Diffuse Large B-Cell Lymphoma: Frontline Treatment Options


A review of frontline treatment options for DLBCL informed by comprehensive patient workup and the efficacy of available therapies.

Daniel O. Persky, MD:What first-line treatment options are available for the patient? Well, for diffuse large B-cell lymphoma [DLBCL] not otherwise specified [NOS], the standard remains R-CHOP [rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone]. There continue to be arguments about dose-adjusted to EPOCH-R [etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, rituximab] and other more intensive regimens for double- and triple-hit lymphoma in first-line therapy as compared to R-CHOP. There is still a lot of controversy of what the right treatment for them is. For nongerminal center B-cell-like [GCB]-derived DLBCL, we do consider the addition of lenalidomide to R-CHOP, but that’s based on phase 2 data. Phase 3 data did not show a difference in progression-free overall survival. Therefore, while some physicians actually do add lenalidomide to R-CHOP for non-GCB DLBCL, I would assess that the majority of physicians still give R-CHOP for a non-GCB DLBCL.

In terms of FISH [fluorescence in situ hybridization] testing, I don’t know how it works in your facility, but in my facility, FISH testing does take a week or two to get back. Most of our patients with more aggressive DLBCL cannot wait that long for treatment. Most commonly what we do in our practice is we initiate R-CHOP as we wait for FISH results. If FISH results come back a week or two later showing that there is a presence of double- or triple-hit [lymphoma], we do consider switching therapy in our practice to typically dose-adjusted EPOCH-R. Again, as I mentioned, this is controversial for some. At this point, we still do, and then we complete 6 cycles total of therapy.

Overall, we’re fortunate that in DLBCL, the response rate is generally pretty high. It’s over 90%, with CR [complete response] rates being quoted typically around 80% to 85%. Duration of response, so let’s say progression-free survival [PFS] after R-CHOP for again, DLBCL NOS is typically very good, on the order of 50% to 60%. Generally speaking, the PFS for non-GCB DLBCL is a bit lower, and PFS for double- and triple-hit lymphoma is a lot lower for R-CHOP. At least that’s what the majority of the data point to.

This transcript has been edited for clarity.

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