What is the recommended approach to stage testicular Diffuse Large B-Cell Lymphoma (DLBCL)?

Staging of Testicular Diffuse Large B-Cell Lymphoma (DLBCL)

FDG-PET/CT scan is the gold standard for staging testicular DLBCL, along with specific additional evaluations for CNS involvement risk and contralateral testis assessment. 1

Standard Staging Procedures

• Physical examination and assessment of performance status and B symptoms are necessary initial steps 1
• Complete blood count, routine blood chemistry including LDH and uric acid, as well as screening tests for HIV, HBV, and HCV are required 1
• Protein electrophoresis is recommended to identify potential paraproteinemia 1
• FDG-PET/CT scan is the recommended gold standard for staging, providing superior sensitivity for both nodal and extranodal sites 1
• Contrast-enhanced CT (CeCT) may be necessary in combination with PET/CT for better delineation of lymphadenopathy, assessment of vascular compression, or more accurate measurement of nodal sites 1
• Bone marrow assessment via biopsy is not required when PET/CT demonstrates bone or marrow involvement, but should be performed in PET-negative cases where results would change prognosis and treatment 1

Special Considerations for Testicular DLBCL

Testicular DLBCL requires additional evaluation due to its unique characteristics:

• CNS evaluation is mandatory as testicular DLBCL has high risk of CNS relapse 1

  • Magnetic resonance imaging (MRI) of the brain is the modality of choice for suspected CNS involvement 1
  • Diagnostic lumbar puncture should be performed for cerebrospinal fluid analysis 1

• Contralateral testis examination is essential as testicular DLBCL has increased risk of involvement of the contralateral testis 1

• Orchiectomy of the affected testis is typically performed for both diagnostic confirmation and as part of initial treatment 2

Risk Assessment

• Ann Arbor staging system should be used to establish the stage (I-IV) 1
• International Prognostic Index (IPI) should be calculated for prognostic purposes 1
• Assessment of MYC and BCL2 rearrangements using interphase FISH is recommended in newly diagnosed patients treated with curative intent 1

Response Evaluation

• Abnormal radiological tests at baseline should be repeated after 3-4 cycles and after the last cycle of treatment 1
• PET/CT is highly recommended for post-treatment assessment to define complete remission 1
• Bone marrow assessment should be repeated at the end of treatment only if initially involved 1

Clinical Pearls and Pitfalls

• Testicular DLBCL is characterized by an increased risk of extranodal relapse, particularly in the CNS and contralateral testis, requiring specific prophylactic measures 1
• The standard treatment for localized (stage I-II) testicular DLBCL is R-CHOP21 with CNS prophylaxis and contralateral testis irradiation 1
• Radiation therapy to the contralateral testis is associated with improved survival and should be considered for all testicular DLBCL patients 3
• Most testicular DLBCL cases have a non-germinal center B-cell like immunophenotype (84%) and an activated B-cell like gene expression profile (86%), which may contribute to their aggressive behavior 4

By following this comprehensive staging approach, clinicians can accurately assess disease extent and risk factors to guide appropriate treatment decisions for patients with testicular DLBCL.