I. Overview: Diffuse large B-cell lymphoma (DLBCL) is the most common type of malignant lymphoma with significant heterogeneity in clinicopathology. It accounts for 30%-40% of adult non-Hodgkin’s lymphoma in Western countries and up to 60% in developing countries. This type of lymphoma is more malignant but responds well to chemotherapy, with a 5-year survival rate of 75% -80%. Complete remission (CR) and maintenance of CR after treatment is a prerequisite for cure in DLBCL, and many studies have shown that CR after treatment is closely related to overall patient survival. In general, the prognosis of lymphoma and the time to achieve complete remission with initial chemotherapy have an important relationship, and the fewer the cycles of chemotherapy required, the longer the time to achieve complete remission and the better the prognosis. According to immunohistochemistry, DLBCL can be divided into two subtypes, GCB type and non-GCB type, and the prognosis of the former is generally better than that of the latter, while the main subtype in China is the latter non-GCB type.
II. Clinical manifestations: Like general non-Hodgkin’s lymphoma, the main manifestations are.
1.Lymph node enlargement: the most common first symptom, painless lymph node enlargement in the neck is the most common, followed by axillary and inguinal lymph nodes, the lymph nodes are progressively enlarged, asymmetric, without pressure pain, solid and elastic in texture.
2.Deep lymph node enlargement: mainly lymph node enlargement in the hilum, mediastinum, mesentery and retroperitoneum, which may be asymptomatic in the early stage, but the symptoms may appear after the lesion develops to a certain extent.
3.Extra-nodal manifestations: extra-nodal origin accounts for about 35%, mainly in the stomach, skin, oropharyngeal cavity, small intestine and central nervous system, others such as sinus, testis, thyroid, etc., have different manifestations depending on the location.
4. Systemic symptoms: fever, night sweats, weight loss, commonly in the more advanced stages.
3. Routine tests: complete blood cytometry, biochemical tests, head/neck/thorax/abdomen/pelvis CT, cardiac function, PET scan or 67 scan, LDH, β2 microglobulin, bone marrow aspiration, hepatitis B-related tests, HIV tests, lumbar puncture, abdominal ultrasound, lymph node biopsy.
Typical immunophenotypes: CD20+ , CD10, bcl-6, MUM1, Ki-67, CD43, CD45+, CD3-.
Molecular genetic analysis tests: bcl-2, bcl-6, c-myc.
IV. Treatment principles.
Phase I and II induction therapy.
Non-megaloblastic type (<10 cm):① presence of adverse risk factors (elevated LDH, stage II, age >60 years, PS score ≥2): R-CHOP 6-8 courses ± local radiotherapy (IF 30-36Gy) or R-CHOP ×3 courses + local radiotherapy (IF 30-36Gy) ② absence of adverse risk factors: R-CHOP ×3 courses + local radiotherapy (IF 30-36Gy) or R-CHOP 6-8 courses.
Macroblock type (>10cm): R-CHOP 6-8 courses + local radiotherapy (IF 30-36Gy) (Category 1)
Stage I and II follow-up (review of all positive results prior to radiotherapy evaluation).
Complete remission or CRu: follow-up after completion of the established course of treatment.
Partial remission: completion of high-dose radiotherapy (40-45 Gy) or autologous stem cell transplantation or clinical trial, review at the end of treatment, follow-up for complete remission, others treated as relapse.
No remission or disease progression: high-dose therapy or clinical trial.
Phase III and IV induction therapy.
Low/low-intermediate risk (IPI0-1): 6-8 courses of R-CHOP (Class 1).
Intermediate-high/high risk (IPI ≥ 2): Clinical trial (preferred) or R-CHOP 6-8 sessions (category 1).
Stage III, IV follow-up (review all positive results after 3-4 courses).
Complete remission or CRu: continue R-CHOP regimen until 6-8 courses are achieved followed up.
Partial remission: continue R-CHOP regimen until 6-8 courses are reached or clinical trial, followed by review of all positive results, no remission or progression to first-line therapy or stem cell transplantation or clinical trial.
No remission or disease progression: 2nd line therapy or stem cell transplantation or clinical trial with radiation therapy for patients not eligible for chemotherapy.
Recommended treatment regimen.
First-line treatment regimen: R-CHOP (class 1), R-ECHOP (class 2B).
Second-line treatment regimens: DHAP±R, ESHAP±R, GDP±R, ICE±R, MINE±R.