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Diffuse large B-cell lymphoma

Key sources
The following summarized guidelines for the evaluation and management of diffuse large B-cell lymphoma are prepared by our editorial team based on guidelines from the British Society for Haematology (BSH 2024; 2020; 2019; 2016), the European Society of Medical Oncology (ESMO 2018; 2016; 2015), and the British HIV Association (BHIVA 2014).
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Guidelines

1.Classification and risk stratification

Staging: use the Ann Arbor classification system for staging DLBCL.
A
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  • Prognostic scores

2.Diagnostic investigations

History and physical examination: perform a physical examination and assess performance status and B symptoms in patients with DLBCL.
B

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  • Imaging for staging

  • Laboratory evaluation

  • Cardiac evaluation

3.Diagnostic procedures

Biopsy and histopathology
As per BSH 2024 guidelines:
Perform excision biopsy to provide optimal material for diagnosis.
B
Consider performing needle-core biopsy when a surgical approach is either impractical or entails excessive risk or delay.
C

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  • Ancillary testing

  • Bone marrow biopsy

  • Lumbar puncture

4.Medical management

General principles: as per BSH 2024 guidelines, diagnose DLBCL in a reference hematopathology laboratory with access to a full range of phenotypic and molecular investigations.
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  • Induction and consolidation therapy (young patients, early/low-risk disease)

  • Induction and consolidation therapy (young patients, advanced/high-risk disease)

  • Induction and consolidation therapy (elderly/frail patients)

  • CNS prophylaxis

  • Febrile neutropenia prophylaxis

  • Infection prophylaxis

  • Management of osteoporosis

5.Specific circumstances

Patients with plasmablastic lymphoma: obtain immunohistochemistry tests (for CD38, CD20, PAX5, CD138, EBER, CD30, MUM-1, Kappa-lambda, HHV8, andALK ) as part of diagnostic assessment in HIV-negative patients with suspected plasmablastic lymphoma.
B
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  • Patients with HIV-associated DLBCL

  • Patients with HBV infection

  • Patients with CNS DLBCL (diagnosis)

  • Patients with CNS DLBCL (baseline imaging)

  • Patients with CNS DLBCL (ophthalmological assessment)

  • Patients with CNS DLBCL (cognitive assessment)

  • Patients with CNS DLBCL (induction chemotherapy)

  • Patients with CNS DLBCL (consolidation therapy)

  • Patients with CNS DLBCL (management of intraocular lymphoma)

  • Patients with CNS DLBCL (assessment of treatment response)

  • Patients with CNS DLBCL (salvage therapy)

  • Patients with primary mediastinal DLBCL (mediastinal biopsy)

  • Patients with primary mediastinal DLBCL (bone marrow biopsy)

  • Patients with primary mediastinal DLBCL (baseline imaging)

  • Patients with primary mediastinal DLBCL (fertility counseling)

  • Patients with primary mediastinal DLBCL (pregnant patients)

  • Patients with primary mediastinal DLBCL (induction therapy)

  • Patients with primary mediastinal DLBCL (consolidation therapy)

  • Patients with primary mediastinal DLBCL (assessment of treatment response)

  • Patients with primary mediastinal DLBCL (salvage therapy)

  • Patients with primary extranodal DLBCL

  • Patients with testicular DLBCL

  • Patients with breast DLBCL

  • Patients with bone DLBCL

  • Patients with gastric DLBCL

  • Patients with cutaneous DLBCL

  • Patients with intravascular large B-cell lymphoma

6.Patient education

General counseling: discuss and explain all diagnoses and treatment plans with the patient and their family or carer if appropriate. Refer to additional sources of support.
B

7.Follow-up and surveillance

Serial clinical assessment: elicit careful history and perform physical examination every 3 months for 1 year, every 6 months for 2 further years, and then once a year with attention to the development of secondary tumors or other long-term side-effects of chemotherapy.
B

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  • Serial laboratory assessment

  • Serial imaging assessment

  • Repeat biopsy