Guidelines on Diagnosis and Treatment of Malignant Lymphomas

Stage 1 (bulky) and stages II – IV
R-CHOP for 6-8 cycles. The decision in low or low-intermediate
risk IPI patients is based on giving 2 cycles beyond achievement
of complete response. Those with high-intermediate or high IPI
scores should have maximum treatment. Accelerated R-CHOP at
14 day intervals with G-CSF for 6 cycles may be equally effective.
Consolidation radiation to sites of bulky disease should be
considered. The OS at 5 years of 65% remains sub-optimal and
approaches such as the NCI-sponsored DA-R-EPOCH using
infusional chemotherapy appears to result in a higher OS of 73%
and PFS of 70% at 5 years. Prognostic factor adjusted
chemotherapy in DLBCL has not yet been adopted in a uniform
fashion, though it is clearly an area of critical importance.
Response Evaluation
Response should be evaluated every two cycles of treatment,
with radiological evaluation after 4 cycles and at the end of
treatment. Infiltration of marrow or CSF at diagnosis, needs to be
rechecked at the end of treatment. Patients who are not in PET
negative CR at the end of treatment have primary refractory
disease and should be considered for salvage therapy.
Follow up
Clinical: History and physical examination every 3 months for
2 years, every 6 months for 3 years and then yearly with particular
attention to second malignancies.
Relapsed or Resistant DLBCL
Patients with primary refractory disease may not need to be
re-biopsied before initiating salvage therapy, but all patients
with relapsed disease should be re-biopsied. Assessment and
staging is the same as in newly-diagnosed disease. The total
anthracycline dose must be assessed if they are to be used in
salvage therapy and a pre-treatment ECHO is advised.
Treatment: In patients