NCCN Guidelines for Patients® | Diffuse Large B-cell Lymphoma

42 NCCN Guidelines for Patients ® : Diffuse Large B-cell Lymphoma, 2017 Stages III & IV Guide 5 maps the initial treatment of stages III and IV. These lymphomas are on both sides of your diaphragm. Otherwise, they have widely spread outside the lymphatic system. Rituximab-based chemotherapy One option includes 6 cycles of rituximab-based chemotherapy. For select people, radiation to bulky sites may be received beforehand. A second option is to join a clinical trial. Some chemotherapy may harm your health. Thus, your current health and age will affect which chemotherapy you will receive. Start treatment with RCHOP if you are healthy. If you have heart problems or are frail, your options include RCEPP, RCDOP, DA-EPOCH with rituximab, RCEOP, and RGCVP. RGCVP and R-mini-CHOP can be received if you are older than 80 years of age and have multiple health conditions. Sometimes DLBCL spreads into the CNS ( c entral n ervous s ystem). This system includes your brain and spinal cord. If this is the case, other cancer drugs will be added to the treatment described above. Most CNS disease can be treated with methotrexate. The two innermost layers of your brain’s membrane are called the leptomeninges. If the cancer has spread to this site, treatment includes both methotrexate and cytarabine. Treatment results After 2 to 4 chemotherapy cycles, treatment results will be assessed. Imaging tests are used. PET/CT has been found to be very useful for checking results. Imaging should occur at least 8 weeks after treatment. Test results are used to advise the next steps in treatment. If the cancer appears to be gone or smaller, complete the 6 cycles of chemotherapy. Another option is to join a clinical trial. If the cancer looks the same or larger, a biopsy may be done to confirm there’s cancer. If no cancer is found, complete the 6 cycles of chemotherapy. Another option is to join a clinical trial. If cancer is found or a biopsy isn’t done, read Guide 8 for treatment options. Radiation therapy may also be an option. Guide 6 lists options if first-time treatment worked. If treatment worked, the signs of cancer will be gone or greatly reduced on tests. One option is to start observation. Observation or “watch-and-wait” is a period of testing to see if cancer grows. A second option is radiation therapy. It may be given to sites where the cancer had grown large. It may also be used to treat lymphoma that has spread to small areas of the bone. A third option is maintenance treatment. The goal of maintenance is to prevent the cancer from returning. Lenalidomide maintenance has been studied among older people who received RCHOP. A fourth option is consolidation treatment with an autologous blood stem cell transplant. The chance of the cancer coming back may be high for some people. The goal of consolidation treatment is to kill any cancer cells that may remain. Follow-up care Guide 7 provides follow-up care options for when there are no signs of cancer after treatment. This care may include a medical history, physical exam, imaging, and blood tests. Imaging will involve a CT scan of your chest, abdomen, and pelvis. Contrast should be used. A biopsy is often needed to confirm there’s cancer. If the cancer returns (relapses), read Guide 8 for options. 4 Treatment guide First-line treatment | Follow-up care