What are the treatment options for B cell lymphoma?

Treatment Options for B-Cell Lymphoma

For CD20-positive diffuse large B-cell lymphoma (DLBCL), the standard treatment is 6-8 cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) given every 21 days, which cures more than 60% of patients. 1, 2

First-Line Treatment by Patient Population

Young Low-Risk Patients (Age-Adjusted IPI ≤1)

• Administer 6-8 cycles of R-CHOP-21 (every 21 days) as the standard regimen 1
• For patients with bulky disease (lymph nodes >5 cm), add involved-field radiotherapy to sites of previous bulky disease after completing R-CHOP 1
• Eight doses of rituximab should be given with the chemotherapy cycles 1
• Consolidation by radioimmunotherapy has no proven benefit and should not be used 1

Young High-Risk Patients (Age-Adjusted IPI ≥2)

• Give 6-8 cycles of R-CHOP every 14-21 days as the most frequently applied regimen 1
• These patients should preferentially be enrolled in clinical trials, as there is no current standard with sufficient efficacy 1
• Central nervous system prophylaxis is recommended: perform diagnostic lumbar puncture with simultaneous prophylactic intrathecal cytarabine and/or methotrexate 1
• Consolidation radiotherapy to sites of bulky disease has not proven benefit 1
• High-dose chemotherapy with stem-cell transplantation as part of first-line therapy remains experimental and should only be done in clinical trials 1

Elderly Patients (>60 Years)

• Administer 8 cycles of R-CHOP-21 (every 21 days) as the current standard 1
• If R-CHOP is given every 14 days with growth factor support, 6 cycles are sufficient 1
• Prophylactic use of hematopoietic growth factors is justified in all elderly patients to prevent febrile neutropenia 1

Critical Treatment Principles

Tumor Lysis Syndrome Prevention

• In patients with high tumor burden or bulky disease, administer prednisone 100 mg orally for several days as "prephase" treatment before starting R-CHOP to prevent tumor lysis syndrome 1, 3
• For high-risk patients (bulky disease >5 cm, elevated LDH >2x normal, elevated uric acid), give rasburicase 0.20 mg/kg/day at least 4 hours before starting chemotherapy 3
• Provide aggressive intravenous hydration and monitor serum electrolytes (potassium, phosphorus, calcium), uric acid, and renal function closely 3

Dose Intensity Maintenance

• Avoid dose reductions due to hematological toxicity 1
• Use prophylactic hematopoietic growth factors (G-CSF) in patients with febrile neutropenia to maintain dose intensity 1

Relapsed/Refractory Disease Treatment

Transplant-Eligible Patients (<65-70 Years, Good Performance Status)

• Administer salvage immunochemotherapy (R-DHAP or R-ICE) followed by high-dose chemotherapy with autologous stem-cell transplantation in responding patients 1
• R-DHAP consists of rituximab, cisplatin, cytosine arabinoside, and dexamethasone 1
• R-ICE consists of rituximab, ifosfamide, carboplatin, and etoposide 1
• These two salvage regimens show equivalent outcomes 1
• BEAM (carmustine, etoposide, cytosine-arabinoside, melphalan) is the most frequently used high-dose conditioning regimen before transplant 1
• Rituximab maintenance after transplant is not recommended 1
• Consider allogeneic transplantation for patients with refractory disease, early relapse, or relapse after autologous transplant 1

Transplant-Ineligible Patients

• Treat with salvage regimens such as R-GEMOX (rituximab, gemcitabine, oxaliplatin) combined with involved-field radiotherapy 1
• Preferentially enroll in clinical trials testing novel agents 1

Response Evaluation Strategy

During Treatment

• Perform imaging (CT or PET-CT) after 3-4 cycles to assess response and exclude disease progression 1
• PET-CT is strongly recommended when positive at baseline, as it better defines complete remission according to revised criteria 1
• If PET shows residual activity with therapeutic consequences, obtain histological confirmation before changing treatment 1
• Early PET (after 1-4 cycles) is predictive of outcome but should not guide treatment changes outside clinical trials 1

End of Treatment

• Repeat all abnormal baseline imaging studies after the final chemotherapy cycle 1
• Repeat bone marrow biopsy only if initially involved 1
• PET-CT findings at end of treatment are the best predictors of long-term outcome 1

Follow-Up Protocol

• Perform history and physical examination every 3 months for year 1, every 6 months for years 2-3, then annually 1
• Check complete blood count and LDH at 3,6,12, and 24 months, then only for suspicious symptoms 1
• Obtain CT scans at 6,12, and 24 months after treatment completion 1
• Routine surveillance PET scans are not recommended, as they do not improve outcomes 1
• Monitor for secondary malignancies and long-term chemotherapy side effects at all visits 1

Common Pitfalls to Avoid

• Do not reduce chemotherapy doses for hematological toxicity—instead, use growth factor support to maintain dose intensity, as this directly impacts cure rates 1
• Do not skip tumor lysis syndrome prophylaxis in high-risk patients (bulky disease, high LDH, high tumor burden), as this can be fatal 1, 3
• Do not omit CNS prophylaxis in high-risk patients (IPI >2, bone marrow involvement, testicular involvement, paranasal sinus involvement) 1
• Do not use rituximab maintenance after autologous transplant, as it provides no benefit 1
• Ensure CD20 positivity is confirmed before using rituximab-containing regimens, especially in relapses >12 months after initial diagnosis 1