Large cell Diffuse B lymphomas
Therapeutic means
This is an emergency...
The treatment must be set up quickly and should not be deferred.
IMMUNO-Chemotherapy, the current STANDARD...
The first line treatment consists of 6 to 8 cycles of R-CHOP14 or 21 (Rituximab + chop [Cyclophosphamide, Doxorubicin (formerly known as Hydroxydaunorubicine), vincristine (Oncovin ™) and Prednisone] all 14 or 21 days or R-CHOEP (R-CHOP and Etoposide).
This scheme can be adapted according to the IPI score, the patient and its general condition
R-ACVBP [Doxorubicin (ADRIBLASTINE), cyclophosphamide, Vindesine, bleomycin, prednisone] is the reference chemotherapy of GELA (Adult Lymphoma Study Group) in aggressive lymphomas in young subjects.
Recently, the R-Chop + bortezomib (Velcade ™) Association has proven to be more active in a subgroup of patients called ABC subset (activated B Cell) than the usual treatment, R-Chop.
The current trend of treatment is an increase in the intensity dose.
Neuroméningées Relapse prophylaxis It is an option for patients in complete remission who initially presented specific high-risk locations (sinuses, palates, paravertebral mass and bone marrow), but also in those whose IPI score is high.
The consolidation treatment high-dose chemotherapy it generally uses BEAM [Carmustine (BICNU), Eétoposide, cytosine-Arabinosine, and Melphalan] protocol followed by autografting hematopoietic stem cells is an option. This treatment should be discussed according to the age and severity of lymphoma and can hopefully cure in more than half of the cases.
In patients eligible for intensive treatment the alternative is an irradiation of the whole body and a very high dose chemotherapy, often based on cyclophosphamide and etoposide, or, finally, the Association of BEAM with a Radio-Immunotherapy by the ibritumomab Tiuxetan administered 1 week before.
Second line treatments
You are eligible for intensive treatment the most commonly proposed protocols are R-Ptwi (rituximab, cisplatin, cytosine-Arabinosine, dexamethasone) or R-ICE (rituximab, ifosfamide, carboplatin, etoposide).
You are not eligible for intensive treatment in this case, you will be offered an R-GEMOX protocol (rituximab, gemcitabine, oxaliplatin), whether or not associated with radiotherapy of the ganglion fields concerned. The response to treatment is evaluated after 3 or 4 treatment cycles and at the end of any treatment.
Other therapeutic means surgery
Large cell B lymphoma-prognostic INDEX
Age < 60 years versus > 60 years old
Stage I/II versus III/IV
The general state ECOG 0-2 versus > 2
Elevation of the blood level of LDH, reflecting the tumor mass
For patients over 60 years, the number of glands reached, 0-2 versus > 2 treatments According to the stage of the disease
At localized stages (I & II) In the absence of derogatory factors the standard treatment combines 3 cycles of chemotherapy R-CHOP14 (Rituximab + Cytoxan ™, Adriblastine ™, Oncovin ™, prednisone), locoregional irradiation centered on the ganglion (s).
In the presence of several bad prognosis factors the disease is treated in the same way as the advanced stages.
Prophylaxis of relapses neuroméningées it can be proposed in the case of specific locations at high risk of the disease but also in patients with a high IPI score.
It involves a intrathecal injection (lumbar puncture injection) of methotrexate during the first 4 cycles of chemotherapy.
In advanced stages treatment with Rituximab (MabThéra ™) is often proposed. As with low-grade lymphomas, two situations are to be considered according to age.
You are under 60 years if there is no prognostic factor, the reference protocols are the 6 to 8 cycle of R-CHOP14
3 or 4 cycles of R-ACVBP if there is more than one prognostic factor, a consolidation with a protocol methotrexate + etoposide + aracytine + interferon, will be carried out.
You are over 60 years old the reference protocol is then 8 cycles of R-CHOP21.
If you have one to three prognostic factors and a PS > 2, the reference protocol is then the mini-CEOP treatment of relapses
A SIMPLE MESSAGE...
A high-grade treated lymphoma in relapse can still heal and the recurrences of the disease are themselves curable.
You are under 60 years the goal is to get a new remission. This is obtained over 50% of cases, thanks to alternative chemotherapy.
Ptwi: cisplatin to J1 + Cytarabine to J1 and J2 + dexamethasone from J1 to J5)
IVAM: Ifosfamide (Holoxan ™) from J1 to J5 + Vépeside ™ from J1 to J3 + Aracytine ™ from J1 to J3 + methotrexate to J5 and folinic acid from J6 to J9.
This protocol is administered in four cycles.
A collection of peripheral stem cells is carried out at the end of the 3rd and/or 4th cycle. Patient responders undergo intensified treatment followed by autografting.
You have over 60 years the standard chemotherapy treatment is 8 CHOP cycles.
In lymphoma forms with several prognosis criteria, the autografting of purged hematopoietic stem cells can be proposed as a front-line treatment.
You can also participate in a therapeutic trial at this stage.
Special cases
In an elderly subject
To make the diagnosis, it is indispensable. On the other hand, resection surgery in the Ganglionic area where the disease was developed, or the organ that is invaded, regardless of its site, does not allow lymphoma to be cured, local or remote recurrences are common.
Radiotherapy radiation therapy has been used in the treatment of strictly localized forms of disease (Ann Arbor stages I and II) in the absence of associated ill-prognosis factors (satisfactory general condition, serum levels of normal LDH). Total doses of 35 or 40 Gy allow the disease to be treated locally, but the risk of relapse at a distance is very important. It must therefore, including in these localized forms of good prognosis, always be associated with a polychemotherapy, which will usually precede it in time.
If you are over 75 years old, the immediate toxicity of the drugs and the risks of intercurrent complications warrant precautions.
The localized stages are treated with short-type R-Chop or R-mini-chop chemotherapy followed by irradiation of the initial territories.
Scattered stages are treated with exclusive chemotherapy
A lenalidomide maintenance treatment for two years is a possible new option.
In case of immunosuppression the frequency of lymphomas developing in subjects receiving immunosuppressive therapy, after organ transplantation for example, or after infection with HIV (AIDS) is increasing.
The treatment of these patients is more difficult because of the aggressiveness of the lymphomas and the poor tolerance of the polychemotherapy protocols due to immunosuppression.
During pregnancy, the treatment-related fetal risk leads to deferred therapy beyond the first trimester, except for patients with symptomatic, disseminated or large Mediastinalal disease.
Voluntary termination of pregnancy is possible before 20 weeks, in the presence of criteria of severity or in the presence of a recurrence of a previously treated disease.
Treatment options include localized diaphragmatic irradiation with uterine protection and monitoring of the fetal dose, chemotherapy by vinblastine or ABVD. In the case of an isolated cervical or axillary attack, suitable irradiation may precede the more complete treatment after delivery.
During the second and third trimester, the indications of a suitable treatment should not be deferred, and the management of the Obstetrical team allows to organize the delivery in the optimum conditions.
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