Updated 31 January 2007

Treatment of malignant lymphoma is based on histologic subtype, extent of disease, and age of the patient as is shown in the following table. In the case of discordant;(two separate sites of disease with differing types of lymphoma), composite (one site of disease with two discrete types of lymphoma at that site) or transformed (a second lymphoma developing out of a background of previously known lymphoma) lymphoma, treatment must be directed at the most aggressive phase of the disease

See Table 3.1 for specific subtypes of lymphoma. Note that the approaches outlined in this table are generally applicable to both B-cell and T-cell lymphomas, however, special approaches to gastric low grade MALT, mycoses fungoides, HTLV-1 lymphoma and lymphomas presenting at special sites or in association with immunodeficiency are outlined in the Special Problems section. In addition, the use of rituximab is only appropriate for B cell lymphomas.

Type	Stage	Age	Treatment
Indolent	Limited	All	Involved field radiation therapy (IFRT)
	Advanced	All	Asymptomatic - close follow-up under continued observation
			Symptomatic - CVP + rituximab (LYCVPR) (Marcus, Blood, 2005;105:1417-23). Localized irradiation can be useful for local symptoms
Aggressive*	Limited	All	CHOP + rituximab (LYCHOPR)** x 3 After completion of above chemotherapy: If PET positive or indeterminate -> involved field irradiation; If PET negative -> 1 more cycle of CHOP + rituximab** Exceptions: (1) Limited stage composite indolent and aggressive lymphoma or limited stage mantle cell lymphoma treat with LYCHOPR x 3 then IFRT; (2) Limited stage aggressive T-cell lymphoma treat with LYCHOP x 3 then IFRT.
	Advanced	All (note dose modifications for age > 70)	CHOP + rituximab (LYCHOPR)** (Coiffier, N Engl J Med, 2002;346:235-42) x 6 then CT scan and biopsies or other assessment as needed if originally positive After completion of above chemotherapy: If CR, no further treatment; if otherwise in CR but residual mass > 2 cm do PET scan; if PET neg, no further treatment; if PET pos and encompassable in a reasonable radiation field -> residual disease radiotherapy; if PET pos and not encompassable in a reasonable radiation field -> close observation or biopsy to direct further treatment on proof of persistent lymphoma
Special	All	All	These diagnoses constitute an emergency. They may require intensive high dose chemotherapy with central nervous system prophylaxis. Treatment with cyclophosphamide or multi-agent chemotherapy as needed should begin within 48 hours whether staging is complete or not. The patients should be managed at a major referral Center. They often require high dose chemo/radiotherapy and hematopoietic stem cell transplantation as part of their management.

*Central Nervous System Prophylaxis. Patients with initial involvement of paranasal sinuses with diffuse large B-cell or peripheral T-cell lymphoma (all subtypes) may require prophylactic intrathecal chemotherapy as outlined in the Special Problems section. The specific dose and schedule are shown in the Central Nervous System (CNS) Lymphoma section.

** Rituximab should only be included if the type of lymphoma is B-cell