Diffuse Large B-Cell Lymphoma (DLBCL): What to Know

This page is for people with diffuse large B-cell lymphoma (DLBCL) and their families. It covers biopsies, risk scores, report terms, first treatment, and what happens if the lymphoma comes back.

Diffuse large B-cell lymphoma, usually shortened to DLBCL, is the most common aggressive non-Hodgkin lymphoma. It grows fast. Untreated, it does not sit still for long.

That speed cuts both ways. Fast-dividing cells are the ones chemotherapy hits hardest. So unlike most advanced solid tumors, DLBCL is treated with the aim of cure even when it has spread widely.

Stage in lymphoma also does not mean what it means in breast or colon cancer. Stage IV DLBCL is common at diagnosis and is still treated for cure. What you know about stages in other cancers may not apply here.

The pathologist needs enough tissue to see the architecture, not just the cells.

A French national review found that lymph node excisions gave more precise lymphoma diagnoses than core needle biopsies. A core needle takes a thin cylinder. An excisional biopsy takes the whole node.

If a needle biopsy came back as "B-cell lymphoma" with no further detail, ask whether a larger sample is needed. Getting the subtype wrong changes the whole plan.

NCI publishes the NCCN International Prognostic Index for aggressive lymphoma. It scores five things:

• Age, scored in bands: under 40 scores 0, ages 41 to 60 score 1, ages 61 to 75 score 2, and over 75 scores 3.
• Stage III or IV adds 1.
• Performance status of 2, 3, or 4, meaning illness keeps you from work or usual activities, or limits you more than that, adds 1.
• Two or more sites outside lymph nodes adds 1.
• LDH (see below) adds 0 to 2.

LDH, short for lactate dehydrogenase, is a blood enzyme that rises when cells break down fast. A normal LDH scores 0. Up to three times the upper limit scores 1. Above three times scores 2.

The totals map onto outcomes. Overall survival means being alive. Progression-free survival means being alive without the lymphoma growing.

• 0 or 1, low risk: 5-year overall survival 96%, progression-free survival 91%.
• 2 or 3, low intermediate: 82% and 74%.
• 4 or 5, high intermediate: 64% and 51%.
• Above 6, high risk: 33% and 30%.

Ask which band you fall into. The gap between the top and bottom band is large enough to change how you plan the next year.

Some reports mention rearrangement of the MYC gene together with BCL2, BCL6, or both. NCI states plainly that this pattern carries a particularly poor prognosis.

The current name for it is high-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements. It is found by a lab test on the tumor, often one called FISH, which uses fluorescent probes to spot the specific gene breaks. NCI notes studies of more intensive treatment for it, so ask whether this result changes your plan.

Ask whether FISH for MYC, BCL2, and BCL6 was performed. If your report does not mention it, the test may still be pending.

Lymphoma reports describe "bulky disease." The cutoff is not the same across lymphomas.

NCI notes that in DLBCL, published cutoffs range from 5 cm to 10 cm, and that 10 cm is the recommended figure. In Hodgkin lymphoma, by contrast, bulk means a mass wider than one third of the chest on CT, or a mass over 10 cm.

The difference between sources is real, not a typo. If a report calls your 7 cm mass bulky, ask which definition the team is using. What the Lugano criteria mean covers the staging and response rules behind these terms.

The standard first treatment is R-CHOP: rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. R-CHOP day by day walks through a cycle.

POLARIX tested a change. It randomized 879 people with untreated DLBCL and an IPI score of 2 or higher. One arm got standard R-CHOP. The other got Pola-R-CHP, in which polatuzumab vedotin replaced vincristine, chosen partly to reduce nerve damage.

At a median follow-up of 28.2 months, 2-year progression-free survival was 76.7% with Pola-R-CHP and 70.2% with R-CHOP. The hazard ratio was 0.73. (A hazard ratio below 1 means fewer events, such as relapse, in the new treatment group.)

But 2-year overall survival was 88.7% versus 88.6%, with a hazard ratio of 0.94 and a p-value of 0.75. In other words, fewer people relapsed, and so far the same number are alive. That is a real difference worth discussing, and it is not the same as a survival gain. Both numbers deserve to be on the table.

A PET-CT scan partway through treatment is common. Its predictive value in DLBCL is weaker than many people assume.

NCI states that multiple studies have shown interim PET scans done after two to four cycles of therapy do not give reliable prognostic information. Two prospective trials and one meta-analysis found no difference in outcome between people who were PET-negative and people who were PET-positive but biopsy-negative. A large cooperative group trial also ran into trouble with different readers scoring the same scan differently.

So an interim scan may be used to reassure rather than to change the plan. Ask directly whether a particular result would alter treatment. What a Deauville score means explains the 1 to 5 scale the report will use.

Relapse timing drives the next decision, and 12 months is the dividing line.

ZUMA-7 studied 359 people whose disease did not respond to R-CHOP or returned within 12 months of it. One arm got the CAR T-cell product axicabtagene ciloleucel. The other got standard chemoimmunotherapy, usually R-ICE or R-DHAP, followed by an autologous stem cell transplant. At a median follow-up of 47.2 months, median overall survival was not reached in the CAR T group and was 31.1 months in the chemotherapy group. Estimated 4-year overall survival was 54.6% versus 46.0%.

TRANSFORM tested lisocabtagene maraleucel in the same setting, in 184 people. Median progression-free survival was not reached with CAR T and was 6.2 months with chemotherapy then transplant, a hazard ratio of 0.40.

One number from that trial explains a lot. On the chemotherapy arm, 53% never reached transplant, because their lymphoma did not respond enough to get them there. CAR T-cell therapy covers what the process involves.

• Call 911 or go to an emergency department if you have new back pain with leg weakness, numbness, or loss of bladder or bowel control. The American Cancer Society calls spinal cord compression an emergency that needs treatment right away. Do not drive yourself.
• Call 911 or go to an emergency department if your face or neck swells, or you have trouble breathing. A lymph node mass can press on the superior vena cava, a large vein in the chest. The American Cancer Society says this can be life-threatening and must be treated right away. Do not drive yourself.
• Call your cancer team right away, at any hour, for a fever of 100.4°F (38°C) or higher after chemotherapy. CDC says fever may be the only sign of an infection, and an infection during chemotherapy can be life-threatening. If you cannot reach the team, go to an emergency department and say you are on chemotherapy.
• Call your cancer team right away if you pass much less urine than usual in the first days of treatment, or your muscles cramp badly. NCI notes that fast tumor breakdown can raise potassium and phosphate in the blood and harm the kidneys.
• Call your cancer team right away if veins newly stand out on your chest, since that can be an early sign of pressure on the superior vena cava.
• Call your cancer team the same day if a lymph node grows noticeably in a week, or drenching night sweats return.

• https://www.cancer.gov/types/lymphoma/hp/aggressive-b-cell-lymphoma-treatment-pdq
• https://www.cancer.gov/types/lymphoma/patient/adult-nhl-treatment-pdq
• https://www.cancer.gov/about-cancer/treatment/side-effects/infection
• https://medlineplus.gov/ency/patientinstructions/000913.htm
• https://www.cdc.gov/cancer-preventing-infections/patients/fever.html
• https://www.cancer.org/cancer/types/non-hodgkin-lymphoma/detection-diagnosis-staging/signs-symptoms.html
• https://www.cancer.org/cancer/supportive-care/advanced-cancer/bone-metastases.html
• https://www.fda.gov/drugs/drug-approvals-and-databases/fda-grants-accelerated-approval-epcoritamab-bysp-relapsed-or-refractory-diffuse-large-b-cell
• https://www.fda.gov/drugs/drug-approvals-and-databases/fda-grants-accelerated-approval-glofitamab-gxbm-selected-relapsed-or-refractory-large-b-cell