Our Current Approach To Treatment Of Dlbcl

Patients with early stage (I—II) disease are treated with CHOP-R for three to six cycles, depending on the stage-adjusted IPI. Those with 0-1 risk factors are given three cycles of CHOP-R followed by radiation. This is generally a very well-tolerated approach. For those with a stage-adjusted IPI >1, we prefer to administer six cycles of chemotherapy with CHOP-R. Radiation therapy is not routinely administered for such patients, but is considered for those with residual masses, especially if those masses are PET positive.

Patients with advanced disease are staged with CT scans and a bilateral bone marrow biopsy. We include a PET scan in our initial staging work-up and will routinely restage patients after four cycles of treatment. Modifications in treatment strategy will be considered for those with residual PET positivity after four cycles. A lumbar puncture is a part of the staging work-up for those with IPI greater than 2, those with testicular lymphoma, those with lymphoma in the head and neck area, and those with large cell lymphoma in the bone marrow. We currently do not have guidelines for prophylactic intrathecal treatment. Our patients with advanced stage lymphoma are treated with CHOP-R for six cycles at 21-day intervals. We will consider CHOP-R-14 with G-CSF support for patients with an increased LDH. We do not usually recommend autologous transplant in first remission, unless there is major concern for residual disease after completion of treatment, usually based on the presence of residual PET positivity. Our recommendations are admittedly somewhat guided by empiricism. Continued accrual to prospective studies is indicated, especially for patients with unfavorable prognostic features.

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