Guidelines for the diagnosis and treatment of diffuse large B-cell lymphoma

This study reviewed updated guidelines for the staging and treatment of diffuse large B-cell lymphoma (DLBCL). 

DLBCL accounts for 30%–58% of non-Hodgkin lymphomas. In recent years there have been improvements in the treatment of DLBCL. The European Society for Medical Oncology (ESMO) recently gathered a panel of experts to update guidelines for the staging and treatment of DLBCL.

This article reviewed the ESMO guidelines.

After diagnosis, DLBCL should be staged, in order to predict outcome and direct treatment. An FDG-PET/CT scan can measure tumor activity in the body. This can help to determine where tumors are located and how many sites are involved. This scan can also measure DLBCL activity in the bone marrow. The bone marrow is the spongy center of bones where stem cells, or immature blood cells, are formed. An MRI scan or lumbar puncture (removal of fluid from the spine) can diagnose any central nervous system involvement. Heart function and fertility preservation should be discussed and tested before treatment.

Treatment should be decided based on stage and risk levels of the disease. Risk levels increase with factors such as increased age and disease stage, and increased lymph node and organ involvement.

In younger, low-risk patients, treatment should include six cycles of chemotherapy, such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Younger patients with intermediate risk disease should also receive radiation (for those with larger, bulky tumors), or the more intense chemotherapy R-ACVBP (rituximab, doxorubicin, vincristine, cyclophosphamide, bleomycin, and prednisolone). High-risk patients may also be treated with R-CHOP, but should consider taking part in a clinical trial.

R-CHOP is the standard treatment in patients 60–80 years of age. Patients over 80 should be treated with lower-intensity chemotherapy.

Patients at high risk for central nervous system disease (CNS) relapse should undergo treatment to prevent this type of disease spread. This may be methotrexate (Trexall).

FDG-PET scans can be used to measure response to treatment (after 3 to 4 cycles) and to rule out disease progression. A complete metabolic response refers to no cancer activity seen on the scan. It is not recommended to change treatment plan based on the results of these scans, unless the disease is clearly progressing.

After treatment, patients should be followed every 3 months for the first year, and every 6 months for 2 more years. Once a year follow-up should then watch for new tumors. Patients who have not relapsed by 2 years have similar survival rates to the general population.

More than 30% of patients may relapse. Patients should undergo testing to restage the disease. Treatment in patients under the age of 65–70 should include rituximab and chemotherapy. This should be followed by high-dose chemotherapy and stem cell transplantation with cells removed from the patient. If patients relapse after this transplant, stem cells from a sibling or matched donor (someone with a similar genetic makeup) can be tried. Patients who are older or cannot undergo high-dose treatment should consider a clinical trial.

Clinical trials are examining treatments based on genetic subtypes of DBLCL. For example, the ABC subtype may respond better to the chemotherapy combination R-ACVBP compared to R-CHOP. Ibrutinib (Imbruvica) is a treatment that targets a certain protein involved in cancer cell growth. This may be useful in patients with ABC-DLBCL.

This study reviewed the ESMO recommendations for the diagnosis and treatment of DLBCL non-Hodgkin lymphoma.