Treatment Protocol for Diffuse Large B-cell NHL (DLBCL)



Treatment Protocol for Diffuse Large B-cell NHL (DLBCL)

I. Introduction:

The commonest adult NHL: 30−40%.

A diverse group of neoplasms with heterogeneous genetic abnormalities, clinical features, treatment responses, and prognoses.

The WHO classification classified DLBCL as a mature B-cell neoplasm.

They usually arise de novo (referred to as primary) but can represent progression/transformation (referred to as secondary) of a less aggressive lymphoma, for example, chronic lymphocytic leukemia,

follicular lymphoma, marginal zone B-cell lymphoma,

or nodular lymphocyte-predominant Hodgkin's lymphoma.

The median age is in the sixth decade.

Patients frequently have a rapidly enlarging mass or acute onset of symptoms. Extranodal involvement is seen in 40% of cases.

DLBCL is curable with combination chemotherapy and should be treated promptly and aggressively.

The overall survival (OS) and progression-free survival (PFS) are approximately 50% and 32%, respectively, at 5 years.

II. For previously untreated DLBCL:

A. Localized/limited stage (stage I and nonbulky stage II disease):

1.Age < 60 y/o:

3 cycles of CHOP(CEOP) with involved field radiation(IFR)

(SWOG trial),

based on survival advantages through the first 9 years and

less associated toxicity. (Better than 8 cycles of CHOP)

SWOG trial involved field radiation: dose and schedule?

2.Age 60-80 y/o:

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2) given on day 1 of each cycle every 3 weeks.

B. Localized/limited stage (bulky stage II disease, three or more disease sites and/or a modified IPI score of 3 or more):

1.Age < 60 y/o:

8 cycles of CHOP(CEOP)

plus IFR for bulky disease

(Definition of bulky disease: 5 cm??)

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2): optional without evident support currently

2.Age 60-80 y/o:

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2) given on day 1 of each cycle every 3 weeks.

plus IFR for bulky disease

C. Nonlocalized DLBCL: low and low-intermediate risk IPI group DLBCL patients

1.Age < 60 y/o:

8 cycles of CHOP(CEOP)

plus IFR for bulky disease

CHOP: CR rates of 45−53%, with 30−37% long-term survivors.

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2): optional without evident support currently

2.Age 60-80 y/o:

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2) given on day 1 of each cycle every 3 weeks.

plus IFR for bulky disease

D. Therapy for high-intermediate and high-risk IPI group DLBCL patients

1.Age < 60 y/o:

8 cycles of CHOP(CEOP)

plus IFR for bulky disease

Current therapy with CHOP is unsatisfactory for patients with DLBCL in high-intermediate or high-risk IPI categories, with 54 and 34% 2 year survivals, respectively.

Other options: if feasible

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2)

High-dose chemotherapy (HDT) with autologous stem cell rescue

(Timing: after CR or PR?; Regimen: )

2.Age 60-80 y/o:

8 cycles of CHOP(CEOP) plus rituximab (375 mg/m2) given on day 1 of

each cycle every 3 weeks.

plus IFR for bulky disease

III. Primary refractory DLBCL:

Progressive disease after 1-2 cycles of CEOP: change to ESHAP

Rapidly regrowed disease between C/T:

CEOP every 2 weeks (German and Japanese trials)

IFR for bulky disease

Chemosensitive (CR or PR) disease after salvage regimen:

Consider HDT with ASCT

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