ACR Appropriateness Criteria® Diffuse Large B-Cell Lymphoma

Abstract

The management of diffuse large B-cell lymphoma depends on the initial diagnosis including molecular and immunophenotypic characteristics, Ann Arbor staging, and International Prognostic Index (IPI score). Treatment approaches with different chemotherapy regimens used is discussed in detail. The role of radiation as a consolidation is discussed including: (1) the prerituximab randomized trials that challenged the role of radiation, (2) recent prospective studies (UNFOLDER/RICOVER-60), and (3) retrospective studies; the last 2 showed a potential benefit of radiation both for early and advanced stage. The document also discusses the role of positron emission tomography/computed tomography for predicting outcome and potentially guiding therapy. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Radiotherapy for early stage diffuse large B-cell lymphoma with or without double or triple hit genetic alterations

“…The optimal management of early stage DLBCL is debated. For the most part, these patients are treated uniformly with rituximab-based regimens with RT being optional [1]. In the pre-rituximab era, consolidative RT failed to demonstrate improved outcomes in four randomized trials, yet many retrospective studies and subgroup analyses of prospective trials in the modern era have demonstrated improved tumor control with consolidative RT following rituximab-based regimens [27].…”

“…Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of aggressive non-Hodgkin lymphoma (NHL). Although most present with advanced disease, approximately a one-third of patients presented with early stage disease (stages I-II) [1]. Management of early stage disease has evolved over the last several decades from wide-field radiotherapy (RT) alone to multiagent immunochemotherapy consisting of cyclophosphamide, doxorubicin, vincristine, and prednisone with rituximab (R-CHOP), with or without conformal consolidative RT [2,3].…”

Low total gamma globulin level discovery at diffuse large B cell lymphoma diagnosis predicts high risk of infection-related death: data from a monocentric retrospective study

“…Our population was close to what has been described in France during this period of time, with a median age of 69 years, representing 35 to 40% of patients with lymphoma. (23,24) At DLBCL diagnosis SEP is not unanimously recommended according to the international workgroup guidelines for malignant lymphoma (13)(14)(15), however from the results in our study we propose SEP to be performed at diagnosis. In our study, there were no significant differences between the two subgroups regarding inflammatory parameters, as assessed using CRP level, and albuminemia, suggesting that the decrease in TGL may not be secondary to metabolic/inflammatory causes or to increased loss of immunoglobulins but is probably directly related to low gamma-globulin production.…”

“…No study has yet determined the prevalence of PIDs in adults revealed by lymphoma since the diagnostic criteria of PIDs do not take into account lymphoma. (10)(11)(12)(13)(14)(15) On the one hand, humoral PIDs, including CVID, are frequent forms of PIDs and can be easily be suggested by low serum total gamma-globulin level identified using serum electrophoresis (SEP) performed at DLBCL diagnosis. On the other hand, DLBCL, the most frequent of lymphoproliferative disorders, can also induce a decrease in serum total gamma-globulin level (TGL) because of clonal selection and proliferation.…”

Consolidative Radiotherapy to Residual Masses After Chemotherapy Is Associated With Improved Outcome in Diffuse Large B-Cell Lymphoma. A Retrospective, Population-Based Study

“…27 The possible role of consolidation RT in DLBCL, also in advanced stage III to IV disease, has recently been discussed. 29 However, the role of RT in this clinical setting is still not established.…”