📋 Key Information Summary
- Lymphoma comprises Hodgkin lymphoma (HL; ~10% of cases in Australia) and non-Hodgkin lymphoma (NHL; ~90%), each with distinct biology, prognosis, and treatment paradigms.
- HL is characterised by Reed–Sternberg cells (CD15⁺/CD30⁺) and typically presents in young adults with contiguous nodal spread; cure rates exceed 80% with modern therapy.
- Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive NHL subtype; rituximab plus CHOP (R-CHOP) is the standard first-line regimen, achieving 60–70% durable remission.
- Follicular lymphoma is the most common indolent NHL; watchful waiting remains appropriate for asymptomatic low-tumour-burden disease.
- Ann Arbor staging (modified Lugano classification) is used for both HL and NHL, with PET-CT now the standard imaging modality replacing prior CT-based staging.
- Fluorodeoxyglucose (FDG) PET-CT is essential for staging, interim response assessment (Deauville score), and end-of-treatment evaluation in FDG-avid lymphomas.
- ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine) is the standard first-line regimen for classical Hodgkin lymphoma in Australia.
- R-CHOP-21 (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone every 21 days) is first-line for DLBCL and most aggressive B-cell NHL.
- Involved-site radiotherapy (ISRT) consolidates bulky disease or residual masses after chemotherapy; modern techniques minimise toxicity.
- Brentuximab vedotin (anti-CD30) and checkpoint inhibitors (nivolumab, pembrolizumab) are available in Australia for relapsed/refractory HL under PBS Authority criteria.
- Autologous and allogeneic haematopoietic stem cell transplantation remain important for relapsed/refractory disease at specialised Australian centres.
- Aboriginal and Torres Strait Islander peoples have lower survival rates for lymphoma due to delayed presentation, reduced access to specialist services, and higher comorbidity burden.
Introduction & Australian Epidemiology
Lymphoma is a heterogeneous group of malignancies arising from lymphocytes, classified broadly into Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Together they represent the sixth most common cancer in Australia, with approximately 7,000 new diagnoses annually. Treatment is guided by histological subtype, stage, and patient fitness, with CHOP-based chemotherapy regimens and anti-CD20 monoclonal antibody therapy (rituximab) forming the mainstay of management for the majority of aggressive B-cell lymphomas.
In Australia, NHL accounts for approximately 5,600 cases per year (age-standardised rate ~21 per 100,000), with incidence increasing steadily over recent decades, particularly in older adults. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype (~35–40% of NHL), followed by follicular lymphoma (~20–25%), marginal zone lymphoma, mantle cell lymphoma, and Burkitt lymphoma. T-cell and NK-cell lymphomas constitute approximately 10–15% of NHL cases.
Classical Hodgkin lymphoma (cHL) accounts for ~600–700 new cases annually in Australia, with a bimodal age distribution peaking in the 20–30 and >60 year age groups. Nodular sclerosis is the most common subtype (60–80%), followed by mixed cellularity. Lymphocyte-predominant HL (nodular lymphocyte-predominant Hodgkin lymphoma, NLPHL) is a distinct entity (~5% of HL) with different immunophenotype (CD20⁺, CD15⁻, CD30⁻) and management.
Five-year relative survival for all lymphomas in Australia is approximately 72%, with HL achieving >85% and aggressive NHL 60–70%. Survival has improved significantly with the introduction of rituximab, PET-adapted therapy, and novel targeted agents. Indigenous Australians experience worse outcomes, reflecting disparities in access to timely diagnosis and specialist oncology services.
Classification (HL vs NHL Subtypes)
The World Health Organization (WHO) Classification of Haematolymphoid Tumours (5th edition, 2022) is the standard for lymphoma classification in Australia. Accurate histopathological diagnosis by a specialist haematopathologist is essential before initiating therapy. Immunohistochemistry, flow cytometry, and molecular/cytogenetic studies are integral to classification.
Classical Hodgkin Lymphoma (cHL)
cHL is defined by the presence of Reed–Sternberg cells (large binucleated cells) within an inflammatory microenvironment. Reed–Sternberg cells are typically CD15⁺, CD30⁺, CD20⁻/weak, CD45⁻, and PAX5⁺ (weak).
| Subtype | Frequency | Key Features |
|---|---|---|
| Nodular sclerosis (NSHL) | 60–80% | Most common; young adults; mediastinal involvement; collagen bands; lacunar cells |
| Mixed cellularity (MCHL) | 15–30% | Older adults; EBV-associated; diffuse inflammatory background |
| Lymphocyte-rich (LRHL) | ~5% | Rare; favourable prognosis; nodular pattern |
| Lymphocyte-depleted (LDHL) | <1% | Very rare; advanced stage; HIV-associated; poor prognosis |
NLPHL (nodular lymphocyte-predominant HL) is a distinct B-cell neoplasm (CD20⁺, CD15⁻, CD30⁻, CD45⁺) with "popcorn cells" (lymphocyte-predominant cells). It follows a more indolent course and is treated differently from cHL — rituximab monotherapy and limited-field radiotherapy are often appropriate.
Non-Hodgkin Lymphoma — Major Subtypes
NHL encompasses a broad spectrum of B-cell (~85–90%), T-cell, and NK-cell lymphomas. Aggressive subtypes require urgent treatment; indolent subtypes may be observed.
| Subtype | Behaviour | Immunophenotype / Genetics | First-Line Therapy |
|---|---|---|---|
| Diffuse large B-cell lymphoma (DLBCL), NOS | Aggressive | CD20⁺, CD19⁺; GCB vs ABC subtypes (Hans algorithm); MYC/BCL2/BCL6 rearrangements (double/triple hit) | R-CHOP-21 × 6 cycles ± ISRT |
| Follicular lymphoma (FL) | Indolent | CD20⁺, CD10⁺, BCL2⁺, BCL6⁺; t(14;18); grading 1–3B | Watch & wait (low burden); R-CHOP or R-CVP or BR (high burden) |
| Mantle cell lymphoma (MCL) | Aggressive (usually) | CD20⁺, CD5⁺, cyclin D1⁺; t(11;14); SOX11⁺ | R-CHOP or R-HyperCVAD; R-CHOP/R-DHAP alternating; ASCT consolidation in eligible patients |
| Burkitt lymphoma | Highly aggressive | CD20⁺, CD10⁺, BCL6⁺, BCL2⁻, MYC rearrangement; Ki-67 ~100% | DA-EPOCH-R or intensive protocols (HyperCVAD/MA) |
| Marginal zone lymphoma (MZL) | Indolent | CD20⁺, CD5⁻, CD10⁻, CD23⁻; MALT — t(11;18) in gastric | Localised: RT or H. pylori eradication (gastric); Disseminated: R-bendamustine |
| Peripheral T-cell lymphoma (PTCL), NOS | Aggressive | CD3⁺, CD4⁺ or CD8⁺; heterogeneous genetics | CHOEP or CHOP; consider ASCT consolidation |
| Anaplastic large cell lymphoma (ALCL) | Aggressive | CD30⁺, ALK⁺ (favourable) or ALK⁻ (unfavourable) | CHOP or CHOEP; brentuximab vedotin + CHP (ALK⁻) |
Double-hit and triple-hit lymphomas (MYC + BCL2 and/or BCL6 rearrangements) are high-grade B-cell lymphomas with poor outcomes on standard R-CHOP. Intensive regimens such as DA-EPOCH-R or HyperCVAD/MA are recommended. All DLBCL cases should undergo FISH for MYC, BCL2, and BCL6 rearrangements.
Ann Arbor Staging (Modified Lugano Classification)
The Ann Arbor staging system, as updated by the Lugano Classification (2014), remains the standard for staging both HL and NHL. PET-CT has replaced bone marrow biopsy as the primary modality for detecting marrow involvement in FDG-avid lymphomas (HL, DLBCL, FL). The Cotswolds modifications define bulk disease and extranodal involvement.
Stage I
Single Region
Involvement of a single lymph node region (I) or single extralymphatic organ/site (IE).
Localised disease
Stage II
Two or More Regions — Same Side
Two or more lymph node regions on the same side of the diaphragm (II) ± contiguous extralymphatic extension (IIE).
Regional disease
Stage III
Both Sides of Diaphragm
Lymph node regions on both sides of the diaphragm (III), may include spleen (IIIS).
Advanced — systemic therapy required
Stage IV
Diffuse Extranodal Involvement
Diffuse/disseminated involvement of one or more extralymphatic organs (e.g., bone marrow, liver, lungs) ± lymph node involvement.
Advanced — systemic therapy required
Additional Designations
- A — absence of B symptoms
- B — presence of B symptoms: unexplained fever >38°C, drenching night sweats, or >10% unintentional weight loss over 6 months
- E — extralymphatic extension from adjacent nodal disease
- S — splenic involvement
- X — bulky disease: mediastinal mass >⅓ thoracic diameter, or nodal mass >10 cm
Prognostic Scores
| Score | Applies To | Variables | Risk Stratification |
|---|---|---|---|
| International Prognostic Score (IPS) | Advanced-stage cHL | 7 factors: albumin <40 g/L, Hb <105 g/L, male sex, stage IV, age ≥45, WCC ≥15 × 10⁹/L, lymphocytes <0.6 × 10⁹/L or <8% of WCC | 0–1 favourable (5-yr FFS ~85%); ≥4 unfavourable (~55%) |
| IPI (International Prognostic Index) | Aggressive NHL (esp. DLBCL) | 5 factors: age >60, stage III–IV, ECOG ≥2, LDH >ULN, >1 extranodal site | Low (0–1), Low-intermediate (2), High-intermediate (3), High (4–5) |
| FLIPI / FLIPI-2 | Follicular lymphoma | FLIPI: age >60, stage III–IV, Hb <120 g/L, LDH >ULN, >4 nodal sites | Low (0–1), Intermediate (2), High (≥3) |
Clinical Features & Investigations
Clinical Presentation
Lymphoma presentation varies by subtype, stage, and site of involvement. Painless lymphadenopathy is the most common presenting feature of both HL and NHL. Constitutional (B) symptoms are present in approximately 20–30% of HL and 20–40% of aggressive NHL at diagnosis and indicate more advanced disease.
- Hodgkin lymphoma: Painless cervical or supraclavicular lymphadenopathy (60–80%); mediastinal mass with cough/dyspnoea (NSHL); pruritus; alcohol-induced nodal pain (rare but pathognomonic); B symptoms in ~20–25%
- NHL — nodal: Painless lymphadenopathy (cervical, axillary, inguinal); B symptoms more common in aggressive subtypes
- NHL — extranodal: Gastrointestinal (MALT, DLBCL), skin (CTCL, DLBCL leg type), CNS (primary CNS lymphoma), testis, bone, Waldeyer's ring
- Burkitt lymphoma: Rapidly enlarging abdominal mass, jaw involvement (endemic form), tumour lysis syndrome at presentation
- Richter transformation: CLL transforming to DLBCL — rapid clinical deterioration, new B symptoms, enlarging nodes
Essential Investigations
Essential
Excisional lymph node biopsy
Gold standard for diagnosis. FNA alone is insufficient for lymphoma classification. Core biopsy acceptable only if excisional biopsy not feasible. Provide fresh tissue for flow cytometry, cytogenetics, and molecular studies.
Essential
PET-CT (whole body, FDG)
Standard staging modality for all FDG-avid lymphomas. Replaces contrast-enhanced CT for staging. Interim PET (iPET) after 2 cycles guides response-adapted therapy (Deauville 5-point scale). MBS item 61431 — PET for lymphoma staging (Medicare-eligible).
Essential
Full blood count with differential
Anaemia, lymphopenia (prognostic in HL), eosinophilia, cytopenias suggesting marrow involvement.
Essential
LDH, β₂-microglobulin, albumin, ESR
LDH elevated in aggressive lymphomas and is a component of IPI. ESR prognostic in HL. β₂-microglobulin prognostic in FL and MCL.
Available
Bone marrow biopsy
Now optional in PET-avid lymphomas staged as I/II by PET-CT. Still indicated in stage III/IV, non-FDG-avid subtypes (e.g., some indolent lymphomas), and cytopenias unexplained by PET findings.
Available
Immunohistochemistry panel
CD20, CD3, CD15, CD30, CD10, BCL2, BCL6, MUM1, Ki-67, cyclin D1, MYC, ALK, PAX5. Essential for WHO classification. Available at all Australian anatomical pathology laboratories.
Specialist
FISH for MYC, BCL2, BCL6 rearrangements
Essential in all DLBCL to identify double/triple-hit lymphomas. Available at major referral laboratories (Sonic, Douglass Hanly Moir, state referral labs). Turnaround ~7–14 days.
Available
Echocardiography
Baseline assessment prior to anthracycline-based therapy (CHOP, ABVD). LVEF assessment mandatory. MBS item 55122.
Available
Pulmonary function tests (PFTs)
Required before bleomycin-containing regimens (ABVD). Baseline DLCO; discontinue bleomycin if DLCO decline >25%.
Available
Hepatitis B & C serology, HIV
Mandatory before rituximab (HBV reactivation risk). HBsAg, anti-HBc, HBV DNA if anti-HBc positive. Lamivudine or entecavir prophylaxis if HBsAg⁺ or anti-HBc⁺/HBV DNA detectable.
Management — Chemotherapy Regimens & Radiotherapy
Treatment of lymphoma depends on histological subtype, stage, prognostic score, and patient fitness. Multidisciplinary team (MDT) discussion at a specialised lymphoma centre is mandatory for all new diagnoses in Australia.
Hodgkin Lymphoma — First-Line Therapy
ABVD Regimen
Standard first-line for cHL (all stages)
Regimen
Doxorubicin 25 mg/m² IV D1,15 · Bleomycin 10,000 IU/m² IV D1,15 · Vinblastine 6 mg/m² IV D1,15 · Dacarbazine 375 mg/m² IV D1,15
Schedule
Every 28 days (1 cycle = 2 fortnightly doses)
Duration
Early stage favourable: 2–4 cycles + 20–30 Gy ISRT; Early stage unfavourable: 4–6 cycles ± ISRT; Advanced: 6 cycles (Deauville-adapted escalation)
Key toxicity
Bleomycin pulmonary toxicity (monitor PFTs); anthracycline cardiotoxicity; peripheral neuropathy (vinblastine)
PBS status
✔ PBS General Benefit
PET-adapted therapy in HL: Interim PET after 2 cycles (iPET2) using Deauville score guides escalation/de-escalation. Deauville 1–3 (negative): proceed with ABVD, omit bleomycin (AVD) from cycle 3 onward to reduce pulmonary toxicity. Deauville 4–5 (positive): escalate to escalated BEACOPP or continue ABVD based on centre protocol and MDT discussion.
Escalated BEACOPP
Escalation option for advanced cHL with positive iPET2 or high-risk disease
Regimen
Cyclophosphamide 1250 mg/m² IV D1 · Doxorubicin 35 mg/m² IV D1 · Etoposide 200 mg/m² IV D1–3 · Procarbazine 100 mg/m² PO D1–7 · Prednisolone 40 mg/m² PO D1–14 · Vincristine 1.4 mg/m² (max 2 mg) IV D8 · Bleomycin 10,000 IU/m² IV D8
Schedule
Every 21 days with G-CSF support
Duration
6–8 cycles (Deauville-adapted)
PBS status
✔ PBS General Benefit
Diffuse Large B-Cell Lymphoma — R-CHOP
R-CHOP-21
MabThera® (rituximab) · Standard first-line for DLBCL
Regimen
Rituximab 375 mg/m² IV D1 · Cyclophosphamide 750 mg/m² IV D1 · Doxorubicin 50 mg/m² IV D1 · Vincristine 1.4 mg/m² (max 2 mg) IV D1 · Prednisolone 100 mg PO D1–5
Schedule
Every 21 days
Duration
6 cycles (limited stage with non-bulky disease may be treated with 3–4 cycles + ISRT)
Key toxicity
Myelosuppression (neutropenia — consider G-CSF); tumour lysis syndrome; cardiac (doxorubicin cumulative); peripheral neuropathy (vincristine); HBV reactivation (rituximab)
PBS status
✔ PBS General Benefit (rituximab — Authority Required for NHL)
Tumour lysis syndrome (TLS) prophylaxis: High-risk patients (Burkitt, high-grade lymphoma, LDH >2× ULN, large tumour bulk) require aggressive hydration (≥3 L/m²/day IV), allopurinol 300 mg PO daily or rasburicase 0.2 mg/kg IV, and close electrolyte monitoring (potassium, phosphate, calcium, uric acid) 12–24 hourly for the first 48–72 hours of treatment.
Alternative & Salvage Regimens
| Regimen | Indication | Components |
|---|---|---|
| R-CEOP | DLBCL — cardiac contraindication to doxorubicin | Rituximab, cyclophosphamide, etoposide, vincristine, prednisolone |
| R-CVP | Indolent NHL (FL, MZL) — first-line | Rituximab, cyclophosphamide, vincristine, prednisolone |
| Bendamustine + Rituximab (BR) | FL, MCL, CLL/SLL — first-line or relapse | Bendamustine 90 mg/m² IV D1–2 · Rituximab 375 mg/m² IV D1; every 28 days × 6 |
| R-DHAP | Relapsed/refractory DLBCL — salvage pre-ASCT | Rituximab, dexamethasone, high-dose cytarabine, cisplatin |
| R-ICE | Relapsed/refractory DLBCL — salvage pre-ASCT | Rituximab, ifosfamide, carboplatin, etoposide |
| GDP (Gemcitabine, dexamethasone, cisplatin) | Relapsed/refractory HL or NHL — salvage | Gemcitabine 1000 mg/m² IV D1,8 · Dexamethasone 40 mg PO D1–4 · Cisplatin 75 mg/m² IV D1; every 21 days |
| DA-EPOCH-R | Double-hit DLBCL, Burkitt lymphoma, primary mediastinal B-cell lymphoma | Dose-adjusted etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin, rituximab; 96-hr continuous infusion |
Novel & Targeted Agents (Relapsed/Refractory)
Brentuximab vedotin
Adcetris® · Anti-CD30 antibody-drug conjugate
Indication
Relapsed/refractory cHL; CD30⁺ PTCL (ALCL); frontline cHL (brentuximab + AVD replacing bleomycin — ECHELON-1 trial)
Dose
1.8 mg/kg IV every 21 days
Key toxicity
Peripheral neuropathy (dose-limiting); neutropenia; tumour lysis
PBS status
⚡ PBS Authority Required (relapsed/refractory cHL; post-ASCT consolidation)
Nivolumab
Opdivo® · Anti-PD-1 checkpoint inhibitor
Indication
Relapsed/refractory cHL after ASCT and brentuximab vedotin failure (CheckMate-205)
Dose
3 mg/kg IV every 14 days until disease progression
Key toxicity
Immune-related adverse events: pneumonitis, colitis, hepatitis, thyroiditis, hypophysitis
PBS status
⚡ PBS Authority Required (relapsed/refractory cHL)
Tisagenlecleucel / Axicabtagene ciloleucel
Kymriah® / Yescarta® · CAR-T cell therapy
Indication
Relapsed/refractory DLBCL after ≥2 lines of therapy (JULIET / ZUMA-1 trials)
Administration
Single IV infusion after lymphodepletion (fludarabine + cyclophosphamide)
Key toxicity
Cytokine release syndrome (CRS); immune effector cell-associated neurotoxicity syndrome (ICANS)
PBS status
🔒 PBS Authority Required — Life Saving Drugs Programme (restricted to approved CAR-T centres)
Radiotherapy in Lymphoma
Modern radiotherapy for lymphoma uses involved-site radiotherapy (ISRT) or involved-node radiotherapy (INRT) techniques, significantly reducing treatment volumes compared to historical extended-field approaches. This has markedly reduced late toxicity including secondary malignancies and cardiovascular disease.
| Indication | Dose | Setting |
|---|---|---|
| Early-stage HL (favourable) — consolidation | 20–30 Gy ISRT | After 2–4 cycles ABVD |
| Early-stage HL (unfavourable) — consolidation | 30 Gy ISRT | After 4–6 cycles ABVD |
| Advanced-stage HL — residual PET-positive mass | 30–36 Gy ISRT | After 6 cycles ABVD or BEACOPP |
| Limited-stage DLBCL — consolidation | 30–36 Gy ISRT | After 3–4 cycles R-CHOP |
| Residual mass post-R-CHOP (PET-negative) | 30–40 Gy ISRT | If bulky disease (>7.5 cm) or Deauville 3 |
| Early-stage FL (localised) | 24–30 Gy ISRT | Definitive treatment; 10-yr PFS ~50–60% |
| Primary CNS lymphoma — WBRT consolidation | 23.4–36 Gy | Only if incomplete response to chemotherapy; neurocognitive risk |
Radiotherapy access in Australia: Radiation oncology services are available in all state capitals and many regional centres. Patients in remote areas may need relocation for treatment — discuss with the treating centre and consider telehealth follow-up post-RT. Royal Australian and New Zealand College of Radiologists (RANZCR) guidelines govern treatment planning standards.
Special Populations
Pregnancy
Diagnosis:
PET-CT is contraindicated. Use MRI and ultrasound for staging. Excisional biopsy is safe. Chest X-ray with abdominal shielding is acceptable.
HL in pregnancy:
ABVD is the preferred regimen (anthracycline-based therapy is considered safe in 2nd and 3rd trimesters — Category D, but benefits outweigh risks). Avoid bleomycin in 3rd trimester if possible. Defer radiotherapy to post-partum unless life-threatening.
NHL in pregnancy:
R-CHOP may be administered in 2nd/3rd trimester for aggressive NHL requiring urgent treatment. Rituximab is Category C — avoid in 1st trimester; monitor neonatal B-cell counts if given near delivery. Consider early delivery if mature fetus and disease controlled.
Contraindicated:
Rituximab in 1st trimester; methotrexate; lenalidomide; checkpoint inhibitors; CAR-T therapy.
Paediatrics
HL in children/adolescents:
OEPA/COPDAC (EuroNet-PHL protocol) is the standard in Australia. Vincristine, etoposide, prednisolone, doxorubicin (OEPA) induction followed by cyclophosphamide, vincristine, prednisolone, dacarbazine (COPDAC) consolidation. ABVD used in adults >18 years. Aim to minimise bleomycin and alkylating agent exposure.
NHL in children:
Burkitt lymphoma: FAB/LMB or BFM protocols (high-dose methotrexate, cyclophosphamide, rituximab). DLBCL in adolescents: R-CHOP or DA-EPOCH-R. Lymphoblastic lymphoma: ALL-type induction/maintenance protocols.
Fertility:
Refer all adolescents to fertility preservation services before treatment. Sperm banking and oocyte/embryo cryopreservation may be discussed — but urgency of treatment takes priority. Gonadotrophin-releasing hormone agonists may be considered in females during alkylating agent therapy.
Elderly (≥65 years)
DLBCL:
R-CHOP remains standard for fit elderly. Full-dose R-CHOP is appropriate if ECOG 0–1 and no significant comorbidities. R-mini-CHOP (reduced-dose) is an alternative for frail patients (Lancet Oncol 2003 — Peyrade et al.). Consider Comprehensive Geriatric Assessment (CGA) to guide treatment intensity.
HL in elderly:
Prognosis significantly worse than in young adults. ABVD with dose reduction may be considered. BV-AVD (brentuximab vedotin + AVD) is an option. Bleomycin should be avoided in patients >60 years due to increased pulmonary toxicity risk.
Cardiac monitoring:
Anthracycline cardiotoxicity risk increases with age. Baseline echocardiogram mandatory. Consider dexrazoxane for cardioprotection if cumulative doxorubicin >300 mg/m². Monitor LVEF every 2–3 cycles.
Renal Impairment
Cyclophosphamide:
Reduce dose by 25% if CrCl <30 mL/min. Adequate hydration essential. Metabolites renally cleared.
Methotrexate (high-dose):
Contraindicated if CrCl <50 mL/min without dose modification. Leucovorin rescue essential. Monitor serum methotrexate levels. Glucarpidase available for life-threatening toxicity.
Cisplatin:
Avoid if CrCl <60 mL/min. Substitute carboplatin if renal function impaired. Aggressive hydration protocol required.
Rituximab:
No dose adjustment required for renal impairment.
Hepatic Impairment
Doxorubicin:
Reduce by 50% if bilirubin 35–51 µmol/L; avoid if bilirubin >51 µmol/L (UGT1A1 hepatic clearance).
Vincristine:
Reduce by 50% if bilirubin 35–51 µmol/L; reduce by 75% if bilirubin >51 µmol/L.
Rituximab:
No dose adjustment; however, monitor for HBV reactivation if underlying hepatic disease.
Immunocompromised / HIV
HIV-associated lymphoma:
cART should be continued through chemotherapy. R-CHOP is standard for HIV-DLBCL. Dose-adjusted EPOCH-R may have superior outcomes in some series. Avoid dose reductions solely based on CD4 count — full-dose therapy with concurrent cART is recommended. Prophylactic antimicrobials (co-trimoxazole, fluconazole, aciclovir) are essential.
Post-transplant lymphoproliferative disorder (PTLD):
Reduce immunosuppression as first step. Early PTLD: rituximab monotherapy. Polymorphic/monomorphic PTLD: R-CHOP. Monitor EBV viral load to guide therapy.
Monitoring & Follow-Up
During Treatment
- Blood tests: FBC, LFTs, renal function, electrolytes before each cycle. Myelosuppression nadir typically days 7–14 post-CHOP/ABVD.
- Interim PET-CT: After 2 cycles of ABVD (HL) or 2–4 cycles of R-CHOP (DLBCL) — Deauville score guides continuation of therapy.
- Cardiac monitoring: Echocardiogram or MUGA scan at baseline, then after every 2–3 cycles of anthracycline-containing therapy if cumulative dose approaching cardiotoxic thresholds.
- Pulmonary monitoring: DLCO before each cycle of bleomycin-containing therapy. Discontinue bleomycin if DLCO declines by >25% from baseline.
- HBV monitoring: HBV DNA if HBsAg⁺ or anti-HBc⁺ at baseline — repeat every 3 months during rituximab therapy.
- TLS monitoring: Uric acid, potassium, phosphate, calcium, creatinine at baseline and 12–24 hourly for 48–72 hours in high-risk patients.
End-of-Treatment Assessment
- PET-CT (Deauville criteria): Deauville 1–2 = complete metabolic response (CMR); Deauville 3 = CMR if uptake ≤ mediastinum; Deauville 4–5 = residual disease — consider biopsy or alternative therapy.
- Complete response criteria (Lugano): PET-CMR + no residual masses on CT + normal clinical examination + normal blood counts.
Long-Term Follow-Up
Years 1–2
Clinical review + examination every 3–4 months. CT chest/abdomen/pelvis at 6 and 12 months (or PET-CT if clinical concern). FBC, LDH, LFTs at each visit.
Years 3–5
Clinical review every 6 months. CT or PET only if clinically indicated. Surveillance imaging not routinely recommended in complete remission (per Lugano guidelines).
Year 5+
Annual review. Monitor for late effects: secondary malignancies (breast, lung — post-RT), cardiovascular disease (post-anthracycline/RT), thyroid dysfunction (post-neck RT), infertility.
Late effects surveillance: Patients treated with mantle/mediastinal radiotherapy have increased risk of breast cancer — annual mammography/MRI from 8–10 years post-RT (or age 25, whichever is later) per Cancer Australia guidelines. Cardiovascular risk screening (lipids, BP, glucose) is recommended annually for all patients who received anthracyclines or thoracic RT.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
📚 References
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