What is the appropriate review of systems and treatment approach for an older adult patient with newly diagnosed Diffuse Large B-Cell Lymphoma (DLBCL)?

Review of Systems for Diffuse Large B-Cell Lymphoma (DLBCL)

Essential Constitutional and B-Symptom Assessment

A systematic review of systems for DLBCL must prioritize identification of B-symptoms (fever >38°C, drenching night sweats, unintentional weight loss >10% over 6 months), performance status evaluation, and screening for high-risk extranodal involvement that impacts staging, prognosis, and treatment intensity. 1

Constitutional Symptoms

• Document presence of B-symptoms including unexplained fever above 38°C, drenching night sweats requiring clothing changes, and weight loss exceeding 10% of body weight over the preceding 6 months 1
• Assess performance status using ECOG scale (0-4), as this directly influences treatment eligibility and is a component of the International Prognostic Index 1
• Evaluate for fatigue severity and functional capacity, particularly in elderly patients where this determines eligibility for standard R-CHOP versus dose-reduced regimens 2, 3

Critical Extranodal Site Assessment

High-Risk CNS Involvement Screening

• Screen for CNS symptoms including new-onset headaches, visual changes, focal neurological deficits, cranial nerve palsies, altered mental status, or seizures 1
• Identify high-risk features mandating diagnostic lumbar puncture: elevated LDH combined with bone marrow involvement, testicular involvement, kidney involvement, or multiple extranodal sites (≥2) 1, 2
• MRI is the imaging modality of choice when CNS lymphoma is suspected 1

Bone and Bone Marrow Involvement

• Assess for bone pain, pathological fractures, or focal skeletal symptoms, as bone involvement combined with elevated LDH places patients in higher IPI risk categories requiring intensified treatment and CNS prophylaxis 2
• Document any history of unexplained bone pain or limitation in mobility 1

Gastrointestinal Tract

• Evaluate for abdominal pain, early satiety, bowel obstruction symptoms, gastrointestinal bleeding, or dysphagia, as GI involvement is common in DLBCL and may require endoscopic evaluation 1, 4
• Document any unexplained nausea, vomiting, or changes in bowel habits 1

Other Extranodal Sites

• Respiratory symptoms: dyspnea, cough, chest pain, or hemoptysis suggesting mediastinal or pulmonary involvement 1
• Testicular examination: unilateral or bilateral testicular enlargement or masses (high CNS relapse risk) 1, 2
• Renal symptoms: flank pain, hematuria, or decreased urine output 1
• Skin lesions: new nodules, plaques, or ulcerations suggesting cutaneous involvement 4

Lymph Node Assessment

• Document all palpable lymphadenopathy by anatomic region, size (measure largest dimension), consistency, mobility, and tenderness 1
• Identify bulky disease defined as any mass ≥10 cm in diameter or mediastinal mass with maximum width >1/3 of thoracic diameter on chest radiograph 1, 5
• Assess for rapidly enlarging masses, which may indicate high tumor burden requiring prephase corticosteroid treatment before chemotherapy 3

Cardiovascular Assessment

• Evaluate cardiac history and symptoms including prior myocardial infarction, heart failure, arrhythmias, or valvular disease, as anthracycline-based therapy (R-CHOP) requires adequate cardiac function 1
• Document baseline left ventricular ejection fraction (LVEF) assessment before treatment initiation 1
• Screen for symptoms of heart failure (dyspnea on exertion, orthopnea, peripheral edema) that would contraindicate full-dose doxorubicin 1

Infectious Disease Screening

• Mandatory screening for HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) as these infections alter treatment approach and require prophylaxis or antiviral therapy 1
• HBV-positive patients require antiviral prophylaxis during rituximab-containing therapy to prevent reactivation 1
• Document any history of opportunistic infections or chronic immunosuppression 1

Hematologic Review

• Assess for cytopenias: unexplained anemia (fatigue, pallor, dyspnea), thrombocytopenia (bruising, petechiae, bleeding), or leukopenia (recurrent infections) 1
• Document any history of autoimmune cytopenias or prior hematologic disorders 4

Tumor Lysis Syndrome Risk Assessment

• Identify high-risk features: bulky disease (≥10 cm), elevated LDH, elevated uric acid, renal impairment, or multiple extranodal sites 3
• These patients require prephase corticosteroid treatment (prednisone 100 mg orally daily for 5-7 days) before starting R-CHOP to prevent tumor lysis syndrome 2, 3

Geriatric-Specific Assessment for Elderly Patients

• For patients ≥60 years, assess comorbidities including diabetes (high-dose corticosteroids cause hyperglycemia), renal function (affects chemotherapy dosing), and hepatic function 2, 3
• Evaluate for frailty indicators: unintentional weight loss, exhaustion, weakness, slow gait speed, and low physical activity, as these determine eligibility for standard R-CHOP versus R-miniCHOP 2, 3
• Document polypharmacy and potential drug interactions with chemotherapy 6

Common Pitfalls to Avoid

• Do not omit CNS symptom screening in patients with elevated LDH and extranodal involvement, as missing CNS involvement leads to inadequate prophylaxis and poor outcomes 1, 2
• Do not overlook B-symptoms as their presence affects Ann Arbor staging (A versus B designation) and prognosis 1
• Do not fail to assess cardiac function before anthracycline therapy, as unrecognized cardiac dysfunction leads to treatment-related cardiotoxicity 1
• Do not miss HBV screening, as rituximab can cause fatal HBV reactivation without prophylaxis 1