Transcription
Let's continue our discussion of diffuse large b-cell lymphoma. Today, you will learn how to diagnose and treat diffuse large b-cell lymphoma.
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As you know, non-Hodgkin's lymphoma can be aggressive or indolent. Aggressive, such as diffuse large b-cell lymphoma, which is today's topic. Diffuse large b-cell lymphoma is the most common subtype of non-Hodgkin's lymphoma. The aggressive non-Hodgkin's lymphoma is treated with chemotherapy. The non-aggressive, indolent non-Hodgkin's lymphoma is managed by observation or watch and wait. Since diffuse large b-cell lymphoma is an aggressive lymphoma, it will be treated with chemotherapy.
Diffuse large b-cell lymphoma: the most common aggressive lymphoma, CD20 positive, median survival rate is short, could be de novo or transformed from a previous indolent lymphoma, associated with EBV, can be nodal and external, including the lungs, liver, testicles, brain, and eye, as well as GI tract. Meet an aged 65-year-old male. If CLL becomes diffuse large b-cell lymphoma, this is a Rift or syndrome due to rapid cell turnover. It can have tumor lysis syndrome. Will have high potassium, high phosphate, high uric acid in the blood, but low calcium. Why is that? Because now you are releasing lots of phosphate, it will bind to calcium, and now we end up with low free calcium in the blood. LDH is usually high.
How to diagnose diffuse large b-cell lymphoma? You need an excisional biopsy to take the architecture of the node and the cell appearance. And the cells here are large, since the name is diffuse large b-cell lymphoma. You need CBC, blood chemistry, and LDH will be high. Uric acid level will be high because this is a high-grade aggressive lymphoma. We need HIV testing, yes, staging, physical exam, and CT scan. Kind of musical in the slit lamp exam for the ophthalmologic abnormalities. Diffuse large b-cell lymphoma can involve the eye. PET scan can help you with the diagnosis and follow-up with the disease. If we use immune histological stain, you will find CD20 positive because this is a B-cell lymphoma. If there is cytopenia, such as anemia, thrombocytopenia, leukopenia, please do a bone marrow biopsy to get the etiology right. Now, on lymph node biopsy, which by the way, is an excisional biopsy, never fine needle aspirations, always excisional, you'll find neoplastic cells because the name is diffuse large b-cell lymphoma. The cells are heterogeneous, predominantly large with vesicular chromatin and prominent nucleoli. A prominent nucleolus is one of the criteria of malignancy.
How to treat diffuse large b-cell lymphoma? We use our CHOP regimen. R-right, A-oxamide, and CHOP as I've told you before: Cyclophosphamide, Doxorubicin, Vincristine, Prednisone. Prophylaxis for CNS, yes, because it can involve the brain. Intrathecal chemotherapy. Why intrathecal? Because if you give chemotherapy like in the bloodstream, it cannot pass the blood-brain barrier. It's difficult to go to the brain, so we use intrathecal chemotherapy. We inject methotrexate in high dose directly into the CSF if there are CNS lymphoma. Again, chemotherapy. This is the only brain cancer that's not treated by surgical resection. Instead, it's treated by chemo, such as methotrexate. Corticosteroids can help. If the diffuse large b-cell lymphoma is localized, use three cycles of R-CHOP plus radiation because it's localized. Only radiate localized lesions. If it's spread, advanced, generalized, disseminated, radiation is not going to work. You need six to eight cycles of R-CHOP. This is a lot. The response to treatment is good. Almost all patients respond to treatment. This is great. 50% of patients get disease control. Half of them will get refractory or recurrence of the cancer. If you have recurrence, depends on the age. Old patients: palliative chemo. Young patients: again, repeat chemotherapy and use hematopoietic stem cell transplant. We preserve the stem cell transplant for the young, not the old, and I've told you why before.
Don't forget our CHOP for diffuse large b-cell lymphoma. We have tried this case in the previous video, but today I've added a new question. So again, 64-year-old male comes to your office, pain in the chest, coughing. You order an X-ray, and X-ray showed a mass in the mediastinum. Excisional biopsy was performed, giving you a diffuse large b-cell lymphoma diagnosis. On further investigation, multiple inguinal and iliac lymphadenopathy. Which stage of Ann Arbor classification system this is? And the next question: what is the treatment of choice? Is it arsenic trioxide, CHOP, R-CHOP, watch and wait, or radiation? Please let me know below in the comments, and I'll see in the next video.
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