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Biological therapy for non Hodgkin lymphoma

Men and women discussing non Hodgkin's lymphoma

This page tells you about treatment with monoclonal antibodies for non Hodgkin lymphoma. There is information about

 

A quick guide to what's on this page

What are monoclonal antibodies?

There are several different types of biological therapies. The type used most often in lymphoma is a monoclonal antibody. Monoclonal antibodies (MABs) are proteins made in the laboratory that target the cells of particular types of cancer. A MAB called rituximab is now commonly used to treat some types of lymphoma. It is also called Mabthera.

Who can be treated

Rituximab is part of standard treatment for high grade diffuse large B cell lymphoma. Rituximab is also part of standard treatment for low grade follicular NHL that needs treatment. 

Having the treatment

You have rituximab through a drip (infusion). You may have to stay in hospital overnight for your first treatment. The number of doses of rituximab and how often you have it depend on your type of lymphoma, and whether you are having it with other drugs.

Side effects

During the infusion, you may have fever, chills and shivering, feel sick, or have an itchy rash, or headache. A small number of people also have wheezing and a drop in blood pressure. But the nurse looking after you will monitor you closely while you have the treatment.

CR PDF Icon You can view and print the quick guides for all the pages in the treating NHL section.

 

 

What monoclonal antibodies are

Monoclonal antibodies are the most common type of biological therapy used in lymphoma. Monoclonal antibodies (MABs) are proteins made in the laboratory from a single copy of a humanised antibody.

Many different monoclonal antibodies are being investigated for cancer treatment. Rituximab was the first to be licensed in the UK and is now commonly used to treat some types of lymphoma. It is also called Mabthera. Other MAB therapies are being tested for NHL.

 

Treatment with rituximab

Rituximab is the most common monoclonal antibody used in NHL.

How rituximab works

Monoclonal antibodies target particular proteins found on the surface of cells. Rituximab targets a protein called CD20. All mature B cells have the CD20 protein on the outside of the cell. The most common types of non Hodgkin’s lymphoma develop when some of the B cells become cancerous. The cancerous B cells also carry the CD20 protein. The antibody sticks to all the B cells it finds with the CD20 protein. The cells of the immune system then pick out these B cells and kill them.

B cells develop from cells in the bone marrow called stem cells. B cell stem cells do not have the CD20 protein. So they are not killed by rituximab, and normal healthy B cells can grow to replace the ones that have been killed. So normal B cell levels in the blood are restored within a few months of having the treatment in most patients. 

Who has rituximab 

Rituximab is used to treat different types of NHL, including high grade diffuse large B cell lymphoma (DLBCL) and low grade follicular lymphoma. These are the most common types of NHL.

For DLBCL, you usually have rituximab in combination with chemotherapy such as CHOP. This is called R-CHOP.

Rituximab is also standard treatment for follicular lymphoma. You may have it with chemotherapy to get rid of all signs of the lymphoma (in other words, to induce remission). Once in remission you may have rituximab regularly for up to 2 years as maintenance treatment. This aims to delay the lymphoma from coming back.

If your lymphoma comes back, you may have more chemotherapy with rituximab or rituximab on its own.

Having the treatment

You have rituximab through a drip (infusion). You may have to stay in overnight for your first treatment, but after that it is often given as an outpatient and you can go home after your treatment is over. Some people have a reaction to rituximab and need some extra drugs. The number of doses of rituximab and how often you have it depend on

  • Your type of lymphoma
  • Whether you are having it with other drugs.

Side effects of rituximab

All treatment has some side effects. But rituximab side effects tend to be mild.

You are most likely to have side effects when you first have the drug. During the infusion, you may have

  • Fever
  • Chills and shivering (rigors)
  • Feeling sick
  • Itchy rash
  • Headache

About half of the people treated with rituximab have a reaction to it. About 1 in every 20 people treated will also have

  • Wheezing
  • A drop in blood pressure

These side effects are most likely to come on in the first 2 hours of your first dose. The reaction can usually be prevented by having paracetamol and an anti histamine drug before the drip starts. If you do get side effects, they can usually be controlled by slowing down the drip or stopping it for a while. If you have a severe reaction, you may have to stay in hospital the first time you have rituximab.

 

Other monoclonal antibodies used in NHL

Ibritumomab (Zevalin) is another monoclonal antibody that is licensed for NHL. Other MABs being developed and tested include

Bexxar and Zevalin are radiolabelled monoclonal antibodies. This means they have a radioactive molecule attached to an anti CD20 monoclonal antibody. The antibodies target the B cells and the radioactive molecule kills them. Because the treatment is targeted to the B cells, only a very small amount of radioactive material has to be used for each treatment. So there should be fewer side effects than with standard radiotherapy. Low blood counts seem to be the main side effect with this type of treatment. Low blood counts can cause

  • Increased risk of infection
  • Increased risk of bruising or abnormal bleeding
  • Tiredness and breathlessness from anaemia (shortage of red blood cells)

The blood count usually recovers on its own over about 2 weeks but it may take several weeks. 

Zevalin is an anti CD20 antibody connected to a molecule of radioactive yttrium (Y-90). Zevalin is licensed for use in the UK in people with CD20 positive follicular B cell NHL who have had rituximab and either it hasn't worked or their NHL has come back since their treatment. It is also licensed as a maintenance treatment for follicular lymphoma in remission after the first course of treatment. Maintenance treatment is ongoing therapy aimed at keeping the lymphoma in remission. Zevalin is not widely available in the UK. The Scottish Medicines Consortium (SMC) has not recommended the use of Zevalin. And the National Institute of Health and Clinical Excellence (NICE) has not assessed it yet.

Bexxar is an anti CD20 antibody connected to a molecule of radioactive iodine (I-131), and epratuzumab is a monoclonal antibody that seeks out the CD22 protein. This is also found on the outside of B cells.

Alemtuzumab (MabCampath) is a monoclonal antibody that seeks out the CD52 protein. This protein is on the outside of B and T cells. It is licensed as a treatment for chronic lymphocytic leukaemia. This drug has been tested to treat NHL in combination with chemotherapy before a transplant. And it is also being looked at for T cell lymphoma of the skin.

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Updated: 31 October 2012