Large B-Cell Lymphoma: Treatment Approaches and Evolving Therapies

Opinion
Video

Expert insight into current treatment strategies and emerging therapies for diffuse large B-cell lymphoma, a challenging malignancy.

Diffuse large B-cell lymphoma (DLBCL) presents unique challenges in its treatment, and the transcript delves into the evolving landscape of therapeutic approaches. The standard of care for the majority of DLBCL patients has been R-CHOP, a regimen combining rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone. Although this treatment has been effective for several decades, recent clinical trials are exploring new options, with the addition of a drug called polatuzumab challenging R-CHOP's status as standard-of-care.

For more aggressive, rapidly proliferating cases and double or triple-hit lymphomas, an intensified regimen called R-dose-adjusted EPOCH (R-EPOCH) with the addition of etoposide is employed. Additionally, R-EPOCH plays a significant role in treating high-grade, rapidly proliferating Burkitt lymphoma. Approximately 60% of patients with DLBCL achieve remission with frontline R-CHOP–like therapy, leaving 40% who either don't achieve complete remission (primary refractory) or relapse after initial treatment. Historically, these patients have undergone salvage chemotherapy, utilizing regimens such as R-GemOx (rituximab, gemcitabine, and oxaliplatin), R-ICE (rituximab, ifosfamide, carboplatin, etoposide), or R-DHAP, (rituximab, cisplatin, cytosine arabinoside, dexamethasone) with no definitive superiority among them. Treatment choice often depends on individual centers or practitioners.

Patients with chemotherapy-sensitive disease may become candidates for autologous stem cell transplant. However, a significant percentage of patients do not respond to salvage chemotherapy, presenting a challenging prognosis. Recent advancements in cellular therapeutics and bispecific antibodies are changing the landscape. Chimeric antigen receptor (CAR) T-cell therapy has emerged as a potential game-changer for patients with relapsed or refractory DLBCL. As part of tailoring treatments to individual patients, some regimens may exclude doxorubicin due to its potential for cardiotoxicity, especially in those with preexisting heart conditions. Regimens are adapted for older patients with various comorbidities such as heart disease, diabetes, or lung disease. In the context of evolving therapies, there's a growing need for consensus among health care teams. The lymphoma care team at the University of Kansas meets to discuss individual patient cases and formulating tailored treatment plans. This is particularly crucial for advanced-age patients with significant comorbidities.

In summary, the treatment landscape for DLBCL is continuously evolving. Although R-CHOP has been the mainstay, ongoing clinical trials and emerging therapies, such as CAR T-cell therapy, offer new hope for patients who previously had limited options. The approach to treatment must be tailored to the individual patient, considering their age, overall health, and comorbidities, as the field continues to make significant strides in improving outcomes for patients with DLBCL.

Video synopsis is AI-generated and reviewed by OncLive editorial staff.

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