What is the management for a patient with diffuse large B-cell lymphoma (DLBCL) with localized involvement of the right cervical lymph nodes, as shown on PET scan, and a biopsy confirming DLBCL?

Management of Localized Right Cervical DLBCL

For this patient with stage I DLBCL (localized right cervical lymph nodes only on PET), the recommended treatment is 6 cycles of R-CHOP-21 (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone every 21 days) with consideration of consolidation radiotherapy to the involved cervical region, particularly if bulky disease is present. 1, 2

Initial Risk Stratification Required

Before finalizing the treatment plan, you must:

• Calculate the age-adjusted International Prognostic Index (aaIPI) to determine risk category, which incorporates: age >60 years, elevated LDH, ECOG performance status ≥2, and Ann Arbor stage III-IV 1
• Assess for bulky disease (typically defined as mass >7.5-10 cm), as this influences radiotherapy decisions 1, 2
• Verify cardiac function with left ventricular ejection fraction assessment before anthracycline-based therapy 1
• Screen for HIV, hepatitis B and C as these require specific management modifications 1

Treatment Algorithm Based on Age and Risk

For Patients <60 Years Old with Low-Intermediate Risk (aaIPI ≤1):

Primary recommendation: 6 cycles of R-CHOP-21 plus involved-site radiotherapy to the right cervical region if bulky disease is present 1, 2. This approach is based on the MINT study demonstrating effectiveness in this population 1.

Alternative option: R-ACVBP (rituximab with doxorubicin, vindesine, cyclophosphamide, bleomycin, prednisolone every 2 weeks with sequential consolidation) has shown superior survival compared to 8 cycles of R-CHOP, though radiotherapy was omitted in that trial 1, 2. This is more intensive but may be considered for fit younger patients.

For Patients 60-80 Years Old:

Standard treatment: 6-8 cycles of R-CHOP-21 (typically 6 cycles for localized disease) 1, 2. Consolidation radiotherapy provides no proven benefit in the rituximab era for elderly patients with localized disease 1, 2, so it should generally be omitted unless there is residual PET-positive disease after chemotherapy.

For Patients >80 Years Old:

• Perform comprehensive geriatric assessment to evaluate comorbidities and functional status before committing to full-dose therapy 1, 2
• R-CHOP can be used in fit patients up to age 80 1, 2
• Consider R-miniCHOP (attenuated chemotherapy with rituximab) for patients over 80, which can still achieve complete remission and long survival 1, 2
• Substitute or omit doxorubicin if cardiac dysfunction is present—consider etoposide, gemcitabine, or liposomal doxorubicin as alternatives 1, 2

Critical Pre-Treatment Measures

Tumor lysis syndrome prevention is mandatory in cervical lymphadenopathy with high tumor burden:

• Administer prednisone 100 mg orally daily for 5-7 days as "prephase" treatment before starting R-CHOP 1, 3, 2
• Ensure aggressive hydration 3
• Consider prophylactic allopurinol or rasburicase in highest-risk patients 3, 2

Supportive Care During Treatment

• Prophylactic G-CSF (granulocyte colony-stimulating factor) is mandatory for all patients to prevent febrile neutropenia, particularly given the dose-intensive nature of R-CHOP 3, 2
• Avoid dose reductions due to hematological toxicity as this compromises treatment efficacy and cure rates 1, 3, 2
• Use G-CSF support rather than dose reduction if febrile neutropenia occurs 1, 2

CNS Prophylaxis Considerations

CNS prophylaxis is NOT routinely indicated for localized cervical lymph node disease unless additional high-risk features are present 1, 2:

• High-intermediate or high-risk IPI score with >1 extranodal site 1, 2
• Markedly elevated LDH 1, 2
• Specific high-risk extranodal sites (testicular, renal, adrenal involvement) 1, 2

If CNS prophylaxis is indicated, intravenous high-dose methotrexate is superior to intrathecal therapy alone 1, 2.

Response Assessment Strategy

• Repeat PET/CT after 3-4 cycles to assess response 1, 3
• Do NOT change treatment based on interim PET/CT unless there is clear evidence of progression—early PET has controversial predictive value and should not guide treatment modifications outside clinical trials 1, 3
• Mandatory end-of-treatment PET/CT using the 5-point Deauville scale to define complete remission 1, 3
• Biopsy any residual PET-positive tissue if salvage treatment is being considered 1

Radiotherapy Decision-Making

The role of consolidation radiotherapy in localized DLBCL remains nuanced:

• For patients <60 years with bulky disease: Consolidation involved-site radiotherapy to the right cervical region after 6 cycles of R-CHOP-21 is recommended based on MINT study data 1, 2
• For patients 60-80 years: Radiotherapy provides no proven benefit in the rituximab era and should generally be omitted 1, 2
• Reserve radiotherapy for PET-positive residual disease (Deauville score 4-5) after chemotherapy completion 3

Common Pitfalls to Avoid

• Do not use R-CHOP-14 (every 14 days) instead of R-CHOP-21—dose-dense scheduling has NOT demonstrated survival benefit over standard 21-day cycles 1, 2
• Do not reduce chemotherapy doses after prephase treatment due to hematological concerns unless absolutely necessary, as this compromises efficacy 1, 3, 2
• Do not omit rituximab from any cycle—all 6-8 cycles should include rituximab 1, 2, 4
• Do not perform routine surveillance PET scans during follow-up after achieving complete remission 1

Follow-Up Protocol After Treatment Completion

• History and physical examination: Every 3 months for 1 year, every 6 months for 2 additional years, then annually 1, 3
• Blood count and LDH: At 3,6,12, and 24 months, then only as clinically indicated 1, 3
• CT imaging: Minimal adequate radiological examinations at 6,12, and 24 months are common practice, though there is no definitive evidence that routine imaging in patients in complete remission provides outcome advantage 1
• Routine surveillance PET scanning is NOT recommended 1, 3
• Monitor for secondary malignancies and long-term chemotherapy side effects 1