Diffuse Large B-Cell Lymphoma: Treatment

Diffuse Large B-Cell Lymphoma: overview

This algorithm covers treatment of diffuse large B-cell lymphoma from frontline therapy through later relapses. Frontline, the standard is six cycles of R-CHOP (GELA LNH98-5), with Pola-R-CHP shown as the option with improved PFS (POLARIX). In the site's POLARIX summary, Pola-R-CHP improved PFS over R-CHOP in patients with IPI 2 or higher, the first regimen to do so in a phase III trial, with similar safety and no OS benefit at the primary analysis.

At first relapse in transplant-eligible patients, the chart branches on timing. Early relapse is directed to CD19 CAR-T therapy (ZUMA-7). Late relapse is treated with salvage chemotherapy followed by autologous stem cell transplant (CORAL), a trial in which R-ICE and R-DHAP gave equivalent salvage outcomes and prior rituximab exposure was the dominant adverse prognostic factor. In later lines, the options are tafasitamab plus lenalidomide (L-MIND), the bispecific antibodies glofitamab or epcoritamab, and the ADC loncastuximab tesirine (LOTIS-2). L-MIND reported a 57.5% response rate with durable responses in transplant-ineligible relapsed or refractory disease.

Trials behind this algorithm

• POLARIX Tilly H et al, NEJM, 2022; PMID: 34904799
• ZUMA-7: Axicabtagene Ciloleucel as Second-Line Therapy for Large B-Cell Lymphoma Locke et al, NEJM, 2021, PMID: 34891224
• CORAL Gisselbrecht C et al, JCO, 2010; PMID: 20660832
• L-MIND Salles G et al, Lancet Oncol, 2020; PMID: 32511983
• LOTIS-2 Caimi PF et al, Lancet Oncol, 2021; PMID: 33989558

Background reading: Diffuse large B-cell lymphoma (DLBCL) board review notes.