Lymphoma Followup Guidelines – pro

NCCN Guidelines for surveillance of aggressive lymphoma read:“Clinical follow-up every three to six months for five years and then yearly or as clinically indicated”(NCCN Guidelines™ Version 3.2011, Non-Hodgkin’s Lymphoma, page BCEL-4)May;9(5):575-84). This review concludes “Retrospective series show that most relapses are detected by signs and symptoms regardless of the imaging schedule.”

“Clinical follow-up” refers to history and exam. It does not include scans. The subject of surveillance imaging in lymphoma was also recently reviewed (Wagner-Johnston ND, Bartlett NL. Role of routine imaging in lymphoma. J Natl Compr Canc Netw. 2011

Other reviews conclude:

“Routine surveillance CT scans are of limited value in detecting asymptomatic early relapse and

other approaches are required in order to identify patients destined to relapse at an earlier stage.”

(Guppy AE, Tebbutt NC, Norman A, Cunningham D. The role of surveillance CT scans in

patients with diffuse large B-cell non-Hodgkin’s lymphoma. Leuk Lymphoma. 2003


The International Working Group is a panel of clinicians, radiologists, and pathologists with

expertise in the management of non-Hodgkin’s lymphoma. The International Working Group

2007 Guidelines for the surveillance of non-Hodgkin’s lymphoma recommend against regular

surveillance CT or PET scans (Cheson BD, Pfistner B, Juweid ME, et al. Revised response

criteria for malignant lymphoma. J Clin Oncol 2007;25:579–586).

BC Guidelines:

The following minimum follow-up tests and examinations should be performed on all patients after treatment for malignant lymphoma. Visits should be every 3 months for 2 years, then every 6 months for 3 years, then annual. Patients should be encouraged to perform careful breast and skin examination on a regular basis and to keep their immunizations up to date.

Interval Test
Every visit Lymph node, abdominal, thyroid, and skin examinationCBC, alkaline phosphatase, LDH

Chest radiograph if original disease was in the thorax

Annually Chest radiograph
  TSH level (if the thyroid gland was irradiated)
  Mammography for women beginning 10 years after diagnosis of lymphoma or at age 40 years, whichever comes first
  Pap smear
  Influenza immunization (see Appendix III)
Every 5 years Pneumococcal immunization (see Appendix III)


Family Practitioners’ Guideline for followup of lymphoma (

  • · Careful examination of lymph node sites, lungs, abdomen (liver/spleen, masses) and skin.
  • · Dental follow-up and patients should make their dentist aware if previous irradiation to mouth/salivary glands.
  • · It is appropriate to screen for secondary malignancies including myelodysplasia/acute myelogenous leukemia with a CBC, breast cancer with annual mammography after age 40-50years, melanoma with skin exam, and cervical carcinoma-in-situ with a Pap smear for the remainder of the patient’s life
  • · After external beam thyroid irradiation to doses sufficient to cure malignant lymphoma, 40-50% of patients will eventually become hypothyroid. These patients require annual TSH measurements. If the TSH level becomes elevated, the patient should be treated with life-long T4 replacement in doses sufficient to suppress TSH levels to low normal.
  • · In general, after treatment, women who continue menstruating are fertile, but men require semen analysis to provide a specific answer as to their fertility status
  • · Routine Body CT scanning.

- If a residual mass is seen on the CT after completion of all therapy, then consider PET/CT scan or consider a repeat CT scan 6 months later. Otherwise, no further routine CT scans are required.

  • · Influenza vaccine is recommended annually and pneumococcal immunization is recommended once every 6 years.
  • · Patients should be encouraged to perform careful breast and skin examinations on a regular basis.



  • · Clinical exam (neck, supraclavicular, axillary, inguinal lymph nodes, lungs, abdomen, thyroid, and skin)
  • · CBC, creatinine, LDH
  • · Chest x-ray if prior intrathoracic lymphoma


  • · Pap smear
  • · Breast exam (CBE) and Mammogram* for women after age 40 if prior chest radiotherapy (otherwise age 50)
  • · TSH** (only if the thyroid was irradiated)
  • · Influenza immunization

Elis A, Blickstein D, Klein O, Eliav-Ronen R, Manor Y, Lishner M.
Detection of relapse in non-Hodgkin’s lymphoma: role of routine follow-up studies.Am J Hematol. 2002 Jan;69(1):41-4.

Detection of relapse in non-Hodgkin’s lymphoma: Role of routine follow-up studies
Avishay Elis 1, Dorit Blickstein 2, Osnat Klein 1, Rivka Eliav-Ronen 1, Yosef Manor 1, Michael Lishner 1 *
1Departments of Medicine and Hematology, Meir Hospital, Kfar Saba and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
2Division of Hematology, Rabin Medical Center, Beilinson Campus, Petach-Tikva, and Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel

*Correspondence to Michael Lishner, Departments of Medicine, Meir Hospital, Kfar Saba 44281, Israel



non-Hodgkin’s lymphoma; relapse; remission; follow-up




Complete remission can be achieved in 60-80% of adults with diffuse aggressive non-Hodgkin’s lymphoma. However, 20-40% of them will subsequently relapse. Nevertheless, formal follow-up guidelines for recurrence detection have never been advocated. We analyzed the pattern of relapse in 30 patients with intermediate- and high-grade non-Hodgkin’s lymphoma and the value of intensive protocol for relapse detection. This protocol includes frequent follow-up visits, complete blood count, and serum LDH tests along with annual chest, abdominal, and pelvic CT scans. The median duration of complete remission was 12 months. Twenty-five relapses (83%) were suspected after an interim history and /or physical examination, whereas only 5 relapses (17%) were detected by routine radiographic or laboratory follow-up studies. The majority of relapses (19/30) were detected in sites that included the sites of prior disease. For the first 12 months of complete remission, the estimated cumulative save in charge for a follow-up strategy, based on regular visits in the hematology clinic and performing laboratory and radiologic studies as clinically indicated, is 44% of the cost of a routine intensive evaluation. A reliable and cost-effective follow-up method for non-Hodgkin’s lymphoma patients in complete remission should include frequent history and physical examination. Complementary studies should be performed according to clinical indications. Am. J. Hematol. 69:41-44, 2002. © 2002 Wiley-Liss, Inc.



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