Lymphoma NICE guidelines July 2016 SSG 1/3/17

Diagnosis Consider excision biopsy first line “risk of surgical procedure outweighs the potential benefits” – needle core biopsy Excision if first core non-diagnostic Consider MYC FISH in all HG B-NHL BCL2 and BCL6 FISH if MYC rearranged Interpret FISH results together with age and IPI and explain potential prognostic value to patients Do not use IHC for COO prognostication

PET/CT Offer PET/CT at diagnosis for Stage I DLBCL Stage I or localised II FL Stage I or II BL with low risk features If the results will alter management Do not routinely offer for interim assessment Offer PET/CT at completion of treatment DLBCL BL Consider pre ASCT in HG NHL

FL – 1st line Offer RT first line in localised stage IIA if treatable within suitable RT volume Offer rituximab induction therapy for asymptomatic advanced FL R-CVP, R-CHOP, R-MCP, R-CHVP1, R-chlorambucil recommended first line in symptomatic, advanced FL. R-benda not considered as subject of another appraisal. R maintenance recommended as option for those responding to 1st line therapy.

r/r FL R-chemo, R-maintenance, R-monotherapy all acceptable Offer ASCT in 2nd or subsequent remission if fit enough Consider allograft if ASCT failed or not possible

Transformed FL Consider ASCT consolidation Consider allograft if needed more than one line of therapy Do not offer auto/allo to people presenting concurrently with LG and HG disease, responding to first line therapy

MALT NHL H. pylori eradication, even if negative Consider W+W if residual disease and no high risk features R-chemo or gastric radiotherapy for high risk residual disease (H.pylori –ve at diagnosis or t(11;18), or for those with symptomatic disseminated disease

Mantle cell NHL RT for localised disease W+W for non-progressive/asymptomatic Bortezomib (VR-CAP) if unsuitable for ASCT Rituximab up-front Cytarabine-containing regimen for younger, fitter patients Consolidate with ASCT if chemosensitive Bendamustine not considered Maintenance R every 2 months until disease progression in less fit, every 2 months for 3 years post ASCT

DLBCL – 1st line Consider 30Gy consolidation RT to sites of initial bulk Offer CNS prophylaxis if Testis, breast, renal or adrenal involvement IPI 4 or 5 Consider CNS prophylaxis if IPI 2 or 3

DLBCL salvage Consider R-GDP – as effective as other salvage regimens and less toxic. Primarily aiming to get to ASCT, but also beneficial if not followed by transplantation Offer ASCT if fit enough and at least a PR Consider allograft if ASCT fails or not possible

Burkitt’s R-BFM, R-CODOX-M/R-IVAC, R-HyperCVAD or R-LMB are recommended Consider DA-EPOCH-R plus IT/IV MTX in low-risk BL If not fit enough, consider R-CHOP, R-CHOEP, DA-EPOCH-R

PTCL Consider CHOP with ASCT in first CR/PR

Information and support Explain to patients with LG NHL about the risk of transformation to HG NHL

DLBCL Follow-up Offer regular clinical assessment Consider stopping regular assessment 3 years after EOT Do not offer LDH surveillance or routine surveillance imaging

Survivorship Provide EOT summaries