NCCN Updates Guidelines for B-Cell Lymphomas
The National Comprehensive Cancer Network (NCCN) released updated guidelines for a variety of B-cell lymphomas, including follicular lymphoma, marginal zone lymphoma (MZL), mantle cell lymphoma (MCL), and diffuse large B-cell lymphoma (DLBCL).
For pediatric-type follicular lymphoma in adults, treatment with CHOP is now specified for patients “with extensive local disease who are not candidates for excision or involved site radiation therapy ISRT.” In the first-line setting, bendamustine plus rituximab, RCHOP, and RCVP were changed to a category 2A recommendation. In the second-line setting, ibritumomab tiuxetan was changed from a category 1 to a category 2A recommendation, and both fludarabine plus rituximab as well as RFND (rituximab, fludarabine, mitoxantrone, and dexamethasone) were removed.
Multiple changes were made to the MZL section of the guideline. For splenic MZL with present splenomegaly, hepatitis C negative, cytopenias and other symptoms, “preferred” was added to rituximab and “if not responsive to rituximab” was added to splenectomy. Among the suggested treatment regimens added to the guideline were “rituximab (375 mg/m2 weekly for 4 doses)” as a preferred regimen and both lenalidomide plus rituximab as well as ibritumomab tiuxetan as category 2B recommendations.
For aggressive first-line therapy to treat MCL, bendamustine plus rituximab was added as a category 2B recommendation and both CALGB as well as sequential RCHOP/RICE were removed. RBAC (rituximab, bendamustine, and cytarabine) was added as a category 2B recommendation and cladribine plus rituximab was removed as less aggressive first-line options. In the second-line setting, RCHOP and VRCAP (both if not previously given) were added as category 2B recommendations. “Plus rituximab” was added to ibrutinib and “if not previously given” was added to bendamustine plus rituximab in the second-line setting as well. Cladribine plus rituximab, FC (fludarabine and cyclophosphamide) plus rituximab, and PCR (pentostatin, cyclophosphamide, and rituximab) were removed.
Revisions were made for stage I/II non-bulky DLBCL, first-line therapy, and second-line/subsequent therapy sections of DLBCL treatment. “RCHO-14 x 4-6 cycles” was added as a first-line therapy for stage I/II non-bulky disease. In the first-line setting, dose-adjusted EPOCH plus rituximab was changed to a category 2A recommendation. In very frail patients and those at least 80 years of age with comorbidities in the first-line setting, RCEPP and RCDOP were added as options. For non-candidates for high-dose therapy in the second-line and subsequent therapy setting, ibrutinib (non-GCB DLBCL) was added as a category 2A option.
In the section for supportive care for B-cell lymphomas, a new page was added: “Bone Health: Recommendations for Patients Who Have Received Steroid-Containing Regimens.”
In the section for principles of radiation therapy, a few general dose guidelines were added. For palliative radiation therapy in follicular lymphoma, MZL, and MCL, the guideline reads, “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.” For palliative radiation therapy in DLBCL, the guideline reads, “24-30 Gy.”—Zachary Bessette