Non-Hodgkin Lymphoma (NHL) Treatment Regimens: Extranodal NK/T-cell Lymphoma

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NON-HODGKIN LYMPHOMA TREATMENT REGIMENS:
Extranodal NK/T-Cell Lymphoma

Clinical Trials: The National Comprehensive Cancer Network recommends cancer patient participation in clinical trials as the gold standard for treatment.

Cancer therapy selection, dosing, administration, and the management of related adverse events can be a complex process that should be handled by an experienced healthcare team. Clinicians must choose and verify treatment options based on the individual patient; drug dose modifications and supportive care interventions should be administered accordingly. The non-hodgkin lymphoma (extranodal nk/t-cell lymphoma) cancer treatment regimens below may include both U.S. Food and Drug Administration-approved and unapproved indications/regimens. These non-hodgkin lymphoma (extranodal nk/t-cell lymphoma) cancer treatment regimens are only provided to supplement the latest treatment strategies.

These Cancer Treatment Guidelines are a work in progress that may be refined as often as new significant data becomes available. The NCCN Guidelines® are a consensus statement of its authors regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult any NCCN Guidelines® is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient's care or treatment. The NCCN makes no warranties of any kind whatsoever regarding their content, use, or application and disclaims any responsibility for their application or use in any way.

(Revised 9/2016)

© 2016 by Haymarket Media, Inc.

Systemic Therapy for Extranodal NK/T-cell Lymphomas1

Note: All recommendations are Category 2A unless otherwise indicated.

Combination Chemotherapy Regimens (pegaspargase-based)

REGIMEN

DOSING

AspaMetDex2,a,b

Day 1: Methotrexate 3g/m2 IV

Days 1–4: Dexamethasone 40mg orally

Days 2, 4, 6, and 8: L-asparaginase 6000U/m2 IM.

Repeat every 21 days for 3 cycles.

SMILE3,4

Day 1: Methotrexate 2g/m2 IV

Days 2–4: Dexamethasone 40mg IV or orally + leucovorin 15mg × 4 doses/day IV or orally + ifosfamide 1500mg/m2 IV + etoposide 100mg/m2 IV

Days 8, 10, 12, 14, 16, 18, and 20: L-asparaginase 6000U/m2 IV.

Repeat every 21 days for 3 cycles.

GELOX5

Day 1: Oxaliplatin 130mg/m2 IV + pegaspargase 2500U/m2 IM

Days 1 and 8: Gemcitabine 1000mg/m2 IV.

Repeat every 21 days for a maximum of 6 cycles (including 3 cycles induction chemotherapy for stage stage IE/IIE patients followed by involved-field radiotherapy).

Concurrent Chemoradiation Therapy

DeVIC + RT6,7

Radiation 50Gy and 3 courses of DeVIC (dexamethasone, etoposide, ifosfamide, carboplatin)

Level 1 (2/3 DeVIC)

Day 1: Carboplatin 200mg/m2 IV over 30 minutes

Days 1–3: Dexamethasone 40mg IV + etoposide 67mg/m2 IV over 2 hours + ifosfamide 1g/m2 IV over 3 hours.

Level 2 (100% DeVIC)

Day 1: Carboplatin 300mg/m2

Days 1–3: Dexamethasone 40mg IV + etoposide 100mg/m2 IV + ifosfamide 1.5mg/m2.

Repeat chemotherapy every 3 weeks for 3 cycles.

VIPID + RT7,8

Radiation 40–52.8Gy and cisplatin 30mg/m2 IV for 3–5 weeks followed by 3 cycles of VIPD:

Days 1–3: Etoposide 100mg/m2 IV over 90 minutes + ifosfamide 1200mg/m2 IV over 1 hour + cisplatin 33mg/m2 IV over 1 hour + dexamethasone 40mg orally or IV.

Repeat chemotherapy every 3 weeks for 3 cycles.

Sequential Chemoradiation

SMILE + RT (for stage I, II disease)4

Day 1: Methotrexate 2g/m2 IV

Days 2–4: Dexamethasone 40mg IV or orally + leucovorin 15mg × 4 IV or orally + ifosfamide 1500mg/m2 IV + etoposide 100mg/m2 IV

Days 8, 10, 12, 14, 16, 18, and 20: L-asparaginase 6000U/m2.

Repeat every 21 days for 3 cycles, following by radiation treatment at a dose of 45–50.4Gy for 2 to 4 cycles.

Sandwich Chemoradiation

GELOX + RT9,c

Day 1: Oxaliplatin 100mg/m2 IV + pegaspargase 2500U/m2 IM

Days 1 and 8: Gemcitabine 800mg/m2 IV.

Repeat every 21 days for 2 cycles, followed by radiation treatment at a dose of 56Gy, followed by 2 to 4 additional cycles of GELOX.

Radiotherapy Alone

Radiotherapy10

• Recommended tumor dose is ≥ 50Gy

• Early or up-front RT had an essential role in improved overall survival and disease-free survival in patients with localized extranodal NK/T-cell lymphoma, nasal-type, in the upper aerodigestive tract

• Up-front RT may yield more benefits on survival in patients with stage I disease.

a Reported as a second-line regimen.

b In patients older than 70 years old: methotrexate and dexamethasone doses were decreased to 2g/m2 and 20mg for 4 days, respectively.

c Pegaspargase-based regimens are preferred. However, there are no data to recommend 1 particular regimen over another. Treatment should be individualized based on patient's tolerance and comorbidities. GELOX is an option for selected patients who cannot tolerate intensive chemotherapy.

References

1. Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Non-Hodgkin's Lymphomas V.3.2016. Available at: http://www.nccn.org. Accessed August 30, 2016.

2. Jaccard A, Gachard N, Marin B, et al. Efficacy of L-asparaginase with methotrexate and dexamethasone (AspaMetDex regimen) in patients with refractory or relapsing extranodal NK/T-cell lymphoma, a phase 2 study. Blood. 2011;117:1834–1839.

3. Yamaguchi M, Suzuki R, Kwong YL, et al. Phase I study of dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) chemotherapy for advanced-stage, relapsed or refractory extranodal natural killer (NK)/T-cell lymphoma and leukemia. Cancer Sci. 2008;99:1016–1020.

4. Yamaguchi M, Kwong YL, Kim WS, et al. Phase II study of SMILE chemotherapy for newly diagnosed stage IV, relapsed, or refractory extranodal natural killer (NK)/T-cell lymphoma, nasal type: The NK-Cell Tumor Study Group Study. J Clin Oncol. 2011;29:4410–4416.

5. Gao Y, Huang H-q, QiChun C, et al. Efficacy and safety of pegaspargase with gemcitabine and oxaliplatin in patients with treatment-naïve, refractory extranodal natural killer/T-cell lymphoma: A single-centre experience. Blood. 2013;122:642.

6. Yamaguchi M, Tobinai K, Oguchi M, et al. Concurrent chemoradiotherapy for localized nasal natural killer/T-cell lymphoma: an updated analysis of the Japan clinical oncology group study JCOG0211. J Clin Oncol. 2012;30:4044–4046.

7. Yamaguchi M, Tobinai K, Oguchi M, et al. Phase I/II study of concurrent chemoradiotherapy for localized nasal natural killer/T-cell lymphoma: Japan Clinical Oncology Group Study JCOG0211. J Clin Oncol. 2009;27:5594–5600.

8. Kim SJ, Kim K, Kim BS, et al. Phase II trial of concurrent radiation and weekly cisplatin followed by VIPD chemotherapy in newly diagnosed, stage IE to IIE, nasal, extranodal NK/T-cell lymphoma: Consortium for Improving Survival of Lymphoma study. J Clin Oncol. 2009;27:6027–6032.

9. Bi X-w, Zhang W-w, Sun P, et al. Radiotherapy and PGEMOX/GELOX regimen improved prognosis in elderly patients with early-stage extranodal NK/T-cell lymphoma. Ann Hematol. 2015;94(9):1525–1533.

10. Huang MJ, Jiang Y, Liu WP, et al. Early or up-front radiotherapy improved survival of localized extranodal NK/T-cell lymphoma, nasal-type in the upper aerodigestive tract. Int J Radiat Oncol Biol Phys. 2008 Jan 1;70(1):166–174.


Hematologic Cancer Drug Monographs

Leukemias, Lymphomas, And Other Hematologic Cancers

ADCETRIS ALKERAN ALKERAN FOR INJECTION
ARRANON ARZERRA BELEODAQ
BENDEKA BEXXAR BICNU
BLEOMYCIN BLINCYTO BOSULIF
BUSULFEX CAMPATH CERUBIDINE
CLADRIBINE CLOLAR CYCLOPHOSPHAMIDE
CYTARABINE CYTOXAN INJECTION DACOGEN
DARZALEX DEPOCYT DOXIL
DOXORUBICIN HCL DOXORUBICIN HCL SOLUTION DTIC-DOME
EMPLICITI ERWINAZE EVOMELA
FARYDAK FLUDARA FOLOTYN
GAZYVA GLEEVEC GLEOSTINE
HYDREA ICLUSIG IDAMYCIN
IDAMYCIN PFS IMBRUVICA INTRON A
INTRON A SOLN ISTODAX JAKAFI
KEYTRUDA KYPROLIS LEUKERAN
MARQIBO MATULANE METHOTREXATE FOR INJECTION
METHOTREXATE INJECTION MITOXANTRONE HCL MUSTARGEN
MYLERAN NINLARO ONCASPAR
ONTAK OPDIVO PAMIDRONATE DISODIUM INJECTION
PENTOSTATIN POMALYST PURINETHOL
PURIXAN REVLIMID RITUXAN
SPRYCEL SYNRIBO TABLOID
TARGRETIN TARGRETIN GEL TASIGNA
THALOMID TREANDA TREXALL
TRISENOX UVADEX VALCHLOR
VELCADE VENCLEXTA VESANOID
VIDAZA VINBLASTINE FOR INJECTION VINBLASTINE INJECTION
VINCASAR PFS VUMON ZEVALIN
ZOLINZA ZOMETA ZYDELIG

Data provided by the Monthly Prescribing Reference (MPR) Hematology/Oncology Edition.

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