First-line treatment for most kinds of NHL is RCHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). Other recommended regimens include dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) + rituximab.1
Table 1 shows the recommended front-line treatment options for DLBCL. Presenting symptoms include rapidly enlarging masses with both local and systemic symptoms (B symptoms with fever, night sweats and weight loss).1,2
Most patients with localized tumors can be cured with chemotherapy alone or in combination with immunomodulatory agents. For advanced disease, more than half the patients are cured by a doxorubicin-based combination therapy and rituximab.2
Follicular lymphoma is a tumor containing follicle center cells, a combination of centrocytes and centroblasts.2 As it is an indolent tumor, median survival ranges from 8-15 years. Watchful waiting and deferment of treatment until the patient has symptoms is an option in patients with advanced FL and remains a standard of care.3 Rituximab alone or in combination with various chemotherapeutic drugs or in combination with immunomodulating agents (eg, lenalidomide) is a first-line treatment.4
The treatment landscape for R/R FL has changed significantly during the last few years, with several novel agents now available. Recommended regimens for second-line therapy include anti-CD20 mAB-based regimens as well as the CD19-targeted mAB, tafasitamab, in combination with lenalidomide. In the third-line setting, novel immunotherapy options, including CD20 x CD3 bispecific antibodies and CD19-targeted CAR-T cell therapies are available as preferred regimens while tazemetostat, zanubrutinib + obinutuzumab, and the anti-CD19 antibody-drug conjugate, loncastuximab tesirine with rituximab are additional recommended options. Autologous or allogeneic stem cell transplants may also be considered as consolidation therapy for relapsed disease. Table 2 outlines various therapeutic options for R/R FL.1
Patients with indolent lymphomas may have a more aggressive histology when undergoing a relapse, and a biopsy at this stage can help make an appropriate change to the therapy applicable to that histologic state.5
MCL is a heterogenous subtype of B-cell NHL. It is difficult to treat mantle cell lymphomas with conventional chemoimmunotherapy as it has the unfavorable characteristics of both indolent and aggressive NHL with, and a typically more aggressive disease course compared to indolent NHL. The standard treatment regimen for induction therapy is not yet established. There are no prospective randomized studies comparing the various aggressive regimens or for addition of BTK inhibitor to the chemoimmunotherapy regimens. Table 3 illustrates treatment for R/R MCL.1
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