Diffuse Large B-Cell Lymphoma (Non-Hodgkin Lymphoma) Treatment Protocols
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Treatment recommendations for patients with diffuse large B-cell lymphoma (DLBCL) begin with evaluating the extent of the disease, performance status of the patient, and histologic subtypes. Treatment of localized and advanced disease varies considerably.
Below is a general treatment algorithm for DLBCL, followed by treatment recommendations for different stages of disease and for relapsed or refractory disease. [1, 2, 3]
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
Stage I and selected stage II:
Patients without adverse risk factors present:
R+CHOP: Combined therapy with rituximab 375 mg/m2 IV on day 1 plus cyclophosphamide 750 mg/m2 IV on day 1 or 3 plus doxorubicin 50 mg/m2 IV on day 1 or 3 plus vincristine 1.4 mg/m2 (maximum dose, 2 mg) IV on day 1 or 3 plus prednisone 40 mg/m2 PO on days 1-5 or 3-8; every 21d for 3 cycles [5]
Radiographic studies including functional imaging (eg, PET scan) to document response to treatment should be done before initiation of IFRT and/or at the end of therapy
Always confirm residual PET abnormalities with biopsy before modifying therapy
Patients with adverse risk factors present:
R+CHOP: Combined therapy with rituximab plus cyclophosphamide 750 mg/m2 IV on day 1 or 3 plus doxorubicin 50 mg/m2 IV on day 1 or 3 plus vincristine 1.4 mg/m2 (maximum dose, 2 mg) IV on day 1 or 3 plus prednisone 40 mg/m2 PO on days 1-5 or 3-8; every 21d for 3 cycles followed by IFRT [5] or
R+CHOP: Rituximab 375 mg/m2 IV on day 1 plus cyclophosphamide 750 mg/m2 IV on day 1 or 3 plus doxorubicin 50 mg/m2 IV on day 1 or 3 plus vincristine 1.4 mg/m2 (maximum dose, 2 mg) IV on day 1 or 3 plus prednisone 40 mg/m2 PO on days 1-5 or 3-8; every 21d for 6 cycles with or without IFRT [6]
Radiographic studies including functional imaging (eg, PET scan) to document response to treatment should be done before initiation of IFRT and/or at the end of therapy
Always confirm residual PET abnormalities with biopsy before modifying therapy
Stages III-IV:
R+CHOP: Rituximab 375 mg/m2 IV on day 1 plus cyclophosphamide 750 mg/m2 IV on day 1 or 3 plus doxorubicin 50 mg/m2 IV on day 1 or 3 plus vincristine 1.4 mg/m2 (maximum dose, 2 mg) IV on day 1 or 3 plus prednisone 40 mg/m2 PO on days 1-5 or 3-8; every 21d for 6 cycles with or without IFRT [6, 7]
Consider radiation therapy to bulky sites of disease at the end of chemoimmunotherapy
Prophylactic IT chemotherapy with low-dose methotrexate (eg, 12 mg) should be routinely administered to DLBCL patients with the following characteristics [8, 9] :
More than one extranodal site of disease
Testicular or breast involvement, regardless of stage
Lymphoblastic variants
Oropharyngeal or paraspinal sites of involvement
Bone marrow involvement
Concomitant infection with HIV
Patients eligible for HDC-ASCT (treatment goal = cure):
A vast number of regimens are used in the treatment of patients with relapsed or refractory DLBCL. These are primarily based on chemotherapy agents that are not cross-resistant to those used in the front-line setting, with or without rituximab. The goal of salvage regimens is to achieve maximum tumor burden cytoreduction in preparation for HDC with ASCT (HDC-ASCT). [10]
RICE: Rituximab 375 mg/m2 day 1 plus ifosfamide 5 g/m2 on day 2 plus carboplatin AUC 5 plus etoposide 100 mg/m2 daily on days 1-3; every 14 d [11] (see also the Carboplatin AUC Dose Calculation [Calvert formula] calculator) or
ICE: Ifosfamide 5 g/m2 on day 2 plus carboplatin AUC 5 plus etoposide 100 mg/ m2 daily on days 1-3; every 14d [12] or
GDP: Gemcitabine 1000 mg/m2 on days 1 and 8 plus dexamethasone 40 mg on days 1-4 plus cisplatin 75 mg/m2 on day 1; every 21d [13] or
GEM-P: Gemcitabine 1000 mg/m2 on days 1 and 8 plus methylprednisolone 1000 mg/m2 on days 1-5 plus cisplatin 100 mg/m2 on day 15; every 28 d [14, 15] or
Gem-P: Gemcitabine 1000 mg/m2 on days 1 and 8 plus cisplatin 100 mg/m2 on day 1; every 21d [16, 17] or
R+GEMOX: Rituximab 375 mg/m2 plus gemcitabine 1000 mg/m2 plus oxaliplatin 100 mg/m2 on day 1; every 14 d [17] or
ESHAP: Etoposide 40 mg/m2/day plus methylprednisolone 500 mg/day plus cisplatin 25 mg/m2/day by continuous IV infusion (CIVI) for 4 d plus cytarabine (Ara-C) 2 g/m2 on day 5 [18] or
DHAP: Dexamethasone 40 mg on days 1-4 plus cytarabine 2 g/m2 every 12h for 2 doses on day 2 plus cisplatin 100 mg/m2 on day 1; every 21d [19] or
R-DHAP: Dexamethasone 40 mg on days 1-4 plus cytarabine 2 g/m2 every 12h for 2 doses on day 2 plus cisplatin 100 mg/m2 on day 3; every 21 d plus rituximab 375 mg/m2 weekly for 4 wk starting on day 1 of first cycle [20] or
R-DHAP-VIM-DHAP: Cisplatin 100 mg/m2 on day 1 by continuous IV infusion plus cytarabine 2 g/m2 every 12 h for 2 doses on day 2 plus dexamethasone 40 mg/day on days 1-4; VIM = etoposide 90 mg/m2 on days 1, 3, and 5 plus ifosfamide 1200 mg/m2 IV on days 1-5 plus methotrexate 30 mg/m2 IV on days 1 and 5; rituximab 375 mg/m2 is administered on day 5 of the DHAP courses or on day 6 of the VIM course [21] or
DHAP-VIM-DHAP: Cisplatin 100 mg/m2 on day 1 by continuous IV infusion plus cytarabine 2 g/m2 every 12 h for 2 doses on day 2 plus dexamethasone 40 mg/day on days 1-4; VIM = etoposide 90 mg/m2 on days 1, 3, and 5 plus ifosfamide 1200 mg/m2 IV on days 1-5 plus methotrexate 30 mg/m2 IV on days 1 and 5 [21]
CAR T-cell therapy (treatment goal = cure):
Tisagenlecleucel 0.6-6 x 10^8 CAR-positive viable T cells/kg IV infusion at rate of 10-20 mL/min; administer 2-11 days after completing lymphodepleting chemotherapy [34, 35]
Axicabtagene ciloleucel 2 x 10^6 CAR-positive viable T cells/kg body weight, not to exceed 2 x 10^8 CAR-positive viable T cells; infuse IV over 30 min 3 days after completing lymphodepleting chemotherapy [36]
Patients not eligible for HDC-ASCT (treatment goal = palliation):
GV: Gemcitabine 1000 mg/m2 plus vinorelbine 30 mg/m2 on days 1 and 8; every 21 d [22] or
GVP: Gemcitabine 1000 mg/m2 plus vinorelbine 30 mg/m2 on days 1 and 8 plus prednisone 100 mg on days 1-8; every 21d [23] or
ViGePP: Vinorelbine 25 mg/m2 plus gemcitabine 800 mg/m2 on days 1 and 8 plus procarbazine 100 mg/m2 on days 1-7 plus prednisone 60 mg/m2 on days 1-15; every 28 d [24] or
IEV: Ifosfamide 2500 mg/m2 plus etoposide 150 mg/m2 on days 1-3 plus epirubicin 100 mg/m2 on day 1; every 21 d [24, 25] or
MINE: Ifosfamide 2660 mg/m2/day on days 1-3 plus etoposide 300 mg/m2 in 1 dose on days 1-3; followed by ifosfamide 3300mg/m2 on days 1-3 plus mitoxantrone 20 mg/m2 on day 1 if less than complete response is achieved [26] or
IVAD: Ifosfamide 1500 mg/m2plus etoposide 100 mg/m2plus cytarabine 100 mg/m2plus dexamethasone 40 mg on days 1-5; every 21d [27] or
Mini-BEAM: Busulfan 60 mg/m2 on day 1 plus etoposide 75 mg/m2 on days 2-5 plus cytarabine 100 mg/m2 every 12h on days 2-5 plus melphalan 30 mg/m2 on day 6; every 28d [28, 29] or
EPOCH: Doxorubicin 10 mg/m2 plus etoposide 50 mg/m2 plus vincristine 0.4 mg/m2 by continuous IV infusion on days 2-4 plus cyclophosphamide 750 mg/m2 on day 6 plus prednisone 60 mg/m2 on days 1-6; every 21 d [30] or
R-EPOCH: Rituximab 375 mg/m2 IV on day 1 plus doxorubicin 15 mg/m2 plus etoposide 65 mg/m2 plus vincristine 0.5 mg/day by continuous IV infusion on days 2-4 plus cyclophosphamide 750 mg/m2 on day 5 plus prednisone 60 mg/m2 on days 1-14; every 21d [31] or
Lenalidomide 25 mg PO on days 1-21; every 28 d until progression or unacceptable toxicity [32]
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Francisco J Hernandez-Ilizaliturri, MD Professor of Medicine, Department of Medical Oncology, Associate Professor of Immunology, Department of Immunology, Chief, Lymphoma and Myeloma Section, Director, The Lymphoma Translational Research Program, Roswell Park Cancer Institute, University of Buffalo State University of New York School of Medicine and Biomedical Sciences
Francisco J Hernandez-Ilizaliturri, MD is a member of the following medical societies: American Association for Cancer Research, American Society of Hematology
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Christopher D Braden, DO Hematologist/Oncologist, Chancellor Center for Oncology at Deaconess Hospital; Medical Director, Deaconess Hospital Outpatient Infusion Centers; Chairman, Deaconess Hospital Cancer Committee
Christopher D Braden, DO is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology
Disclosure: Nothing to disclose.
Koyamangalath Krishnan, MD, FRCP, FACP Dishner Endowed Chair of Excellence in Medicine, Professor of Medicine, James H Quillen College of Medicine at East Tennessee State University
Koyamangalath Krishnan, MD, FRCP, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Society of Hematology, Royal College of Physicians
Disclosure: Nothing to disclose.
Diffuse Large B-Cell Lymphoma (Non-Hodgkin Lymphoma) Treatment Protocols
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