cell lymphoma, untreated Hodgkin lymphoma, and relapsed or refractory aggressive lymphoma in transplant-eligible patients, and provides recommendations on the use of this imaging modality in these settings.

Genomic Analysis of Lymphoma: Potential for Clinical Application
Wing C. Chan, MD, and James O. Armitage, MD

The application of gene expression profiling (GEP) to the study of lymphomas will significantly influence the way these tumors are diagnosed and treated. Diffuse large B-cell lymphoma is now known to consist of several different genetic entities with different clinical presentations and therapeutic outcomes. In both follicular and diffuse large B-cell lymphoma, these studies have shown that host–tumor interactions have a major impact on the clinical course. Findings of GEP in diffuse large B-cell lymphoma have indicated frequent up-regulation of the nuclear factor-κB and B-cell receptor signaling pathways in the activated B-cell type. Drugs targeting these pathways may be effective in treating patients and clinical trials have been initiated based on these findings. GEP may assist the selection of treatments based on specific metabolic pathways shown to be active in a particular lymphoma. These techniques offer the promise of truly personalized medicine for patients with lymphoma.

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National Comprehensive Cancer Network

NCCN Guidelines® & Clinical Resources

JNCCN – The Journal of the National Comprehensive Cancer Network

Table of Contents - Volume 8, Number 3: March 2010

NCCN Clinical Practice Guidelines in Oncology™

Special Feature

Featured Articles

NCCN Guidelines^® & Clinical Resources