MIN regime in follicular lymphoma?

Question

which are the drugs included in MIN REGIMEN used in chemotherapy of follicular lympoma

Answer 1

I don't see the MIN acronym listed among treatments for follicular lymphoma. Scroll down on the web page for this link for a list of the drug regimens commonly used to treat follicular lymphoma.

http://www.emedicine.com/med/topic1362.htm

Answer 2

1

Answer 3

2

Answer 4

i'm sorry approximately this documents, any analysis like that's extremely difficult to take. Follicular Lymphoma is the main complication-free type of Non-hodgkin's lymphoma interior the US, and the propose survival age is often approximately 7-9 years after analysis. yet this actual relies upon on how plenty the main cancers had progressed after the medical doctors have been able to diagnose the condition. in spite of if, there is something referred to as 'transformation' of the lymphoma, the place the cells swap to a greater aggressive type of maximum cancers. This merely happens in 30-50% of sufferers, however the survival time after this is far less (approximately 300 and sixty 5 days). be sure you reside in close touch along with his wellbeing practitioner, so which you have a very sturdy thought of what to assume interior the arrival years.

Answer 5

3

Answer 6

The different regimens used depend on many factors, the patients age, stage of disease, etc

this link might give you some information
http://www.cancer.gov/cancertopics/pdq/treatment/adult-non-hodgkins/Patient/page6

Answer 7

means follicular disease

Answer 8

Background: Non-Hodgkin lymphoma is a heterogeneous group of malignancies of lymphocyte origin that usually arise or are present in lymphoid tissues, such as lymph nodes, spleen, and bone marrow. Nevertheless, lymphomas can arise in any organ and usually are referred to as primary extranodal lymphomas. Microscopically, follicular lymphomas exhibit a follicular or nodular pattern of growth reminiscent of germinal centers. Despite the fact that most follicular lymphomas are advanced at the time of diagnosis, the median survival of patients with follicular lymphomas is approximately 8-10 years, and many patients may not require treatment for prolonged periods of time.

Pathophysiology: Most lymphomas originate from lymph node tissue and frequently metastasize to other organs. Lymphomas can invade any organ, including the skin and central nervous system. Lymphomas cause detrimental effects by organ invasion and by obstruction of anatomical structures by a tumoral mass. For example, ureteral obstruction by enlarged lymph nodes can lead to renal failure.

Frequency:

* In the US: Non-Hodgkin lymphoma is the seventh most frequently diagnosed malignancy in the United States. Estimates indicate that more than 56,000 cases of non-Hodgkin lymphoma were diagnosed in 2005. Of those, 15-20% were follicular lymphomas.

* Internationally: In general, age-adjusted incidence rates of non-Hodgkin lymphoma are higher in more developed countries. The age-adjusted incidence rates of non-Hodgkin lymphoma varied from 3.7-14 per 100,000 person years from 1983-1987 in different countries.

Mortality/Morbidity:

* The overall survival rate at 5 years is 72-77%. Median survival is approximately 8-10 years.

* The Follicular Lymphoma International Prognostic Index (FLIPI) is predictive of survival in patients with follicular lymphomas. Five adverse prognostic factors have been shown to be correlated with reduced overall survival: age older than 60 years, Ann Arbor stage III or IV disease, hemoglobin less than 12 g/dL, presence of more than 4 nodal sites of disease, and serum lactate dehydrogenase above normal. Patients with 3 or more of the above risk factors have a 10-year overall survival rate of 36% compared with 71% for those with one or none of the above variables.

Race: Variations in racial incidence are found throughout the world. The incidence of follicular lymphomas is low in China and Japan. People of Jewish ancestry have a higher incidence of lymphoma. In the United States, the incidence is 2-3 times higher in Caucasians than in African Americans.

Sex: The male-to-female ratio is approximately 1:1.

Age: Median age at diagnosis is 60-65 years. The incidence of follicular lymphomas increases with age. Follicular lymphomas are extremely rare in children.

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History:

* Painless, slowly progressive adenopathy is the most frequent clinical presentation.

* Some patients have waxing and waning adenopathy.

* Systemic symptoms, such as fever, night sweats, weight loss in excess of 10%, or asthenia, are infrequent at presentation but can be observed in later stages of the disease. Progression to an intermediate-grade or high-grade lymphoma should be considered when a patient develops systemic symptoms.

* Symptoms related to bone marrow dysfunction, such as anemia, leukopenia, or thrombocytopenia, are rare at presentation but can be observed in the later stages of the disease.

Physical:

* All lymph node areas should be examined, including the retroauricular, submandibular, cervical, supraclavicular, axillary, epitrochlear, inguinal, and popliteal areas.

* Involved nodes typically are nontender, firm, and rubbery in consistency.

* Splenomegaly is present in approximately 50% of patients at presentation.

* The throat should be examined for involvement of the oropharyngeal lymphoid tissue (ie, Waldeyer ring).

Causes:

* Acquired nonrandom chromosomal translocations

o The most common in patients with follicular lymphomas is the t(14;18) translocation, which is found in more than 80% of cases. This chromosomal translocation brings the bcl2 protooncogene under the transcriptional influence of the immunoglobulin heavy-chain gene. This translocation leads to the overexpression of a functionally normal bcl-2 protein. Overexpression of the bcl-2 protein, a protein of the mitochondrial membrane, confers a survival advantage to the cancer cells by inhibiting programmed cell death, or apoptosis. Although the exact mechanism of action of bcl-2 is unclear, its interaction with other homologs is felt to determine the likelihood of a cell undergoing apoptosis.

o The detection of the t(14;18) product by polymerase chain reaction is used frequently in the diagnosis and follow-up of patients with follicular lymphomas. Nevertheless, this translocation has been detected in healthy patients and in patients with other types of tumors.

* Viruses have been implicated as etiologic factors for lymphomas, including the Epstein-Barr virus, human T-cell lymphotropic virus type I, and the herpesvirus associated with Kaposi sarcoma (ie, human herpesvirus 8). Nevertheless, these viruses have been linked mostly to diffuse or high-grade lymphomas.

* Chemicals, such as pesticides and hair dyes, have been associated with lymphoma.

* Immunodeficiency states

o Congenital immunodeficiencies have been associated with lymphoma.

o Acquired immunodeficiencies may include infection with the human immunodeficiency virus. Most lymphomas associated with the human immunodeficiency virus are intermediate-grade or high-grade lymphomas.

o Patients who have been on immunosuppressant drugs after organ transplantation may develop lymphoma. Most of the lymphomas observed after organ transplantation are diffuse or high-grade lymphomas.

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Chronic Lymphocytic Leukemia
Lymphoma, Diffuse Large Cell
Lymphoma, Diffuse Mixed
Lymphoma, Lymphoblastic
Mucosa-Associated Lymphoid Tissue


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Lab Studies:

* Complete blood count should be obtained, including examination of the peripheral blood smear.

* Frequently, abnormal lymphocytes can be identified in the blood smear.

* Blood chemistries, including LDH, uric acid, liver function tests, and creatinine, should be assessed.

* LDH is an indicator of tumor load.

o Elevated LDH is a negative prognostic factor.

o Hyperuricemia can be observed upon presentation or during therapy.

o Allopurinol should be considered in patients with hyperuricemia and before treatment to prevent uric acid nephropathy.

o Increased creatinine can be observed in patients with renal obstruction caused by lymphadenopathy.

o Increased alkaline phosphatase and bilirubin can be observed in patients with biliary obstruction due to lymphadenopathy.

Imaging Studies:

* Chest radiograph should be performed.

* CT scan of chest should be considered if the findings from the chest radiograph are abnormal or cause suspicion.

* CT scans of the abdomen and pelvis should be performed to determine if abdominal or pelvic adenopathy is present.

* CT scans allow visualization of the kidneys, ureters, and the hepatobiliary system. At times, these organs are affected by obstruction due to lymphadenopathy or by parenchymal involvement with lymphoma.

* Positron emission tomography (PET) scanning complements standard radiologic testing, but only a minority of patients will be diagnosed with a higher stage of disease.

* PET scanning can distinguish between viable tumor and fibrosis in patients with residual lymphadenopathy after therapy, but because the majority of patients with follicular lymphoma are not curable, this finding will not change management. This is in contrast to Hodgkin lymphoma and intermediate-grade lymphoma where a positive PET scan might prompt salvage chemotherapy or radiation.

Procedures:

* Pathologic diagnosis from biopsy specimen

o Biopsy is essential to establish a diagnosis of lymphoma. Obtain an excisional biopsy of an involved node.

o A needle aspiration is not adequate for the initial diagnosis of lymphoma. If the disease is extranodal, a surgical biopsy sample should be obtained from the involved organ.

* Bilateral posterior iliac crest bone marrow aspiration and biopsies

o Although a diagnosis of follicular lymphoma can be established based on histologic findings from lymph nodes and involvement of the bone marrow can be diagnosed using morphologic criteria, cytogenetic analysis of bone marrow cells should be performed because the t(14;18) translocation is found in the majority of patients with follicular lymphoma and can help establish the diagnosis.

o Immunophenotyping of bone marrow using flow cytometry also should also be performed. It can detect an abnormal clone of B cells, which also can help establish the diagnosis.

o Polymerase chain reaction for bcl-2 in bone marrow also can help establish the diagnosis because the majority of follicular lymphomas are positive for bcl-2.

Histologic Findings: Follicular lymphomas exhibit a follicular or nodular pattern of growth reminiscent of germinal centers. This follicular pattern of growth contrasts with diffuse lymphomas, which usually are intermediate or high-grade neoplasms.

Several pathologic classification systems have been used since the late 1960s, including the Rappaport, Lukes-Collins, Kiel, Working Formulation, Revised European-American Classification of Lymphoid Neoplasms (REAL), and World Health Organization (WHO). Early classification systems relied solely on the architecture and cytologic appearance of lymph nodes. As more sophisticated tests became available, immunophenotypic, cytogenetic, and molecular criteria were incorporated in the diagnosis of lymphomas. REAL was based on the premise that a classification should attempt to define disease entities using all available information, including morphology characteristics and immunophenotypic, genetic, and clinical features.

More recently, the WHO classification of lymphoid neoplasms adopted the REAL classification and proposed several changes. The WHO classification changed the nomenclature from follicle center cell lymphoma to follicular lymphoma. The WHO classification calls for grading of the follicular lymphoma from grades 1-3 based on the number of centroblasts per high-power field (hpf) and recognizes the importance of reporting on the presence of diffuse areas. In addition, the WHO classification recognizes 2 variants of follicular lymphomas: cutaneous follicle center cell lymphoma and diffuse follicle center lymphoma. Follicular lymphoma according to the WHO classification is staged as grade 1 (0-5 centroblasts per hpf), grade 2 (6-15 centroblasts per hpf), and grade 3 (>15 centroblasts). Variants include cutaneous follicle center cell lymphoma and diffuse follicle center cell lymphoma.

Importantly, progression to diffuse large-cell lymphoma occurs in 10-50% of patients depending on the duration of disease presence. Transformation to diffuse large-cell lymphoma frequently is associated with rapid progression of the disease, including increasing adenopathy, development of systemic symptoms, and infiltration of extranodal sites. Progression to large-cell lymphoma is a poor prognostic factor, and most patients who experience transformation succumb to the disease.

Staging: Most patients with follicular lymphoma present at an advanced stage. Most patients have bone marrow involvement at diagnosis.

* Stage I - One involved lymph node or lymph node area

* Stage II - Two or more involved lymph nodes or lymph node areas on the same side of diaphragm

* Stage III - Involved lymph node or lymph node areas on both sides of diaphragm

* Stage IV - Disseminated disease such as bone marrow, liver, or central nervous system involvement

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Medical Care:

* The rare patient who presents with localized disease should be treated with radiation therapy with curative intent because as many as 50% of these patients could be cured. Unfortunately, less than 10% of patients with follicular lymphoma present with localized disease.

* Most follicular lymphomas are disseminated and incurable at the time of diagnosis, and the treatment for these lymphomas is considered palliative. Many experts recommend observation until the patient develops systemic symptoms such as fever, weight loss, or bulky lymphadenopathy. Patients in whom treatment is deferred should be followed closely for complications such as ureteral or biliary obstruction. No universally accepted first-line treatment strategy exists for stage III/IV follicular lymphoma.

* Single-agent oral chemotherapy, such as with chlorambucil, is an option that is easy to administer and well tolerated by patients. Although it rarely leads to a durable response, it may palliate symptoms.

o Fludarabine as a single agent is used less frequently because it must be given intravenously and causes a significant degree of myelosuppression and immunosuppression.

o Rituximab (Rituxan), a monoclonal antibody targeting the CD20 antigen expressed on the cell surface of most lymphoma cells, has demonstrated efficacy as a single agent and as part of combination chemotherapy regimens. Several phase II clinical trials have demonstrated improved progression-free survival when used as initial therapy and in previously treated patients. Recent studies using rituximab as maintenance therapy suggest that this strategy prolongs progression-free survival in patients who had an objective response or stable disease to rituximab monotherapy. It is generally well tolerated but is significantly more expensive than most other therapies with no definitive improvement in overall survival.

* Combination chemotherapy, such as with cyclophosphamide, vincristine, and prednisone (CVP) or cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), is used frequently when patients have recurrence or progression after single-agent chemotherapy or when patients present with rapidly progressive disease. Combination chemotherapy such as CHOP is also used when follicular lymphomas undergo transformation to intermediate or aggressive histology, although the results of therapy for patients who experience transformation to an aggressive histology are poor. Rituximab has also been added to combination chemotherapy regimens, including CVP and CHOP, and has been shown to improve progression-free survival in phase III clinical trials when compared with CVP or CHOP alone.

* Bone marrow/stem cell transplantation is used increasingly as therapy for follicular lymphomas, especially in young patients. Allogeneic bone marrow/stem cell transplantation can induce long-term remissions in patients with follicular lymphomas, but transplant-associated mortality is high. Autologous bone marrow transplantation has low transplant-associated mortality, prolongs progression-free survival, and potentially overall survival in patients with advanced-stage disease, but most patients relapse after this modality of therapy.

* Follicular lymphoma is inherently radiosensitive so the development of targeted radioimmunotherapy to the CD20 marker expressed on B cells has been a significant advance. It enables the delivery of cytocidal doses of radiation to all sites of disseminated disease. Currently, 2 agents are available: iodine-131-labeled tositumomab (Bexxar) and yttrium-90-labeled ibritumomab tiuxetan (Zevalin). In phase III clinical trials, both agents have produced high response rates in patients with relapsed or refractory follicular lymphoma and have demonstrated impressive response rates in treatment-naive patients as well.

Surgical Care: The role of the surgeon is to obtain an excisional biopsy adequate to establish the diagnosis. The surgeon should be instructed about the proper handling of the specimen and the special tests required because the biopsy might require special handling. The surgeon should probably discuss these issues with the pathologist prior to performing the biopsy.

Consultations: Radiation oncologist: Radiation therapy with curative intent should be used in patients with stage I disease, although this represents a minority of cases of follicular lymphoma. Radiation therapy also can be used to treat localized or bulky lymphadenopathy that is causing obstruction or when a more urgent response is desired to relieve obstruction. Radiation therapy usually is tolerated well and, in many instances, can spare the patient the need for additional chemotherapy. The radiation oncologist is also involved in the care of patients receiving radioimmunotherapy.
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The treatment of follicular lymphoma varies widely. At present, defining a standard treatment for follicular lymphomas is difficult. Many patients are asymptomatic at the time of diagnosis and are incurable with conventional chemotherapy; therefore, many experts recommend a watch-and-wait approach. This approach is used most commonly in elderly patients and requires close follow-up to avoid complications of the disease, such as organ obstruction by lymphadenopathy.

Most patients eventually require therapy because of systemic symptoms, increasing adenopathy, or splenomegaly or because of low blood counts due to bone marrow involvement by lymphoma. When these patients require treatment, single-agent oral alkylating agents such as chlorambucil with or without steroids (eg, prednisone), has been the initial regimen for many patients. Phase III clinical trials have recently shown significant improvements in progression-free survival, time to retreatment, and in some studies overall survival in patients who were treated with rituximab alone or in addition to combination chemotherapy regimens.

Single-agent chemotherapy: Because most patients with follicular lymphomas experience a recurrence of disease after the initial treatment, additional therapy usually is necessary. If the patient has enjoyed a prolonged remission after treatment with oral alkylating agents, with or without prednisone, this regimen can be used again. Rituximab, a chimeric antibody that recognizes the CD20 antigen present on most follicular lymphoma cells, is being used increasingly for the treatment of patients with relapsed follicular lymphomas. In patients who responded to rituximab as initial therapy, many will benefit from maintenance rituximab to prolong duration of response or from repeating therapy with rituximab at the time of progression. Fludarabine has been used for treatment as well, but, while it will induce remission, it causes significant bone marrow suppression and immunosuppression.

Combination chemotherapy: Because younger patients are more likely to succumb to the disease, a more aggressive therapy, such as combination chemotherapy, is used frequently to obtain more durable remissions. Combination chemotherapy with CVP or CHOP, with or without rituximab, is used frequently in young patients with follicular lymphomas or in those with rapidly progressive disease. At present, no studies demonstrate the superiority of combination chemotherapy over single agents as initial therapy of follicular lymphomas in terms of an overall survival benefit; however, they are associated with improved progression-free survival. Combination chemotherapy also is used in patients with relapsed disease and in those who do not respond to single-agent therapy. Combination chemotherapy also has been used in patients whose condition transforms to the more aggressive diffuse lymphomas.

Allogeneic stem cell transplantation is generally considered in younger patients with aggressive disease because the process has a significant amount of therapy-related morbidity and mortality. Autologous stem cell transplantation, like combination chemotherapy, has been associated with improvements in progression-free survival, but most patients will relapse following this therapy.

Radioimmunotherapy has been proven to induce high rates of complete remission in both heavily pretreated and treatment-naive patients. Further study is needed to determine if this will translate to an improvement in overall survival to evince where these agents fit in the treatment of follicular lymphoma.

All of the medications listed below should only be ordered by physicians who have training and/or experience in antineoplastic agents.

Drug Category: Antineoplastic agent, alkylating agent -- These agents inhibit cell growth and proliferation.
Drug Name
Chlorambucil (Leukeran) -- A bifunctional alkylating agent of the nitrogen mustard type that has been found to be active against selected human neoplastic diseases. Chlorambucil is known chemically as 4-[bis(2chlorethyl)amino]benzene butanoic acid.
Entire daily dose may be given at one time. These dosages are for initiation of therapy or for short courses of treatment. The dosage must be carefully adjusted according to the response of the patient and must be reduced as soon as an abrupt fall in the white blood cell count occurs.
Adult Dose 0.4 mg/kg PO once q2wk, titrate as needed; or daily dosing as 0.1-0.2 mg/kg PO daily for 3-6 weeks as needed; usual dose for average patient is 4-10 mg/d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; previous resistance to medication; pregnancy
Interactions None reported
Pregnancy D - Unsafe in pregnancy
Precautions Because of carcinogenic properties, should not be given to patients with conditions other than malignant lymphomas or chronic lymphatic leukemia; convulsions, infertility, leukemia, and secondary malignancies observed when employed in therapy of malignant and nonmalignant diseases
Most common adverse effect is bone marrow suppression; although bone marrow suppression frequently occurs, usually reversible if chlorambucil withdrawn early enough; irreversible bone marrow failure reported; should not be given at full dosages until 4 wk after a full course of radiation therapy or chemotherapy because of vulnerability of bone marrow to damage under these conditions; if pretherapy leukocyte or platelet counts are depressed from bone marrow disease process prior to institution of therapy, treatment should be instituted at reduced dosage
GI disturbances (eg, nausea and vomiting, diarrhea, and oral ulceration) occur infrequently
Tremors, muscular twitching, confusion, agitation, ataxia, flaccid paresis, and hallucinations reported as rare adverse effects that resolve upon discontinuation of the drug
Rare, focal, and/or generalized seizures reported to occur in both children and adults at both therapeutic daily doses and pulse-dosing regimens and in acute overdose
Skin hypersensitivity (including rare reports of skin rash progressing to erythema multiforme, toxic epidermal necrolysis, and Stevens-Johnson syndrome) reported
Other reported adverse reactions include pulmonary fibrosis, hepatotoxicity and jaundice, drug fever, peripheral neuropathy, interstitial pneumonia, sterile cystitis, infertility, leukemia, and secondary malignancies
Cross-hypersensitivity (skin rash) may occur between chlorambucil and other alkylating agents
Drug Name
Cyclophosphamide (Cytoxan) -- Cyclic polypeptide that suppresses some humoral activity. Chemically related to nitrogen mustards. Activated in the liver to its active metabolite, 4-hydroxycyclophosphamide, which alkylates the target sites in susceptible cells in an all-or-none type reaction. As an alkylating agent, the mechanism of action of the active metabolites may involve cross-linking of DNA, which may interfere with growth of normal and neoplastic cells.
Biotransformed by cytochrome P-450 system to hydroxylated intermediates that break down to active phosphoramide mustard and acrolein. Interaction of phosphoramide mustard with DNA is considered cytotoxic.
In high doses, affects B cells by inhibiting clonal expansion and suppression of production of immunoglobulins. With long-term low-dose therapy, affects T-cell functions.
Adult Dose CHOP regimen: 750 mg/m2 IV on day 1, repeat q3wk
CVP regimen: 750 mg/m2 IV on day 1, repeat q3wk

Oral regimens: 50-100 mg/m2/d PO continuously or 400-1000 mg/m2 PO in divided doses for 4-5 d or 400-1800 mg/m2 (30-50 mg/kg) IV in divided doses over 2-5 d; may repeat at 2- to 4-wk intervals
Pediatric Dose Not established
Contraindications Documented hypersensitivity; severely depressed bone marrow function
Interactions Allopurinol may increase risk of bleeding or infection and enhance myelosuppressive effects; may potentiate doxorubicin-induced cardiotoxicity; may reduce digoxin serum levels and antimicrobial effects of quinolones; toxicity may increase with chloramphenicol; may increase effect of anticoagulants; coadministration with high doses of phenobarbital may increase leukopenic activity; thiazide diuretics may prolong cyclophosphamide-induced leukopenia; coadministration with succinylcholine may increase neuromuscular blockade by inhibiting cholinesterase activity
Pregnancy D - Unsafe in pregnancy
Precautions Regularly examine hematologic profile (particularly neutrophils and platelets) to monitor for hematopoietic suppression; may cause sterility; nausea and vomiting are common with intravenous dosing regimen; anorexia, diarrhea, mucositis, and stomatitis are also seen; potentially fatal acute hemorrhagic cystitis may occur; facial flushing, headache, and rash may also occur
Drug Category: Antineoplastic, Antimetabolite -- Interfere with metabolic pathways necessary for the survival of target cells.
Drug Name
Fludarabine (Fludara) -- Contains fludarabine phosphate, a fluorinated nucleotide analog of the antiviral agent vidarabine, 9-b-D-arabinofuranosyladenine (ara-A) that is relatively resistant to deamination by adenosine deaminase. Dosage may be decreased or delayed based on evidence of hematologic or nonhematologic toxicity. Physicians should consider delaying or discontinuing drug if neurotoxicity occurs. Optimal duration of treatment not clearly established. Recommended that 3 additional cycles of fludarabine be administered following achievement of maximal response, and then drug should be discontinued.
Adult Dose 25 mg/m2 IV over approximately 30 min qd for 5 d; each 5-d course of treatment should commence q28d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; breastfeeding; bone marrow suppression
Interactions Combination with other purine analogs (eg, pentostatin) because incidence of pulmonary toxicity is unacceptably high when used together
Pregnancy D - Unsafe in pregnancy
Precautions Perform frequent peripheral blood counts to detect development of anemia, thrombocytopenia, and neutropenia; monitor for tumor lysis syndrome; adjust dose for renal impairment, severe bone marrow suppression, severe neurological effects, or life-threatening and fatal autoimmune hemolytic anemia
Drug Category: Antineoplastic agent, anthracycline -- These agents inhibit DNA synthesis.
Drug Name
Doxorubicin (Adriamycin) -- Cytotoxic anthracycline antibiotic isolated from cultures of Streptomyces peucetius var caesius. Blocks DNA and RNA synthesis by inserting between adjacent base pairs and binding to sugar-phosphate backbone of DNA, which causes DNA polymerase inhibition. Binds to nucleic acids presumably by specific intercalation of anthracycline nucleus with DNA double helix. Also a powerful iron chelator. Iron-doxorubicin complex induces production of free radicals that can destroy DNA and cancer cells. Can also cause DNA strand breakage through effects on topoisomerase II. Maximum toxicity occurs during the S phase of the cell cycle.
Has multiphasic disappearance curve, with half-lives ranging up to 30 h. Does not cross blood-brain barrier but is taken up rapidly by the heart, lungs, liver, kidney, and spleen.
This drug is both mutagenic and carcinogenic. Dosage related to body surface area.
Adult Dose CHOP regimen: 50 mg/m2 IV once on day 1, repeat q3wk
Pediatric Dose Not established
Contraindications Documented hypersensitivity; severe heart failure, cardiomyopathy, impaired cardiac function, preexisting myelosuppression
Interactions May decrease phenytoin and digoxin plasma levels; phenobarbital may decrease plasma levels of doxorubicin; cyclosporine may induce coma or seizures; mercaptopurine increases toxicity of doxorubicin; cyclophosphamide increases cardiac toxicity of doxorubicin
Pregnancy D - Unsafe in pregnancy
Precautions Irreversible cardiac toxicity and myelosuppression may occur; extravasation may result in severe local tissue necrosis; reduce dose in patients with impaired hepatic function
Drug Category: Antineoplastic agent, vinca alkaloid -- These agents inhibit cell growth and proliferation at the mitotic phase of the cell cycle.
Drug Name
Vincristine (Oncovin, Vincasar) -- Binds to microtubular protein of the mitotic spindle, inhibiting key steps in the cell cycle
Adult Dose CHOP regimen: 1.4 mg/m2 IV once q3wk maximum single dose not to exceed 2 mg
Pediatric Dose Not established
Contraindications Documented hypersensitivity; intrathecal administration
Interactions Acute pulmonary reaction may occur when taken concurrently with mitomycin-C; asparaginase, CYP450 3A4 inhibitors (eg, itraconazole, quinupristin/dalfopristin, sertraline, ritonavir), GM-CSF (eg, sargramostim, filgrastim), or nifedipine may increase toxicity associated with vincristine; CYP450 3A4 inducers (eg, carbamazepine, phenytoin, phenobarbital, rifampin) may decrease effects
Pregnancy D - Unsafe in pregnancy
Precautions Caution in severe cardiopulmonary disease, hepatic impairment (adjust dose), or pre-existing neuromuscular dysfunction; Constipation, paralytic ileus, and urinary tract disturbances may occur
Drug Category: Corticosteroids -- Have anti-inflammatory effects in disorders of many organ systems. Corticosteroids also are lympholytic and modify the body's immune responses to diverse stimuli.
Drug Name
Prednisone (Deltasone, Orasone, Sterapred) -- Immunosuppressant for treatment of autoimmune disorders; may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear cell activity. Induction of cell death in immature lymphocytes.
Adult Dose 60-100 mg PO qd for 5 d; repeat q21d
Pediatric Dose Not established
Contraindications Documented hypersensitivity; viral, connective tissue, and fungal or tubercular skin infections; peptic ulcer disease; hepatic dysfunction; GI bleeding or ulceration
Interactions Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; concurrent use with NSAIDs may increase the risk of gastrointestinal ulceration; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics
Pregnancy B - Usually safe but benefits must outweigh the risks.
Precautions Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use
Prolonged use of corticosteroids may produce posterior subcapsular cataracts and glaucoma with possible damage to optic nerves and may enhance establishment of secondary ocular infections due to fungi or viruses
Average and large doses of hydrocortisone or cortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium; effects are less likely to occur with synthetic derivatives, except when used in large doses; dietary salt restriction and potassium supplementation may be necessary
All corticosteroids increase calcium excretion
Administration of live or live attenuated vaccines is contraindicated in patients receiving immunosuppressive doses of corticosteroids; killed or inactivated vaccines may be administered to patients receiving immunosuppressive doses of corticosteroids, but response may be diminished
Use of prednisone in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis in which the corticosteroid is used for management of the disease in conjunction with an appropriate antituberculous regimen; if corticosteroids are indicated in latent tuberculosis or tuberculin reactivity, close observation necessary because reactivation of the disease may occur
During prolonged corticosteroid therapy, patients should receive Pneumocystis prophylaxis; if exposed to chicken pox, prophylaxis with varicella-zoster immune globulin (VZIG) may be indicated; if exposed to measles, prophylaxis with pooled intramuscular immunoglobulin (IG) may be indicated; if chicken pox develops, treatment with antiviral agents may be considered
Drug Category: Monoclonal antibodies -- Bind to target cells and recruit immune-effector functions to mediate target-cell lysis.
Drug Name
Rituximab (Rituxan) -- A chimeric murine/human monoclonal antibody directed against the CD20 antigen found on the surface of normal and malignant B lymphocytes. Rituximab binds to the cell surface and activates complement-dependent cytotoxicity and binds to human Fc receptors, mediating cell death through antibody-dependent cellular toxicity.

Can be used as first-line or salvage therapy, as monotherapy, or in addition to combination chemotherapy regimens.
Adult Dose 375 mg/m2 given as IV infusion qwk for 4 doses (days 1, 8, 15, and 22)
Pediatric Dose Not established
Contraindications Documented hypersensitivity to murine proteins or any component of formulation
Interactions Prior exposure to monoclonal antibodies may increase the risk for allergic reactions to rituximab
Pregnancy C - Safety for use during pregnancy has not been established.
Precautions An infusion-related symptom complex consisting of fever and chills/rigors may occur; other frequent infusion-related symptoms include nausea, urticaria, fatigue, headache, pruritus, bronchospasm, dyspnea, sensation of tongue or throat swelling (angioedema), rhinitis, vomiting, hypotension, flushing, and pain at disease sites; reactions generally occur within 30 min to 2 h of beginning of first infusion and resolve with slowing or interruption of infusion and with supportive care (IV isotonic sodium chloride solution, diphenhydramine, and acetaminophen)
Mild-to-moderate hypotension that requires interruption of infusion with or without administration of IV isotonic sodium chloride solution may occur
Adverse effects include angioedema, bronchospasm, asthenia, throat irritation, flushing, tachycardia, anorexia, leukopenia, thrombocytopenia, anemia, peripheral edema, dizziness, depression, respiratory symptoms, night sweats, and pruritus
Severe thrombocytopenia, arrhythmias, neutropenia, anemia, aplastic anemia (pure red cell aplasia), chills, leukopenia, hypotension, bronchospasm, urticaria, headache, abdominal pain, asthenia, hypertension, nausea, vomiting, coagulation disorder, angioedema, arthralgia, pain, rhinitis, increased cough, dyspnea, bronchiolitis obliterans, hypoxia, asthma, pruritus, and rash may occur
Drug Name
Tositumomab and Iodine 131 (Bexxar) -- Murine IgG2a lambda monoclonal antibody directed against the CD20 antigen, found on surface of normal and malignant B lymphocytes. Radiolabeled tositumomab (ie, iodine I131 tositumomab) is administered following nonradiotherapeutic version to direct treatment precisely to the malignancy. Possible mechanisms of action include apoptosis, complement-dependent cytotoxicity, antibody-dependent cytotoxicity, and ionizing radiation. Indicated for CD20 positive non-Hodgkin lymphoma that has relapsed following chemotherapy and is refractory to rituximab.
Adult Dose Dosimetric step: Tositumomab 450 mg IV infused over 1 h, followed by iodine I-131 tositumomab (5 mCi I-131 and 35 mg tositumomab) IV infused over 20 min
Therapeutic step (7-14 d following dosimetric step): Tositumomab 450 mg IV infused over 1 h, followed by iodine I131 (precise dose is dependent on current platelet count)
Pediatric Dose Not established
Contraindications Documented hypersensitivity to tositumomab or murine antibodies
Interactions Live virus vaccines may not generate an immunologic response; due to frequency and duration of thrombocytopenia, antiplatelets or anticoagulants may cause exacerbation; coadministration with other drugs causing bone marrow suppression may cause additive effects
Pregnancy X - Contraindicated in pregnancy
Precautions May cause severe or life-threatening cytopenias (ie, 71% experience grade 3 or 4); may cause hypersensitivity, including anaphylaxis; may cause secondary malignancies or hypothyroidism; infusion-related symptoms (eg, fever, rigors, chills, sweating) may occur; 1 d prior to administration, administer protectant SSKI; administer acetaminophen and diphenhydramine on administration day
Drug Name
Ibritumomab tiuxetan (Zevalin) -- A murine monoclonal antibody that targets the CD20 antigen, which is chelated to the radioisotopes indium-111 or yttrium-90. Used in conjunction with rituximab to treat B-cell non-Hodgkin lymphoma (NHL) or rituximab-refractory follicular NHL. The regimen consists of 2 low doses of rituximab, an imaging dose, 2-3 whole body scans, and a therapeutic dose, which are all delivered on an outpatient basis over 8 d.
Adult Dose Day 1: Rituximab (250 mg/m2) IV infused over 4-5 h; followed by ibritumomab 1.6 mg (5 mCi indium111) IV push over 10 min; followed by a whole body scan at 2-24 h
Day 3 or 4: Whole body scan at 48-72 h
Day 4-5: Whole body scan at 90-120 h (optional)
Day 7-9: Rituximab (250 mg/m2) IV infused over 4-5 h; followed by ibritumomab 0.4 mCi/kg of yttrium90 IV push over 10 min; not to exceed 32 mCi
Note that the dose of rituximab is lower when used with ibritumomab, than as single agent
Pediatric Dose Not established
Contraindications Documented hypersensitivity; prior sensitization to murine proteins; greater than or equal to 25% lymphoma bone marrow involvement; prior myeloablative therapies; platelet count <100,000 cells/mm3; neutrophil count <1500 cells/mm3;
hypocellular bone marrow (< 15% cellularity of marked reduction in bone marrow precursors); history of failed stem cell collection; breastfeeding
Interactions Coadministration with antiplatelet or anticoagulant drugs may increase risk of cytopenias and bleeding
Pregnancy D - Unsafe in pregnancy
Precautions Therapeutic regimen, which includes rituximab administration may cause severe, and potentially fatal, infusion reactions (typically occur during first rituximab infusion with time to onset of 30-120 min) and may require interruption of drug administration (signs and symptoms of severe infusion reactions may include hypotension, angioedema, hypoxia, or bronchospasm); treatment may cause severe and prolonged thrombocytopenia and neutropenia; do not administer to those with altered biodistribution (according to body scan results); use only as single course of treatment; follow radionucleotide precautions; decrease Y-90 ibritumomab to 0.3 mCi/kg with mild thrombocytopenia (ie, 100,000-149,000 platelets/mm3); severe mucocutaneous reactions, some with fatal outcomes, have been reported with the therapeutic regimen