Updated: 13 May 2005
Many patients with malignant lymphoma, especially those below the age of 65-70 years at diagnosis, can be cured. Most cured patients experience minimal long-term toxicity from the treatments, however, certain predictable and occasional rare and unpredictable late effects may occur and require preventive measures and/or recognition and treatment.
The following late effects of malignant lymphoma or its treatment should be considered when patients are reviewed in follow-up:
20% to 80% of patients relapse depending on histologic subtype, stage and bulk of presentation. Careful attention should be directed to lymph node sites, especially if previously involved with disease
Neck or oropharyngeal irradiation may cause decreased salivation. Patients should have careful dental care follow-up and should make their dentist aware of the previous irradiation.
After external beam thyroid irradiation to doses sufficient to cure malignant lymphoma at least 50% of patients will eventually become hypothyroid. Also, there is an increased risk of secondary thyroid carcinoma after irradiation.All patients whose TSH level becomes elevated should be treated with life-long thyroxin replacement in doses sufficient to suppress TSH levels to the low normal range for two purposes: to maintain euthyroidism and to minimize the risk of thyroid carcinoma by reducing overstimulation with endogenous TSH.
Multi-agent chemotherapy and direct or scatter radiation to gonadal tissue may cause infertility, amenorrhea or premature menopause. However, with current chemotherapy regimens and radiation fields, most patients do not develop these problems. All should be advised that they may or may not be fertile after treatment. In general, after treatment, women who continue menstruating are fertile, but men require semen analysis to provide a specific answer.
Although uncommon, certain neoplasms occur with increased frequency in patients who have been treated for lymphoma. These include acute myelogenous leukemia, thyroid, breast, lung and upper gastrointestinal carcinoma and melanoma and cervical carcinoma-in-situ. It is appropriate to screen for these neoplasms for the rest of the patient's life because they may have a lengthy induction period.
The following minimum follow-up tests and examinations should be performed on all patients after treatment for malignant lymphoma. Visits should be every 3 months for 2 years, then every 6 months for 3 years, then annual. Patients should be encouraged to perform careful breast and skin examination on a regular basis and to keep their immunizations up to date (see Appendix III).
Lymph node, abdominal, thyroid, and skin examination
CBC, alkaline phosphatase, LDH
Chest radiograph if original disease was in the thorax
TSH level (if the thyroid gland was irradiated)
Mammography for women beginning 10 years after diagnosis of lymphoma or at age 40 years, whichever comes first
Influenza immunization(see Appendix III)
Every 5 years
Pneumococcal immunization(see Appendix III)