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Types of Lymphoma >
Diffuse Large
B-Cell Lymphomas
Last update:
05/19/2013
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TOPICS
Overview
| Workup |
Prognosis |
Treatment
| Novel Investigational
| Monitoring |
Clinical Trials
Subtypes:
Primary Mediastinal B-Cell
| CNS involvement | Primary Splenic
 TOPIC SEARCH
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PubMed:
Diagnosis
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Review
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Therapies
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Prognosis
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Refractory
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Overview
ABOUT
Lymphomas
Lymphoma Overview
Lymphatic System
Lymphoma Simplified
Overview of genes
and cancer
Lymphoma is a
cancer
About
Lymphoma
- general
Characteristics
of NHL:
Cell type |
Histology |
Grading
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Staging
Ann Arbor Staging
Extranodal notations
Diagnosis
Host/tumor
interaction
Lymphatic System
Risk Factors
Staging
Statistics
Symptoms
Transformation
Guidelines at diagnosis
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"Lymphoma is a blood cell cancer. The effected cells are
called lymphocytes, a type of white blood cell that helps protect us
from infection."
Diffuse Large B-Cell Lymphomas (DLBCL)
is the most common type of
lymphoma. It has an aggressive (fast growing) behavior
and is treated at diagnosis with curative intent.
The word "diffuse" describes the cell
pattern. B-cells arise from the bone marrow and mature or
differentiate into many cell types that tend to migrate to different
areas of the body. See also
What is lymphoma?
Initial presentation:
DLBCL typically presents as a nodal or extranodal mass (outside the
lymphatic system) with fast tumor growth associated with systemic symptoms, such
as sweats, fatigue, and fever. In about 40% of cases, these lymphomas
appear in areas outside lymph nodes, including digestive
tract, skin, bone, thyroid, and testes.
In the News:
Workup (adapted from NCCN Guidelines 2010)
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Calculate
International Prognostic
Index (IPI) |
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Staging
tests:
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CT of Chest/abdominal/pelvic with contrast
of diagnostic quality |
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Unilateral or bilateral bone marrow biopsy
(1-2 cm) + aspirate to document clinical
stage I_II disease |
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PET-CT scan |
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Useful in select cases:
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Lumbar puncture if involvement in
following sites:
paranasal sinus,
testicular,
epidural,
bone marrow with large cell
lymphoma,
HIV lymphoma, or
> 2 extranodal sites
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CT or MRI of neck and head
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Physical
exam:
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Attention to node-bearing areas, including
Waldeyer's ring |
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Examine size of liver and spleen |
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Performance status |
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B symptoms
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Labs and
tests:
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CBC, differential, platelets,
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Beta-2-microglobulin |
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LDH |
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Comprehensive metabolic panel |
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Uric acid |
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Hepatitis B testing |
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MUGA scan / echocardiogram"
(prior to anthracycline-based therapy) |
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Useful in select cases:
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HIV test
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Treatment, age and gender specific:
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Discuss fertility issues |
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Pregnancy testing in women of child-bearing
age if chemo is planned |
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Staging
Staging
refers to the how widespread the disease is. Imaging
tests (CT MRI, PET, Gallium) and bone marrow biopsies are commonly
done to estimate this. See Staging for
more detail.
Questions
Is it DLBCL or Burkitt's?
C-MYC Rearrangements are Frequent in Aggressive Mature
B-Cell Lymphoma with Atypical Morphology
ijcep.com
pdf
"To avoid under- or over-treatment of the
patients, it is critical to distinguish Burkitt's lymphoma (BL)
from DLBCL when encountering these aggressive mature B-cell
lymphomas with atypical morphology. Since diagnosis of BL requires
strict criteria (CD10+, BCL6+, close to a 100% proliferation index
and IG-MYC), many cases that do not meet all these criteria were
diagnosed as DLBCL, and therefore would not receive the benefit of
intensified chemotherapy. More recent studies suggest that some of
those DLBCL cases indeed had the molecular signatures of BL and
over 10% of those molecular BL did not harbor any detectable C-MYC
translocations".
Radiation to involved areas when PET positive after treatment?
FDG-PET Scan Guided Consolidative Radiation Therapy Optimizes
Outcome In Patients with Advanced-Stage Diffuse Large B-Cell
Lymphoma (DLBCL) with Residual Abnormalities on CT Scan Following
R-CHOP
ash.confex.com/ash/2010l
Subtypes of Diffuse Large Cell lymphoma
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Diffuse Large B-Cell (most common)
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Diffuse Mixed Cell
PubMed abstracts: Review
| Therapy
| Diagnosis
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Immunoblastic Lymphoma
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Primary Mediastinal B-Cell Lymphoma (see below)
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Primary Splenic Lymphoma (see below)
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Angiocentric Lymphoma - Pulmonary B-Cell |
Key Resources:
Topics:
Overview
| Workup |
Prognosis |
Treatment
| Monitoring |
Clinical Trials
Subtypes:
Primary Mediastinal B-Cell
| CNS involvement | Primary Splenic |
Prognosis
A prognosis is
NOT a prediction - it's an estimate of risk.
It may tell you what curve you are on, but not where you are on the
curve.
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Prognosis
Germinal center B cell-like (GCB)
has a more favorable response to standard therapies
Activated B cell-like (ABC)
less responsive; pts should consider investigational
treatments.
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Prognosis:
With the arrival of new tests
that determine the molecular characteristics of the lymphoma it's now possible to better determine the odds (or prognosis) of treatment. However, there are many factors that determine response, including age, general health, how widespread the disease is, LDH levels, etc.
Complete response rate: Most of the literature indicates that about
60% to 76% of DLBCL patients can achieve a complete response to
Rituxan-based combination chemotherapy.
"The rate of complete response was significantly
higher in the group that received CHOP plus rituximab than in the
group that received CHOP alone (76 percent vs. 63 percent, P=0.005).
With a median follow-up of two years, event-free and overall survival
times were significantly higher in the CHOP-plus-rituximab group
(P<0.001 and P=0.007, respectively)."
References:
CHOP chemotherapy plus
rituximab compared with CHOP alone in elderly patients with
diffuse large-B-cell lymphoma. N Engl J Med. 2002 Jan
24;346(4):235-42.
PMID: 11807147 PubMed
The addition of rituximab to the CHOP regimen increases the
complete-response rate and prolongs event-free and overall
survival in elderly patients with diffuse large-B-cell lymphoma,
without a clinically significant increase in toxicity.
International
prognostic index-based outcomes for diffuse large B-cell
lymphomas.
Cancer. 2002 Jun 15;94(12):3083-8. PMID: 12115338 PubMed
Expression of a
single gene, BCL-6, strongly predicts survival in patients with
diffuse large B-cell lymphoma. Blood. 2001 Aug 15;98(4):945-51.
PMID: 11493437 PubMed
A
predictive model for aggressive non-Hodgkin's lymphoma. The
International Non-Hodgkin's Lymphoma Prognostic Factors Project.
N Engl J Med. 1993 Sep 30;329(14):987-94. PMID: 8141877 PubMed
Rearrangement of the bcl-6 Gene as a Prognostic Marker in
Diffuse Large-Cell Lymphoma JAMA
7_19_94
Significance
of CD10 expression Medscape (requires login)
Genes pointing the way in lymphoma prognosis
cap.org
Sep 2002
The Modified International Prognostic Index (IPX)
can predict the outcome of localized primary intestinal lymphoma
of both extranodal Marginal Zone B-Cell and Diffuse Large-B-Cell
Histologies. International Extranodal
Lymphoma Study Group (IELSG) British Journal of Haematology,
2002, 118, 218–228 PDF
| PDF Help
Diffuse large B-cell lymphoma outcome
prediction by gene-expression profiling and supervised machine
learning nature.com
full
We analyzed the expression of 6,817 genes in diagnostic tumor
specimens from DLBCL patients who received (CHOP)-based
chemotherapy ... The model also effectively delineated
patients within specific IPI risk categories who were likely to be
cured or to die of their disease.
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Response to Second-line Therapy Defines the
Potential for Cure in Patients with Recurrent Diffuse Large B-cell
Lymphoma: Implications for the Development of Novel Therapeutic
Strategies
http://www.medscape.com/viewarticle/723577
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Subtypes
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Primary Splenic Lymphoma
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Primary Splenic Lymphoma
"Primary
splenic lymphoma (PSL) is rare with a reported incidence of less than
1%. Diffuse large cell pathology has been reported in 22-33% of the
cases and is felt to have a poor outcome. ... Seven of the nine
patients remained in remission from 1 to 19 years. Splenectomy
followed by combination chemotherapy, results in excellent long-term
survival in PSL." [1]
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Postsplenectomy Therapy in Diffuse Large B-cell Lymphoma? - Medscape
(free login req.)
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Primary splenic lymphoma: report of 10 cases using the REAL
classification.
Cancer Invest. 2002;20(5-6):749-53. PMID: 12197231 PubMed
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DLBC
Lymphoma with CNS involvement
Also see:
CNS Lymphomas
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DLBC
Lymphoma with CNS involvement
TOPIC
SEARCH PubMed: Review
| Therapies
"Primary CNS lymphomas (PCNSL), until
recently representing about 1% of all brain tumors, show dramatically
increased incidence both in high-risk groups (immunocompromised, AIDS)
and in the general population. They are extranodal diffuse
non-Hodgkin's lymphomas, the morphology and classification of
which are identical to those of systemic lymphomas, although PCNSL
show different biological behavior and diagnosis according to the New
Working Formulation and updated Kiel classification may be difficult.
The majority are large B cell variants of high-grade malignancy;
low-grade subtypes and T cell lymphomas are rare."[1]
Clinical Trial Search: With
CNS involvement
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Primary central nervous system lymphomas--an update.
J Cancer Res Clin Oncol. 1992;119(1):7-27. Review.
PMID:
1400570
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Long-term remission of primary central nervous system lymphoma
by intensified methotrexate chemotherapy. J Neurooncol. 2003
May;63(1):87-95.
PMID:
12814260
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Addition of Systemic High-Dose Methotrexate to Intrathecal
Chemotherapy for Central Nervous System Prophylaxis Substantially
Reduces CNS Recurrence Rates in Patients with at-Risk Aggressive
Lymphoma: A Historically Controlled Prospective Study
http://ash.confex.com/ash/2008/webprogram/Paper4036.html
Monday, December 8, 2008
n = 85 pts with newly diagnosed aggressive NHL with CNS risk
factors such as multiple extranodal sites and elevated LDH
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DLBC
Lymphoma with testicular involvement
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DLBC
Lymphoma with testis involvement
TOPIC
SEARCH PubMed: Review
| Therapies
WEB
"Advanced stage, elevated
serum LDH, B-symptoms, and high IPI are poor prognostic markers.
R-CHOP based chemotherapy with intrathecal chemotherapy and scrotal
RT is associated with an improved OS."[1]
Clinical Trial Search:
With
CNS involvement
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Outcome of patients with diffuse large B-cell lymphoma of
the testis by era of treatment: the M. D. Anderson Cancer Center
experience.
http://www.ncbi.nlm.nih.gov/pubmed/20443676
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Treatment
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TOPIC
SEARCH PubMed:
Review
| Therapies
| Radiotherapy
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Refractory |
Relapsed
Overview
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Background articles
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Treatment of Non-Hodgkin's Lymphoma: Next Steps
Medscape.com
2004 (free login req.) Review of progress for Follicular, SLL,
Diffuse Large Cell, and Mantle Cell.
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Treatment of Elderly PAL
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Monoclonal Antibodies in Aggressive, De Novo,
or Relapsed Lymphomas
Medscape
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Role of Radiation Therapy in Localized
Aggressive Lymphoma
jco.ascopubs.org (2007, editorial)
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First Primary Treatment
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Report: Dose Intensive R-ACVBP vs Standard R-CHOP In Younger Patients with
DLBCL
http://bit.ly/heJlx2
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Adult Non-Hodgkin’s
Lymphoma ~ Best Practice
Cancer.gov
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"Dose-densing" is the practice of
shorting the cycle time between infusions of treatment (14 vs 21
days) with the goal of increasing efficacy.
R-CHOP-14 in patients with diffuse large B-cell lymphoma:
feasibility and preliminary efficacy. Leuk Lymphoma. 2005
Apr;46(4):541-7.
PMID:
16019482 |
Related
articles
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Combination chemotherapy with adriamycin,
cyclophosphamide, vincristine, methotrexate, etoposide and
dexamethasone (ACOMED) followed by involved field radiotherapy
induces high remission rates and durable long-term survival in
patients with aggressive malignant non-Hodgkin's lymphomas:
long-term follow-up of a pilot study. Leuk Lymphoma. 2005
Dec;46(12):1729-34.
PMID:
16353313
"After a median observation time of 10 years and 2
months, 16/22 (73%) patients are alive in continuous complete
response without evidence of any late toxicities."
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CHOP + Rituxan is the standard of treatment
[2005]
for
Diffuse Large B-cell Lymphoma. See CHOP+R
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Dose-adjusted EPOCH chemotherapy for
untreated large B-cell lymphomas: a pharmacodynamic approach
with high efficacy.
Blood. 2002 Apr 15;99(8):2685-93. PMID:
11929754 PubMed
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Rationale for
Consolidation to Improve Progression-Free Survival in Patients
with Non-Hodgkin's Lymphoma: A Review of the Evidence Full
text:
http://bit.ly/2ttiY3
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CHOP-R + bortezomib (Velcade) as initial therapy for diffuse
large B-cell lymphoma (DLBCL).
http://bit.ly/9ifYVY
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Rituxan maintenance for DLBCL following
CHOP-R ?
ASCO 2007
http://bit.ly/1SkdJX
Maintenance rituximab (MR) compared to observation (OBS) after
R-CHOP or CHOP in older patients (pts) with diffuse large B-cell
lymphoma (DLBCL): An Intergroup E4494/C9793 update.
MR after CHOP, but not after R-CHOP, significantly prolongs TTF,
but fails to prolong OS, possibly due to a delayed pattern of
relapse and/or the efficacy of rituximab in the salvage
setting.
As 6-yr FFS declined to <50% among R-CHOP responders, with or
without MR, there is a need for more effective treatment
strategies in older DLBCL pts.
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Clinical trials in ClinicalTrials.gov
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Adding radiotherapy after
R-chemo?
The decision to add radiotherapy for this indication
seems to be based on individual risk factors, such as stage, areas
of involvement, degree of bulk, perhaps LDH at diagnosis, and
response to induction chemo. I suppose age is a factor, because the
risk of radiotherapy decreases with age. (Reasons to consult an
experts who have first-hand information about your case for a second
opinion, not patients!)
NCCN guidelines, based on risk factors list protocols as
R-CHOP x 3 +RT (with radiotherapy)
R-CHOP x 6 +-RT (with or without radiotherapy)
Here's a fairly recent report on this question - that could help in
the discussion with your
doctors:
JCO, 2010:
Benefit of Consolidative Radiation Therapy in Patients With DLBCL
Treated With R-CHOP
http://171.66.121.246/content/28/27/4170.full
"Of 469 patients, 190 (40.5%) had stage I or II
disease and 279 (59.5%) had stage III or IV disease, 327 (70%) had
at least six cycles of R-CHOP, and 142 (30.2%) had involved-field RT
(dose, 30 to 39.6 Gy) after complete response to chemotherapy.
Although radiation therapy (RT) was the first curative therapy for
aggressive lymphomas, whether it continues to have a role in the
treatment of DLBCL is controversial, with some studies supporting
its use and others not. Four randomized trials were unable to
conclusively determine the benefit of RT for patients with DLBCL
Our findings (with this caveat: retrospective study, single center)
indicate that even in the era of R-CHOP chemotherapy, the use of RT
was associated with significant improvements in OS and PFS for all
patients with DLBCL. The benefit was seen in both univariate and
multivariate analysis, across all disease stages and regardless of
disease bulk. Although both the type and number of chemotherapy
cycles administered varied somewhat, most patients (84%) received
what is considered to be the current standard of care. Moreover, RT
in all cases was delivered only to involved fields and not to
adjacent uninvolved lymph node stations; this was done to minimize
unnecessary toxicity."
Recurrent Diffuse Large B-Cell
Lymphoma
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Adult, Aggressive, Recurrent Non-Hodgkin’s Lymphoma
Standard of Care
Cancer.gov
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Multicenter study of i.v. Bu/Cy/E as
conditioning regimen for autologous stem cell transplantation in
patients with non-Hodgkin's lymphoma. Bone
Marrow Transplant. 2007 Sep 10; PMID:
17846602
In conclusion, the conditioning regimen of i.v. Bu/Cy/E was
well tolerated and seemed to be effective in patients with
aggressive NHL
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NEW
Second SCT for lymphoma patients who relapse after
autotransplantation: another autograft or switch to allograft?
Freytes CO, Lazarus HM. Bone
Marrow Transplant. 2009 Aug 24.
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Reduced-intensity allogeneic stem cell transplantation for
diffuse large B-cell lymphoma: Clinical evidence of a
graft-versus-lymphoma effect. ASCO
2006
Conclusions: The clinical observations of sustained CR/CRu
after withdrawal of immune suppression and DLI suggest that a GVL
effect exists against DLBC. RI alloSCT should be considered as a
treatment option for pts with primary refractory and relapsed DLBC.
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High-dose chemotherapy and autologous
hematopoietic stem-cell transplantation for aggressive
non-Hodgkin's lymphoma. J Clin Oncol 11 (10): 1846-51, 1993.
PUBMED
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BEAM chemotherapy and autologous bone marrow
transplantation for patients with relapsed or refractory
non-Hodgkin's lymphoma. J Clin Oncol 13 (3): 588-95, 1995. PUBMED
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Salvage therapy for relapsed diffuse large B-cell lymphoma remains
poor, except for those patients who have chemotherapy-responsive
disease and are candidates for high-dose therapy.
Preliminary results with a new "standard dose" salvage
regimen were presented. Using a combination of rituximab,
gemcitabine, and oxaliplatin, (R-GEMOX) an overall response
rate of 88% (42% complete responses) was obtained in a small group
of 24 patients.[18] With short follow-up, most of the patients
remained in remission. This regimen, using "newer"
chemotherapeutic agents with presumably less cross-resistance, is
of interest, and further results and follow-up are awaited.
www.medscape.com
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Two
Studies Demonstrate REVLIMID (R) (lenalidomide) Activity In
Patients With Relapsed/Refractory Aggressive Non-Hodgkin's
Lymphoma
medilexicon.com
"The data from these studies are encouraging in that they
show an impressive response to REVLIMID in relapsed/refractory,
aggressive NHL," said John Leonard, M.D., The Richard T.
Silver Distinguished Professor of Hematology Medical Oncology at
Weill Cornell Medical College. "These data justify a wide
exploration of REVLIMID in a variety of lymphoma settings both
alone and in combination, and warrant a detailed assessment of
which patients can particularly benefit."
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Response to Second-line Therapy Defines the
Potential for Cure in Patients with Recurrent Diffuse Large
B-cell Lymphoma: Implications for the Development of Novel
Therapeutic Strategies
http://www.medscape.com/viewarticle/723577
"Because the prospect for cure in
these patients is remote with standard strategies, management
should include a frank discussion of the goals of care,
including issues of the toxicity of therapy and quality of life.
No clear indication exists that palliative approaches are
inferior to further intensive approaches in this setting. This
fact may make a comfort-directed or investigational strategy
more acceptable to some patients, because they do not risk
losing the chance for a cure by choosing an alternative to
established standard chemotherapy regimens."
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Clinical Trials for DLBCL ClinicalTrials.gov
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Stem Cell Transplant in Recurrent DLBCL
Comments: Cancer.gov indicates that high dose therapy with
autologous stem cell rescue is the standard of care (as of Jan
2012). NCCN notes that allogeneic (from donor) SCT is
indicated only in select cases, such as when there are mobilization
failures (inability to harvest stem cells) or persistent bone marrow
involvement.
The following reports suggest also that autologous SCT is the
standard of care for initial relapse of DLBCL for those eligible for
high dose therapy. But that an allogeneic SCT can succeed in those
who relapse following an auto SCT.
Reports:
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DLBL, relapsed - BjH, 2007:
Non-myeloablative (mini) allogeneic stem cell transplantation
for relapsed diffuse large B-cell lymphoma: a multicentre
experience http://bit.ly/wKWvXQ
"Patients with DLBCL who relapse
after, or are ineligible for, autologous HCT have a poor
prognosis with conventional therapy. This study provides
evidence that non-myeloablative allogeneic HCT is an effective
salvage therapy which can produce long-term disease-free
survival in a subset of these patients. Given that virtually
none of these patients would be expected to achieve durable
disease-free survival with conventional therapy, the rate of PFS
seen after non-myeloablative allogeneic HCT is encouraging and
provides proof of the principle that immunological GVL effects
alone can control DLBCL in some cases."
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Aggressive, Recurrent Adult Non-Hodgkin Lymphoma,
Cancer.gov
"In a prospective randomized
study, known as the EORTC-PARMA trial, 215 patients in first or
second relapse of aggressive lymphoma, younger than 60 years,
and with no bone marrow or central nervous system involvement,
were given two cycles of intensive combination chemotherapy. The
109 patients who responded were randomly assigned to receive
four more cycles of chemotherapy and involved-field radiation
therapy (IF-XRT) versus autologous BMT followed by IF-XRT. With
a 5-year median follow-up, the event-free survival was
significantly improved with transplantation (46% vs. 12%).
Overall survival (OS) was also significantly better with
transplantation (53% vs. 32%).[7][Level of evidence: 1iiA]
Salvage BMT was unsuccessful for patients on the nontransplant
arm whose disease relapsed. |
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The International Prognostic Index Correlates to Survival in
Patients With Aggressive Lymphoma in Relapse:
Analysis of the PARMA Trial
"The results presented here show
that the IPI at the date of relapse enables us to distinguish
patients with a very different response rate to the DHAP regimen
and a different survival. The proportion of patients in each
risk group was comparable to that reported in the initial report
of the IPI.18 However, it must be noted that the PARMA trial
selected a population of favorable patients without BM or CNS
involvement." |
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Novel Approaches to DLBCL in Relapse Setting
Here we will list approved and investigational agents that appear
to have promise in the relapse setting as an alternative or "bridge"
to high-dose therapy with stem cell rescue.
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"Most relapses for patients
with aggressive lymphoma are found because of symptoms, new physical
findings or abnormal laboratory tests such as LDH or sedimentation
rate." 4 |
Monitoring aggressive lymphoma after first remission
"Routine imaging of patients with
aggressive lymphoma in complete remission is standard practice in most
of the United States.
The timing (i.e. every 6 months or every year),
the duration (i.e. usually for 3–5 years) and the type of image
performed (i.e. CT scan, PET scan or both) vary among clinicians." 4
In the News
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Onclive: Follow-Up Scans Do Little to Detect Relapse of
Diffuse Large B-Cell Lymphoma
http://bit.ly/105ODYv
Sixty-eight percent of
patients had symptoms at the time of relapse, 55% had abnormal
blood tests, and 42% had an abnormal physical exam finding.
Notably, only eight relapses were detected through a planned
surveillance scan before symptoms appeared—equivalent to just
1.5%.
Comment: A second question is if there is benefit to finding a
relapse early - if doing so improves the chance to cure with
second line therapy. It may turn out that sensitivity to
treatment is more important than the stage at which the relapse
was detected.
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Dr. Armitage writes: "Follow up
visits include interval history, careful physical examination, and
laboratory studies including a complete blood count, chemistry screen,
and serum Lactate Dehydrogenase (LHD).
Once a complete remission is
documented I would do no more images in the absence of some
abnormality hinting at relapse or at the patient’s request. I know
it is standard care in much of the U.S. to do routine images in
complete remission, but this approach cannot be supported with
data.
There is no convincing evidence that
routine images in remission accomplish their goal of improving
survival by finding early relapse although this could be tested in a
prospective trial. While there is at best minimal evidence that
routine images in remission could improve survival,(3) it is certain
that they are expensive.
Whether these studies make a patient
less anxious because a negative test is reassuring, or make them more
anxious by reminding them that they should be afraid of relapsing, is
a point that could be argued. However, given the specificity and
sensitivity of the tests, and the chances of relapse at any particular
point in time, it can be shown that abnormal findings on routine
images are much more likely (i.e. >80% of the time) to represent
false positives and lead to inappropriate further evaluation, or, even
worse, instituting inappropriate therapy.(4) Most patients who are
going to relapse will do so in the first two of three years."
1
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Surveillance imaging during remission identifies a group of patients with more favorable aggressive NHL at time of relapse: a retrospective analysis of a uniformly-treated patient population.
Ann Oncol. 2006 Jun;17(6):909-13. Epub 2006 May 3. PMID: 16672295
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Is there a place for routine imaging for patients in complete remission from aggressive lymphoma?
Ann Oncol. 2006 Jun;17(6):883-4. PMID: 16707741
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Value of serum beta 2 microglobulin as an
indicator of early relapse in diffuse large cell lymphoma
ncbi.nlm.nih.gov
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Clinical Trials
Also see our NHL treatment-specific links to
ClinicalTrials.gov
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ClinicalTrials.gov
searches
Rationale for participation in
clinical trials:
DLBCL is potentially curable with R-CHOP, but roughly 40% of patients
either do not respond to treatment or relapse after achieving remission
(Coiffier. Blood 2010). Further those who do not respond to R-CHOP have
a long-term survival of only 20% (Gisselbrecht, J Clin Oncol 2010).
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Clinical Trials for DLBCL ClinicalTrials.gov
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