Initial treatment of limited stage diffuse large B cell lymphoma
- Arnold S Freedman, MD
Arnold S Freedman, MD
- Section Editor — Lymphoproliferative Disorders
- Professor of Medicine
- Harvard Medical School
- Jonathan W Friedberg, MD
Jonathan W Friedberg, MD
- Professor of Medicine
- James P Wilmot Cancer Center, University of Rochester
Diffuse large B cell lymphoma (DLBCL) is the most common histologic subtype of non-Hodgkin lymphoma (NHL), accounting for approximately 30 percent of patients with NHL [1-4]. It is an aggressive NHL in which survival without treatment is measured in months. (See "Classification of the hematopoietic neoplasms".)
The initial treatment of DLBCL is dependent upon the extent of disease. The staging system used for NHL focuses on the number of tumor sites (nodal and extranodal) and their location (table 1). For treatment purposes, patients with DLBCL are generally classified as having either limited stage disease or advanced stage disease based upon whether or not the tumor can be contained within one irradiation field:
●Limited stage disease (usually stage I or II) – Limited stage DLBCL can be contained within one irradiation field. This population accounts for 30 to 40 percent of patients with DLBCL. Limited stage DLBCL is treated primarily with combined modality therapy consisting of abbreviated systemic chemotherapy (three cycles), the recombinant anti-CD20 antibody rituximab, and involved field radiation therapy. Alternatively, full course (six to eight cycles) systemic chemotherapy plus rituximab without radiation therapy may be used.
●Advanced stage disease (usually stage III or IV) – Advanced stage DLBCL cannot be contained within one irradiation field. This population accounts for 60 to 70 percent of patients with DLBCL. Advanced stage DLBCL is treated with systemic chemotherapy plus the recombinant anti-CD20 antibody rituximab. (See "Initial treatment of advanced stage diffuse large B cell lymphoma".)
Patients with bulky (>10 cm) stage II disease and patients with stage IIB disease have a less favorable prognosis than those with non-bulky stage II disease without systemic B symptoms. Many clinicians treat such patients in a similar fashion to those with advanced stage disease. (See 'Bulky disease' below.)
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- PRETREATMENT EVALUATION
- INITIAL TREATMENT
- Chemotherapy with or without radiation
- - Is radiation therapy necessary?
- - Radiation dose
- - Radiation field size
- Radiation alone
- Our general approach
- SPECIAL SCENARIOS
- Bulky disease
- Unusual sites of involvement
- - Mediastinum
- - CNS involvement
- - Testicular
- - Ovarian
- - Breast
- Double hit DLBCL
- PATIENT FOLLOW-UP
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS