What are the NCCN guidelines on the treatment of diffuse large B-cell lymphoma (DLBCL)?

Updated: Feb 25, 2021
  • Author: Sanjay Vinjamaram, MD, MPH; Chief Editor: Emmanuel C Besa, MD  more...
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National Comprehensive Cancer Network recommendations

NCCN treatment recommendations for stage I/II (nonbulky) disease are as follows [26] :

  • R-CHOP (rituximab, cyclophosphamide, doxorubicin [hydroxydaunorubicin], vincristine [Oncovin], prednisone) for three cycles, followed by involved-field radiation therapy (IFRT)

  • R-CHOP for six cycles with or without IFRT is an acceptable alternative

  • Patients who are not candidates for chemotherapy should receive involved-site radiation therapy (ISRT)

For stage II bulky disease, NCCN recommends R-CHOP for six cycles, with or without radiation therapy.

For stage III/IV (advanced-stage) disease, NCCN treatment recommendations are as follows [26] :

  • R-CHOP every 21 days for six cycles is preferred

  • Consider radiation therapy for bulky sites

  • Other regimens that may be considered include dose-adjusted EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin) plus rituximab or dose-dense R-CHOP-14

  • In patients at increased risk for central nervous system relapse (eg, disease involving the paranasal sinus, testis, epidural, bone marrow, HIV lymphoma, kidney or adrenal involvement or >2 extranodal sites, elevated LDH or concomitant expression of BCL2 and MYC protein), four to eight doses of intrathecal methotrexate and/or cytarabine, or 3-3.5 g/m2 of systemic methotrexate for prophylaxis is recommended

For relapse or refractory disease, high-dose chemotherapy (HDC) and autologous stem cell rescue (ASCR) is the treatment of choice. Before or after HDC and ASCRA, IFRT is given to previous disease sites. Second-line regimens for HDC include the following, which may be given with or without rituximab :

  • DHAP (dexamethasone, cytarabine [high-dose Ara C], cisplatin)

  • ESHAP (methylprednisolone, etoposide, cytarabine, cisplatin)

  • GDP (gemcitabine, dexamethasone, cisplatin)

  • GemOx (gemcitabine and oxaliplatin)

  • ICE (ifosfamide, carboplatin, etoposide)

  • MINE (mitoxantrone, ifosfamide, mesna, etoposide)

Patients with relapsed disease who are not eligible for HDC and ASCR should be enrolled in a clinical trial. If one is not available, they should receive palliative chemotherapy.

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