Consenso colombiano sobre el tratamiento del linfoma folicular no Hodgkin

Autores/as

  • Myriam Rodriguez  Instituto Nacional de Cancerología E.S.E.
  • Juana del Socorro García Instituto Nacional de Cancerología E.S.E.
  • Joaquín Rosales nstituto Nacional de Cancerología E.S.E.
  • Jorge Enrique Duque Centro Medico Imbanaco
  • Virginia Abello Hospital de San José
  • Marco Grajales Universidad Nacional de Colombia
  • Mario Gómez Clínica del Country
  • Claudia Sossa Clínica Carlos Ardila Lulle
  • Claudia Casas Hospital de San José
  • Juan Felipe Combariza Universidad Nacional de Colombia
  • Guillermo Quintero Instituto Nacional de Cancerología E.S.E.
  • Andrés Felipe Cardona Instituto Nacional de Cancerología E.S.E.
  • Martha Daza Clínica Asunción
  • Leonardo Enciso Universidad Nacional de Colombia
  • Alvaro Camacho Clínica Shaio

Palabras clave:

linfoma folicular, diagnóstico, terapia, quimioterapia, radioterapia, linfoma no Hodgkin, Colombia, Consenso Colombiano de Hematología Colombiana

Resumen

Introducción: El Consenso Colombiano de Hematología Oncológica (OCHO) es un proyecto apoyado por el Instituto Na cional de Cancerología, E.S.E y por la Sociedad Colombiana de Hematología y Oncología Clínica. Su propósito es mejorar los resultados de las intervenciones realizadas en los pacientes con cáncer, ayudando a los profesionales en salud a suministrar la mejor evidencia disponible; a fin de optimizar las decisiones clínicas y promover el uso racional de los recursos.
La actividad del CCHO permite desarrollar pautas para la práctica siguiendo la metodología del grupo nominal, y los informes resultantes representan la síntesis de las recomendaciones extraídas de la información recolectada por medio de búsquedas sistemáticas de la literatura médica. La aprobación de las recomendaciones por parte de los miembros del CCHO no significa necesariamente que deba ser adoptada como política; depende del lector.

Métodos: Se revisaron las bases Medline (1966-2005), Cochrane Library (Issue 2, 2005), Embase (1974-2005), Biosis (1992-2005), Lilacs (1989-2005) y otras bases de datos relevantes. Los artículos publicados fueron seleccionados y revisados por el comité central del CCHO.
Esta guía ha sido revisada y aprobada por todos los miembros del Consenso, que incluyó hematólogos, oncólogos, epidemiólogos, hematopatólogos, un especialista en políticas de salud y un miembro de la comunidad. Tres hematólogos internacionales, de manera independiente, hicieron la revisión externa del documento de resumen. El documento final del consenso requirió un proceso formal de estandarización. Será obligatoria la revisión periódica y continua de la literatura científica y, cuando se considere apropiado, se integrara la nueva información relevante al consenso original.

Población: El ámbito del consenso son los pacientes adultos con diagnóstico de linfoma folicular no Hodgkin (LFNH).

Recomendaciones

• Puede utilizarse la escala denominada índice pronóstico internacional para linfomas foliculares (FLIPI), para la evaluación prospectiva del riesgo en los pacientes con LFNH; sin embargo, su utilización no permite modificar o ajustar las intervenciones terapéuticas según el riesgo (recomendación I, nivel de evidencia A).
• Se recomienda el uso de antraciclicos, en regímenes de quimioterapia combinada, para pacientes con linfomas foliculares citológico 3. Para los linfomas foliculares otológicos 1 y 2 también pueden ser utilizadas las antraciclinas asociadas con anticuerpos monoclonales (recomendación IIA, nivel de evidencia c).
• En los pacientes con diagnóstico de LFNH, grados citológicos 1 ó 2, que se encuentren asintomáticos, con estadio avanzado de la enfermedad, que no tengan factores pronósticos adversos y que se presenten con baja carga tumoral puede mantenerse una conducta expectante (recomendación IIB, nivel de evidencia C).
Hasta la fecha, no hay ningún experimento clínico que haya comparado la conducta expectante con algún tipo quimioterapia en pacientes jóvenes con estas características. Del grupo de pacientes con LFNH considerados candidatos para el manejo con conducta expectante que, a pesar de las explicaciones pertinentes sobre el estado de la enfermedad, el pronóstico y la condición funcional, soliciten recibir tratamiento, deben ser considerados para manejo con quimioterapia de primera línea (recomendación IIB, nivel de evidencia C).
• Los pacientes menores de 60 años con diagnóstico de LFNH, asintomáticos y sin factores pronósticos adversos, pueden ser considerados para ingresar a estudios experimentales con asignación aleatoria (recomendación IA, nivel de evidencia A).
• En los pacientes con LNHF en estadios tempranos, carentes de síntomas B, se puede indicar el uso de la radioterapia de campo comprometido, ya que ésta asegura tasas prolongadas de supervivencia libre de enfermedad y total (reco mendación IIB, nivel de evidencia B).
• Se recomienda el uso de anticuerpos monoclonales anti-CD20 en pacientes que no hayan recibido tratamiento previo, o en aquéllos en recaída y sintomáticos, en un estadio temprano o avanzado de la enfermedad pero con una expectativa de vida mayor de 3 meses. También se recomienda la utilización del anticuerpo monoclonal cuando exista compro miso visceral o cuando la enfermedad se presente con gran carga tumoral. El anticuerpo monoclonal anti-CD20 debeadministrarse asociado con esquemas de poliquimioterapia convencional, con análogos de las purinas (fludarabina) o sin ellas (previa evaluación del riesgo-beneficio respecto de las complicaciones infecciosas), debido a la mejoría demostrada en las tasas de remisión completa y de supervivencia libre de progresión (recomendación I, nivel de evidencia A).
• Se puede recomendar el uso de fludarabina en pacientes sintomáticos que se presenten con gran carga tumoral en estadios tempranos y avanzados, y para el manejo en primera línea o como rescate después de recaída o progresión, en asociación con anticuerpos monoclonales anti-CD-20 (recomendación IIB, nivel de evidencia C).
• Se recomienda el uso de radioinmunoterapia en los pacientes en recaída después del uso de esquemas de tratamiento que conten gan el anticuerpo monoclonal anti-CD20 (recomendación HA, nivel de evidencia B). Hace falta un mayor número de experimentos clínicos fase III con asignación aleatoria que evalúen la efectividad de la radioinmunoterapia como tratamiento de primera línea en LFNH. No se recomienda el uso de esta intervención como terapia inicial (recomendación HA, nivel de evidencia B).
• No se recomienda el mantenimiento con interferon (recomendación IA, nivel de evidencia A). Se requiere un número mayor de experimentos clínicos fase III con asignación aleatoria para sustentar la recomendación del uso del Rituximab como terapia de mantenimiento (recomendación IIB, nivel de evidencia B).
• En sujetos con enfermedad sistémica y quimiosensibilidad comprobada, en recaída después de la utilización de esquemas de quimioterapia combinada con anticuerpos anti-CD20, o en aquéllos refractarios al uso de radioinmunoterapia, se recomienda el trasplante de médula ósea (TMO), utilizando el anticuerpo monoclonal anti-CD20 como purga in vivo (recomendación HA, nivel de evidencia B). No hay evidencia suficiente que permita recomendar el uso de trasplante autólogo como primera línea (recomendación HA, nivel de evidencia B).

Biografía del autor/a

Myriam Rodriguez,  Instituto Nacional de Cancerología E.S.E.

 Instituto Nacional de Cancerología E.S.E.
Grupo Hematología y Trasplante de Medula Ósea,
Bogota, D.C. Colombia

Juana del Socorro García, Instituto Nacional de Cancerología E.S.E.

Grupo Hematología y Trasplante de Medula Ósea
Instituto Nacional de Cancerología E.S.E.
Bogota, D.C., Colombia

Joaquín Rosales, nstituto Nacional de Cancerología E.S.E.

Grupo Hematología y Trasplante de Medula Ósea
Instituto Nacional de Cancerología E.S.E.
Departamento de Hematología
Instituto Javeriano de Oncología
Bogota, D.C.
Colombia

Jorge Enrique Duque, Centro Medico Imbanaco


Departamento Hematología y Oncología Clínica
Centro Medico Imbanaco
Cali
Colombia

Virginia Abello, Hospital de San José

Departamento Hematología
Hospital de San José
Fundación Universitaria de Ciencias de la Salud
Grupo de Hematología y Trasplante de Medula Ósea
Clínica Marly
Bogota, D.C.
Colombia

Marco Grajales, Universidad Nacional de Colombia

Departamento de Hematología
Universidad Nacional de Colombia
Bogota, D.C.
Colombia

Mario Gómez, Clínica del Country

Departamento de Hematología
Clínica del Country
Bogota, D.C.
Colombia

Claudia Sossa, Clínica Carlos Ardila Lulle

Centro de Cáncer y Enfermedades Hematológicas
Clínica Carlos Ardila Lulle
Bucaramanga
Colombia

Claudia Casas, Hospital de San José

Departamento Hematología
Hospital de San José
Fundación Universitaria de Ciencias de la Salud
Bogota, D.C.
Colombia

Juan Felipe Combariza, Universidad Nacional de Colombia

Departamento de Hematología
Universidad Nacional de Colombia
Bogota, D.C.
Colombia

Guillermo Quintero, Instituto Nacional de Cancerología E.S.E.

Grupo Hematología y Trasplante de Medula Ósea
Instituto Nacional de Cancerología E.S.E.
Bogota, D.C.
Colombia

Andrés Felipe Cardona, Instituto Nacional de Cancerología E.S.E.

Grupo Oncología Clínica, Instituto Nacional de Cancerología E.S.E., Bogota, D.C., Colombia

Martha Daza, Clínica Asunción

Centro de Cáncer de la Clínica Asunción
Barranquilla
Colombia

Leonardo Enciso, Universidad Nacional de Colombia

Departamento de Hematología
Universidad Nacional de Colombia
Bogota, D.C.
Colombia

Alvaro Camacho, Clínica Shaio

Clínica Shaio
Bogotá, D.C.
Colombia

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Cómo citar

[1]
Rodriguez, M. et al. 2005. Consenso colombiano sobre el tratamiento del linfoma folicular no Hodgkin. Revista Colombiana de Cancerología. 9, 4 (dic. 2005), 149–175.

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01-12-2005

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