Treatment of Non-Hodgkin Lymphoma with Skin Involvement

Introduction to Treatment Approaches

The European Society for Medical Oncology recommends treating non-Hodgkin lymphoma that has spread to the skin secondarily with standard systemic chemotherapy regimens, as skin involvement represents stage IV disease requiring aggressive systemic therapy rather than skin-directed treatments 1

Primary cutaneous lymphomas present in the skin with no extracutaneous disease at diagnosis and require skin-directed therapies, whereas secondary skin involvement from systemic NHL represents disseminated disease and mandates systemic chemotherapy based on the underlying lymphoma histology 1

For patients ≤60 years old with low-risk disease, the current standard is six cycles of R-CHOP given every 14 days with eight doses of rituximab, as recommended by the European Society for Medical Oncology 2
For patients ≤60 years old with high-risk disease, six to eight cycles of R-CHOP given every 14-21 days are most frequently applied, and these patients should preferably be enrolled in clinical trials 4, 6
For patients >60 years old, eight cycles of R-CHOP combined with eight doses of rituximab given every 21 days is the current standard, as recommended by the European Society for Medical Oncology 4, 7, 2

Administer prednisone 100 mg orally daily for 5-7 days as "prephase" treatment before starting R-CHOP in patients with high tumor burden, as recommended by the European Society for Medical Oncology 8
Ensure adequate hydration and consider prophylactic allopurinol or rasburicase for highest-risk patients, as recommended by the European Society for Medical Oncology 8

Complete blood count, LDH, uric acid, HIV and hepatitis B/C screening are necessary, as recommended by the European Society for Medical Oncology 4, 5, 6
CT scan of chest and abdomen, bone marrow aspirate and biopsy, and PET scanning to delineate disease extent and establish baseline for response evaluation are necessary, as recommended by the European Society for Medical Oncology 4, 5, 6, 2

Repeat imaging after 3-4 cycles and after completion of treatment, and PET scanning is highly recommended for post-treatment assessment to define complete remission, as recommended by the European Society for Medical Oncology 4, 7, 2

Do not use skin-directed therapies as primary treatment for secondary cutaneous involvement from systemic NHL, as recommended by the European Society for Medical Oncology 1
Do not reduce chemotherapy doses to accommodate hematological toxicity unless absolutely necessary, as this significantly compromises outcomes, as recommended by the European Society for Medical Oncology 4, 8, 9

Obtain histological verification, especially for relapses >12 months after initial diagnosis, and consider salvage regimen with rituximab and chemotherapy followed by high-dose chemotherapy with stem-cell support for suitable patients, as recommended by the European Society for Medical Oncology 10, 7, 11