Clinical
Practice Guideline
for
NON-HODGKIN’S LYMPHOMA
Developed
for the
Aerospace
Medical Association
by their
constituent organization
American
Society of Aerospace Medicine Specialists
Overview: Non-Hodgkin’s Lymphomas (NHL) are a
heterogeneous group of malignancies of B or T cell that usually originate in
lymph nodes but may originate in any organ of the body.
In 1993,
new cases of NHL in the
Because
there is such histologic diversity among NHL, multiple classification schemes
have been advanced. Recently, the
Working Formulation developed a morphologic classification scheme with
prognostic relevance. In this system,
NHL are divided into low-, intermediate-, and high-grade status. NHL is staged using the four-stage
Many
adverse prognostic factors have been documented, including anaplastic
histologic subtype, advanced stage of disease (III or IV), extranodal disease
(particularly CNS involvement), systemic B symptoms, tumor mass > 10
cm, elevated LDH, T-cell phenotype, nonrandom chromosomal abnormalities, and a
high proliferative index (Ki-67 antigen).
Because of
the wide variety of histologic subtypes of T and B cells, a number of cytotoxic
agents have been used in the treatment of NHL in addition to radiotherapy and
immunotherapy. Predominantly combination
regimes such as CHOP, CVP, and COP-BLAM have produced cure rates (5-year
survival rates) ranging from 20% to 85%.
These cure rates are highly variable and dependent on the previously
mentioned prognostic factors (particularly grade and stage at time of
treatment). Relapse rates up to 50% are
common. Recently bone marrow transplantation has been used in refractory cases
with limited success.
Aeromedical Concerns: If there is involvement of the CNS,
then a risk for sudden incapacitation by seizure is present. However, the greatest concern arises from the
potentially rapid (weeks to months) degradation in mental and physical status
when the lymphoma and/or the treatment protocol is aggressive. Extranodal involvement of the lungs, liver,
spleen, marrow, and heart are frequently seen with progression of disease. Additionally, damage to the cardiopulmonary,
neurologic, and reticuloendothelial systems may occur as a result of
chemotherapy and radiotherapy. Thorough
staging and documentation of status are necessary for waiver consideration.
Treatment and Aeromedical
Disposition: Initial
presentation, as a minimum, should include Hematology/Oncology consultation
CBC, CXR, ECG, PFT, staging and prognosis, with documentation of all
medications and treatments, complications, and sequelae.
Experience: The US Air Force aircrew waiver file
lists four members with NHL in remission and all received waivers (3 of the 4
received FCII waiver). Although these
numbers are small, the possibility of returning to flying status after effective
treatment of NHL is good. In civil
aviation the airman would have to be in remission for approximately one
yr. Medical certification is not granted
during any form of active treatment. At
present there are no separate statistical data on airmen with Non-Hodgkin’s
Lymphoma. Please refer to the FAA
statistical data found under Hodgkin’s Lymphoma for the numbers.
References:
Deangelis
LM. Current management of primary central nervous system
lymphoma. Oncology 1995; 9(1):63-71.
Greer JP, Malon WR, List AF, McCurley TL. Non-Hodgkin’s lymphomas. Lee GR, Bithell,
TC, Foerster J, Athens JW, Lukens JN (eds). Wintrobe’s Clinical
Hematology 1993; 9:2054-2081.
Hartge P, Devesa
SS, Fraumeni JF. Hodgkin’s and non-Hodgkin’s lymphomas Cancer
1994; 19-20:423-53.
Horning
AJ. Hodgkin
disease. Beutler E, Lichtman
MA, Coller BS, Kipps TJ (eds). Williams
Hematology. 1995; 5:1057-1075.
August 2, 2006