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NCCN Flash Update: NCCN Guidelines, NCCN Compendium, & NCCN Templates for B-Cell Lymphomas

NCCN has published updates to the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®), NCCN Chemotherapy Order Templates (NCCN Templates®) and NCCN Drugs & Biologics Compendium (NCCN Compendium®) for B-Cell Lymphomas. These NCCN Guidelines® are currently available as Version 1.2018.

  • General
    • The common bullets related to diagnosis were removed for each subtype and added to a new page, DIAG-1. For each subtype, the diagnosis section is now titled, "Additional Diagnostic Testing."

 

  • Follicular Lymphoma
    • Pediatric-Type Follicular Lymphoma in Adults (FOLL-8)
      • Treatment with CHOP was qualified by adding, “for patients with extensive local disease who are not candidates for excision or ISRT."
    • First-line Therapy (FOLL-B 1 of 4)
      • The regimens were separated into "preferred regimens" and "other recommended regimens" and listed in alphabetical order.
      • Bendamustine + rituximab was changed from a category 1 to a category 2A recommendation.
      • RCHOP was changed from a category 1 to a category 2A recommendation.
      • RCVP was changed from a category 1 to a category 2A recommendation.
    • First-line Consolidation or Extended Dosing (optional) (FOLL-B 1 of 4)
      • Ibritumomab tiuxetan was revised by removing, "(after induction with chemotherapy or chemoimmunotherapy).
    • Second-line and Subsequent Therapy (FOLL-B 2 of 4)
      • The regimens were separated into "preferred regimens" and "other recommended regimens."
      • Ibritumomab tiuxetan was changed from a category 1 to a category 2A recommendation.
      • The following regimens were removed:
        • Fludarabine + rituximab
        • RFND (rituximab, fludarabine, mitoxantrone, dexamethasone)

 

  • Marginal Zone Lymphoma (MZL)
    • Splenic MZL (SPLN-2): For splenomegaly, hepatitis C negative, cytopenias and symptoms present, "preferred" was added to rituximab and "if not responsive to rituximab" was added to splenectomy.
    • Suggested Treatment Regimens (First-line Therapy (MZL-A 1 of 3)
      • The regimens were separated into "preferred regimens" and "other recommended regimens." These were placed in alphabetical order.
        • "Preferred for SMZL" was added to "rituximab (375 mg/m2 weekly for 4 doses)."
        • The following were added as "other recommended regimens"
          • Lenalidomide + rituximab as a category 2B recommendation
          • Ibritumomab tiuxetan as a category 2B recommendation.
  • Mantle Cell Lymphoma (MCL)
    • First-line Therapy (MANT-A 1 of 4)
      • Induction therapy
        • For both aggressive and less aggressive therapy, the regimens were separated into "preferred regimens" and "other recommended regimens" and listed in preference order.
        • Aggressive therapy
          • Footnote was removed, "Oxaliplatin or carboplatin can also be used" and oxaliplatin was added to the regimen RDHAX (rituximab, dexamethasone, cytarabine, oxaliplatin) as an alternative to RDHAP.
          • HyperCVAD, "(NOTE: There are conflicting data regarding the need for consolidation with HDT/ASCR.)" was added to the bullet.
          • Bendamustine + rituximab was added as a category 2B recommendation.
          • The following regimens were removed:
            • CALGB regimen
            • Sequential RCHOP/RICE
        • Less aggressive therapy
          • RBAC (rituximab, bendamustine, cytarabine) was added as a category 2B recommendation.
          • Cladribine + rituximab was removed.
    • Second-line Therapy (MANT-A 2 of 4)
      •  The regimens were reorganized first by "Short response duration to prior chemoimmunotherapy (< expected median PFS)" and "Extended response duration to prior chemoimmunotherapy (> expected median PFS)." Then the regimens were separated into "preferred regimens" and "other recommended regimens."
      • The following regimens were added or revised,
        • RCHOP (if not previously given) (category 2B) was added.
        • VRCAP (if not previously given) (category 2B) was added.
        • "± rituximab" was added to ibrutinib.
        • "(if not previously given)" was added to bendamustine ± rituximab.
      • The following regimens were removed,
        • Cladribine + rituximab
        • FC (fludarabine, cyclophosphamide) ± rituximab
        • PCR (pentostatin, cyclophosphamide, rituximab)
  • Diffuse Large B-Cell Lymphoma (DLBCL)
    • Stage I, II, Non-bulky
      • First-line therapy, "RCHOP-14 x 4–6 cycles" was added.
    • First-line Therapy (BCEL-C 1 of 4)
      • Dose-adjusted EPOCH + rituximab was changed from a category 2B to category 2A recommendation.
      • For very frail patients and patients >80 y of age with comorbidities, RCEPP and RCDOP were added as options.
    • Second-line and Subsequent Therapy (BCEL-C 2 of 4)
      • For non-candidates for high-dose therapy, ibrutinib (non-GCB DLBCL) was added as an option with a category 2A recommendation.
  • Burkitt Lymphoma
    • Relapsed/refractory disease (BURK-3): Recommendations for response assessment after second-line therapy and treatment options for consolidation/ additional therapy were added.
    • Induction therapy, "CALGB 10002 regimen" was removed. (BURK-A)
  • AIDS-Related B-cell Lymphomas
    • Burkitt lymphoma (AIDS-3)
      • The regimens were separated into "preferred regimens" and "other recommended regimen."
        • "CDE (cyclophosphamide, doxorubicin, etoposide) + rituximab" was removed as an option.
        • After treatment, a link was added regarding relapsed disease, “For relapse, see second-line regimens (BURK-A).”
  • Diffuse large B-cell lymphoma, HHV8-positive DLBCL, NOS and Primary effusion lymphoma (AIDS-3)
    • "CDE + rituximab" was removed as an option.
  • Plasmablastic lymphoma (AIDS-4)
    • "Preferred" was added to "dose-adjusted EPOCH."
    • The 3rd bullet was added, "Consider high-dose therapy with autologous stem cell rescue in first complete remission in select high-risk patients."
  • Castleman’s Disease
    • Multicentric (CD-3)
      • Primary treatment, the 2nd bullet was added, "Rituximab (if not candidate for combination therapy)."
  • Supportive Care for B-Cell Lymphomas
    • A new page titled, “Bone Health: Recommendations for Patients Who Have Received Steroid-Containing Regimens” was added. (NHODG-B 4 of 4)
  • Principles of Radiation Therapy
    • The following general dose guidelines were added,
      • Palliative RT(higher doses/fractions typically appropriate))
        • FL/MZL/MCL: 2 Gy X 2 or 4 Gy X 1 (which may be repeated as needed); doses up to 30 Gy may be appropriate in select circumstances
        • DLBCL:  24–30 Gy

The following NCCN Templates® have been deleted to reflect the NCCN Guidelines for B-Cell Lymphoma Version 1.2018:

  • Follicular Lymphoma (grade 1-2)
    • FOL3: Fludarabine + RiTUXimab
    • FOL4: FND (Fludarabine/MitoXANTRONE/Dexamethasone) + RiTUXimab
  • Mantle Cell Lymphoma
    • MCL13: FC (Fludarabine/Cyclophosphamide)
    • MCL14: FCR (Fludarabine/Cyclophosphamide + RiTUXimab)
    • MCL15: PCR (Pentostatin/Cyclophosphamide + RiTUXimab)
    • MCL21: Cladribine + RiTUXimab
    • MCL22a: CALGB59909 Regimen: RiTUXIMAB + Methotrexate with Augmented CHOP (Cyclophosphamide/DOXOrubicin/VinCRIStine/PredniSONE)
    • MCL22b: CALGB59909 Regimen: RiTUXimab Maintenance
    • MCL23a: Dose-Dense R-CHOP-14 (RiTUXimab + Cyclophosphamide/DOXOrubicin/VinCRIStine/PredniSONE) followed by RICE (RiTUXimab + Ifosfamide/CARBOplatin/Etoposide)–Dose-Dense R-CHOP-14 (RiTUXimab + Cyclophosphamide/DOXOrubicin/VinCRIStine/PredniSONE) Course
    • MCL23b: Dose-Dense R-CHOP-14 (RiTUXimab + Cyclophosphamide/DOXOrubicin/VinCRIStine/PredniSONE) followed by RICE (RiTUXimab + Ifosfamide/CARBOplatin/Etoposide)–RICE (RiTUXImab + Ifosfamide/CARBOplatin/Etoposide) Course

 

 

For the complete updated versions of the NCCN Guidelines, NCCN Guidelines with NCCN Evidence Blocks™, the NCCN Drugs & Biologics Compendium (NCCN Compendium®), the NCCN Biomarkers Compendium®, the NCCN Chemotherapy Order Templates (NCCN Templates®), the NCCN Radiation Therapy Compendium™, and the NCCN Imaging Appropriate Use Criteria (NCCN Imaging AUC™), please visit NCCN.org.

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