What is the treatment approach for a patient with Diffuse Large B-Cell Lymphoma (DLBCL) of the stomach who is in denial?

Treatment Approach for Gastric DLBCL in a Patient in Denial

The standard treatment for gastric DLBCL is R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy for 6-8 cycles, which offers a 60-70% chance of cure and should be initiated promptly despite patient denial. 1, 2

Initial Assessment and Diagnosis

Before treatment begins, a comprehensive diagnostic workup is essential:

• Histological confirmation: Surgical excisional biopsy is optimal; core biopsies should only be used when surgical approach is impractical 3

• Mandatory immunohistochemistry: CD45, CD20, CD3, and assessment of MYC and BCL2 rearrangements 3

• Staging workup:

  • FDG-PET/CT scan (gold standard) or CT scan of chest and abdomen if PET unavailable 1, 3
  • Bone marrow aspirate and biopsy 1
  • Laboratory studies: CBC, LDH, uric acid, hepatitis B/C, HIV screening, protein electrophoresis 3
  • Cardiac function assessment (left ventricular ejection fraction) 1
  • Consider diagnostic lumbar puncture in high-risk patients 3

• Prognostic assessment: Calculate International Prognostic Index (IPI) and age-adjusted IPI 1

Treatment Protocol Based on Patient Age and Risk

For Young Patients (Age <60 years)

• Low-intermediate risk (aaIPI=1) or low risk (aaIPI=0) with bulky disease:

  • R-CHOP × 6 cycles with radiotherapy to sites of previous bulky disease 1
  • OR R-ACVBP (rituximab, doxorubicin, vindesine, cyclophosphamide, bleomycin, prednisolone) followed by sequential consolidation 1

• High and high-intermediate risk (aaIPI ≥2):

  • R-CHOP × 6-8 cycles with 8 doses of rituximab 1

For Patients Aged 60-80 Years

• R-CHOP × 8 cycles with 8 doses of rituximab given every 21 days 1
• OR R-CHOP-14 (given every 14 days) × 6 cycles with 8 doses of rituximab 1

For Patients Aged >80 Years

• R-miniCHOP (attenuated chemotherapy) 1
• Consider comprehensive geriatric assessment to guide treatment decisions 1

Addressing Patient Denial

When dealing with a patient in denial about their DLBCL diagnosis:

1. Establish trust and rapport through clear, compassionate communication
2. Provide education about the high curability rate (60-70%) with modern treatment 2
3. Emphasize the consequences of delayed treatment - untreated DLBCL has poor outcomes with significantly reduced survival
4. Consider psychological consultation for persistent denial that threatens treatment adherence
5. Involve family members or caregivers when appropriate to provide additional support

Response Evaluation

• Perform evaluation after 3-4 cycles and after completion of therapy 1
• PET is highly recommended for post-treatment assessment 3
• Bone marrow biopsy should only be repeated at the end of treatment if initially involved 3

Follow-up Protocol

• History and physical examination every 3 months for 1 year, every 6 months for 2 more years, then annually 3
• Monitor for secondary tumors and long-term side effects 3
• Routine surveillance with PET scan is not recommended 1

Management of Relapsed Disease

If relapse occurs:

• Histological verification is mandatory, especially for relapses >12 months after initial diagnosis 1
• For suitable patients (age <65-70 years, good performance status):
  • Salvage regimen with rituximab plus chemotherapy (R-DHAP or R-ICE) 1
  • Followed by high-dose therapy with stem-cell support in responsive patients 1
• For patients not suitable for high-dose therapy:
  • R-GEMOX (rituximab, gemcitabine, oxaliplatin) with possible involved-field radiotherapy 1
  • Consider clinical trials with novel agents 1

Important Considerations

• The addition of rituximab to CHOP significantly improves survival compared to CHOP alone 4, 5
• Gastric DLBCL patients commonly present with epigastric pain and other non-specific gastrointestinal symptoms 5
• Early initiation of treatment is critical as delayed diagnosis significantly impacts mortality and morbidity 3
• For patients in denial, addressing psychological barriers to treatment acceptance is as important as the medical treatment itself