What is the diffuse large B-cell lymphoma (DLBCL) treatment algorithm?

Updated: Jun 12, 2019
  • Author: Francisco J Hernandez-Ilizaliturri, MD; Chief Editor: Koyamangalath Krishnan, MD, FRCP, FACP  more...
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Diagnosis of DLBCL:

  • Staging/IPI score/bulky disease

  • Assess end-organ function

  • Establish therapy endpoints (ie, cure vs palliation)

Stage I/II (nonbulky) disease:

  • Rituximab (R) plus cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) for 3-4 cycles

  • Follow with involved field radiation therapy (IFRT)

  • If positron emission tomography (PET) is positive after 4 cycles, administer 2 more cycles before IFRT

  • If relapse occurs, see step 4

Advanced-stage (stage III-IV) or bulky stage II disease:

  • R+CHOP every 21 d for 6 cycles, with or without IFRT for bulky sites

  • Prophylactic intrathecal (IT) chemotherapy in selected cases or

  • Clinical trial with correlative science studies (eg, R+CHOP-like and other biological agents or small molecules and/or other novel monoclonal antibodies [mAbs] or immunoconjugates)

In cases of relapse:

  • Staging/IPI score/bulky disease

  • Assess end-organ function

In relapse patients, collect lymphoid tissue and store for future analysis or current research evaluating gene profiling, proteomic analysis, biomarkers of disease (MUM-1, Bcl-6, and CD10), and preclinical studies with novel agents

Relapse patients eligible for high-dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT):

  • Platinum-based salvage chemotherapy, [4] including rituximab, ifosfamide, carboplatin, and etoposide (RICE) for 2-3 cycles or

  • Rituximab plus cisplatin, cytarabine, and dexamethasone (DHAP) for 2-3 cycles

  • If partial or complete response is achieved, use HDC and ASCT

  • Observation or clinical trials evaluating agents in the maintenance setting may be recommended

  • If patient relapses, consider clinical trials evaluating novel agents (eg, bortezomib, lenalidomide, or immunoconjugates) or

  • Radioimmunotherapy (RIT)

Relapse patients not eligible for HDC and ASCT:

  • Palliative chemotherapy (gemcitabine-based therapy

  • Clinical trials evaluating novel agents (eg, bortezomib, lenalidomide, or immunoconjugates) or

  • RIT

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