Tumor lysis syndrome
Tumor lysis syndrome is a common complication after treatment of high-grade, bulky NHLs (due to their exquisite sensitivity to therapy and high proliferative capacity). The syndrome is characterized by renal failure, hyperkalemia, hyperphosphatemia, and hypocalcemia.
Measures to prevent this complication include aggressive hydration, allopurinol, alkalinization of the urine, and frequent monitoring of electrolytes, uric acid, and creatinine. Dialysis is sometimes required. Rasburicase, a recombinant urate-oxidase enzyme, is now available for the prevention and treatment of hyperuricemia. (For a more comprehensive discussion of the tumor lysis syndrome, see chapter 38.)
Follow-up of long-term survivors
Relapse
The most important risk to patients with NHL is relapse. Among patients with diffuse aggressive lymphomas, most recurrences are seen within the first 2 years after the completion of therapy, although later relapses may occur. Physical examination and laboratory testing at 2- to 3-month intervals and follow-up CT scans (with or without PET scan) at 6-month intervals for the first 2 years following diagnosis are recommended. However, it is recognized that upon relapse of disease, the patient usually presents with symptoms rather than the relapse being diagnosed purely on the basis of surveillance scans or routine clinic visits.
Early detection of recurrent disease is important because these patients may be candidates for potentially curative high-dose therapy and SCT. Patients with advanced low-grade NHL are at a constant risk of relapse, and late recurrence of disease may be seen, sometimes after more than a decade-old remission.
Secondary malignancies
Long-term survivors are at increased risk of second cancers. In a survey of 6,171 patients with NHL who survived 2 or more years, nearly 1,000 patients lived 15 or more years after diagnosis. Second cancers were reported in 541 subjects, with significant excesses seen for all solid tumors, acute myeloid leukemia, melanoma, Hodgkin lymphoma, and cancers of the lungs, brain, kidneys, and bladder. The actuarial risk of developing a second malignancy at 3 to 20 years after diagnosis of NHL was 21%, compared with a population-expected cumulative risk of 15%.
Treatment complications
There has been a more selective use of irradiation as part of the initial therapy for NHL; therefore, the risk of certain radiation-induced complications has been reduced or eliminated in more recently diagnosed patients. Nevertheless, total-body irradiation may be used as a component of myeloablative conditioning regimens. Also, transplant recipients are at increased risk of secondary myelodysplasia and acute myeloid leukemia, regardless of whether they received a radiation-containing conditioning regimen. All individual chemotherapy agents have their own potential long-term morbidity.
Long-term survivors need continued follow-up for possible treatment-related complications. Some of these toxicities may still be unknown. Careful documentation of late complications will be important in the design of future treatment strategies aimed at preserving or improving response rates and the duration of remission while reducing toxicity.
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Abbreviations in this chapter
ACS = American Cancer Society; ECOG = Eastern Cooperative Oncology Group; EORTC = European Organisation for Research and Treatment of Cancer; GELF = Groupe d'Etude des Lymphomes Folliculaires; GLSG = German Lymphoma Study Group; GMCLG = German Mantle Cell Lymphoma Group; ILSG = International Lymphoma Study Group; ISCL = International Society for Cutaneous Lymphomas; JCOGS = Japanese Clinical Oncology Group Study; NCCN = National Comprehensive Cancer Network; NCCTG = North Central Cancer Treatment Group; NCI = National Cancer Institute; REAL = Revised European-American Lymphoma Classification; SEER = Surveillance, Epidemiology, and End Results; SWOG = Southwest Oncology Group
