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(This section also applies to anaplastic large cell lymphomas, most peripheral T-cell lym- phomas, and follicular or MALT lymphomas that contain diffuse large B-cell lymphoma.)

The diagnosis is made by lymph node biopsy or, sometimes, bone marrow or other tissue. A pathologist experienced in diagnosing lymphomas should examine the sample. The diagnosis should be confirmed by studying the cell surface markers. Sometimes genetic studies are useful. A complete medical history and physical examination should be done. The doctor will want to know if lymph nodes are enlarged or if the spleen or liver is enlarged. The doctor will also examine other

organ systems, ask about the patient’s general health and whether there has been any fever or weight loss.

Blood tests are done to check the blood counts, liver function, kidney function, and calcium, uric acid, beta-2-microglobulin, and LDH levels. All these tests provide informa- tion about the patient’s general health and how advanced the lymphoma is. A chest x-ray or CT scan of the chest is done, as well as a bone marrow test if it hasn’t been done already. A CT scan of the abdomen and pelvis is also recommended. The International Prognostic Index is calculated. Finally, heart function may be tested with a MUGA scan. This may be needed because most chemo-

Treatment Guidelines for Patients

Diagnosis

Lymph node biopsy or bone marrow biopsy for diagnosis of lymphoma Review by pathologist experienced in diagnosis of lymphomas. Repeat biopsy if specimen inadequate for diagnosis

Special tests of biopsy specimen to establish the exact type of lymphoma • Cell surface markers

• Genetic studies (if needed)

This guideline applies whenever diffuse large B-cell lymphoma is present along with follicular, gastric MALT, and nongastric MALT lymphomas. It also applies to anaplastic large cell and peripheral T-cell lymphomas.

Diffuse Large B-Cell Lymphoma

therapy regimens for this type of lymphoma include an anthracycline drug like doxorubicin. Anthracyclines can damage the heart.

Other tests that may be useful are a gal- lium scan or a PET scan. A CT of the neck may be helpful if there is suspicion of

enlarged lymph nodes in this area. A spinal tap may be helpful as might a CT or MRI scan of the brain. HIV testing might be indicated in some patients. Finally, because treatment may affect fertility, this needs to be discussed if the patient wants to have a family.

©2005 by the National Comprehensive Cancer Network (NCCN) and the American Cancer Society (ACS). All rights reserved. The information herein may not be reproduced in any form for commercial purposes without the expressed written permission of the ACS. Single copies of each page may be reproduced for personal and non-commercial uses by the reader.

Evaluation

Doctor must do:

• Physical examination with special attention to areas with lymph nodes, back of throat, liver, and spleen

• Check general health and activity • Ask about fever or weight loss • Complete blood count

• Blood tests of kidney and liver function and LDH, calcium, and uric acid levels

• Chest x-ray

• CT scans of chest, abdomen, and pelvis

• Bone marrow aspiration and biopsy of one or both sides of pelvic bone • Calculate International Prognostic Index (IPI) (see page 16)

• Blood test for beta-2-microglobulin

• Measure heart function with radioactive scan (MUGA) or echocardiogram Useful in some cases:

• Gallium scan or PET scan • CT scan of the neck • CT or MRI of head

• Discuss the effect of treatment on fertility • Stool test for blood if there is anemia • Test for HIV (AIDS virus)

• Spinal tap to test fluid for lymphoma cells if lymphoma is in sinuses, testicles, near the eye or spine, or if HIV test is positive

See initial treatment on next page

If the lymphoma is stage I or II, treatment depends on it size. For tumors smaller than 10 centimeters (4 inches), in patients with a poor outlook, chemotherapy with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) is recommended. Rituximab and/or intermediate-dose radiation (15 to 20 treatments) may be added. The same treat- ment is recommended if the tumor is larger except that radiation therapy should be given.

For patients with a good outlook whose tumor is smaller than 4 inches, only 3 to 4

cycles of chemotherapy are given, followed by radiation.

Stages III and IV patients with a low International Prognosis Index (IPI) are treated mainly with CHOP chemotherapy, usually with added rituximab. If the IPI is high, a clinical trial, with perhaps a stem cell transplant, may be preferred because the outlook is not good. Otherwise CHOP and rituximab may be given with rituximab added for patients over 60 and optional for younger patients. If the lymphoma is in the bone marrow, nasal

Stage

Stage I or II

Tumor larger than 10 cm (4 inches)

Low IPI (0–1)

High IPI (2 or greater) Stage III or IV

Treatment Guidelines for Patients

Tumor smaller than 10 cm (4 inches)

Outlook poorer: • High LDH • Stage II • Over age 60 • Very sick from

lymphoma