The first 60 days: Diffuse large B-cell lymphoma
Diffuse large B-cell lymphoma (DLBCL) is an aggressive but curable lymphoma. CAR-T cures about 40% of relapsed patients, and off-the-shelf bispecifics are now approved. Below, week by week, is what OnCo's record of Diffuse large B-cell lymphoma says about the first two months: the order is typical, the timing is yours to ask about. Sections appear only where the record has something to say. Orientation, not medical advice.
Weeks 1 to 2
What happens now
Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.
From the recorded treatment journey
- Excisional or core biopsy with immunohistochemistry and FISH (MYC, BCL2, BCL6), PET-CT, bloods; cell-of-origin and double-hit status change the plan.
- PET-CT 6-8 weeks after the last cycle; a complete metabolic response (Deauville 1-3) ends treatment.
Biomarkers your report may list
Cell of origin (GCB/ABC)Double-hit (MYC/BCL2)CD19/CD20ctDNA MRDIPI / NCCN-IPICell of origin (Hans IHC, Lymph2Cx)MYC, BCL2, BCL6 FISHTP53 mutationCD19 and CD20 expression (loss after CAR-T or bispecific)Interim and end-of-treatment PET (Deauville)ctDNA (PhasED-seq, clonoSEQ)LDHCNS-IPI for CNS prophylaxis decisions
Ask which of these were tested and what the results were; see the report reader for what each value means.
Tests and imaging linked to this cancer
FDG PETNGS-based MRD (clonoSEQ and molecular MRD)PET-adapted (response-adapted) therapyG8 geriatric screening toolMRD / molecular residual disease testingStrain echocardiography (global longitudinal strain)Troponin and natriuretic peptide monitoring during cancer treatmentctDNA monitoring in lymphoma (PhasED-seq, clonoSEQ)
How it is staged
These specialties appear in the standard of care for this cancer. In most centres they meet weekly as a tumour board to agree each plan; you can ask when yours was discussed and what was decided.
- RadiologistNamed in the standard of care for: Limited stage (I-II, non-bulky).
- Medical oncologistNamed in the standard of care for: Early relapse, Later, Limited stage (I-II, non-bulky), Advanced stage, IPI 0-1 and 6 more.
- Clinical oncologist (radiotherapy)Named in the standard of care for: Limited stage (I-II, non-bulky).
- Transplant and cell therapy teamNamed in the standard of care for: Early relapse, Frail or elderly, Primary refractory or relapse within 12 months, Late relapse (>12 months), transplant-eligible and 1 more.
- Palliative and supportive care teamNamed in the standard of care for: Limited stage (I-II, non-bulky), Advanced stage, IPI 0-1.
A second opinion from a centre that treats many similar cases is normal, not rude; the standard of care tells you what to compare it against.
Each row is a setting from the standard of care, in the order it usually arises. Not all will apply to you; your stage and biomarkers decide which do. The guideline grade, where recorded, says how strong the evidence is.
- 1.Limited stage (I-II, non-bulky)NCCN category Category 1 (R-CHOP × 4 PET-adapted for stage I-II), NCCN B-Cell Lymphomas 2026
R-CHOP × 4 with PET-guided omission of radiation (FLYER, S1001): 4 cycles if interim PET negative; involved-site radiotherapy if PET positive.
R-CHOP or Pola-R-CHP.
R-CHOP × 6 (or Pola-R-CHP); consider 4 cycles plus 2 rituximab in young low-risk patients (FLYER).
Pola-R-CHP × 6 (POLARIX) or R-CHOP × 6; tafasitamab + lenalidomide + R-CHOP (frontMIND) pending approval for IPI 3-5; DA-EPOCH-R for double-hit lymphoma; CNS prophylaxis for high CNS-IPI (contested).
R-mini-CHOP; epcoritamab-based regimens in trials for the elderly (EPCORE NHL-2 cohorts); tafasitamab-lenalidomide where transplant is never an option.
CD19 CAR-T.
CD20×CD3 bispecifics, loncastuximab, tafasitamab.
- 8.Primary refractory or relapse within 12 monthsNCCN category Category 1 (axi-cel, liso-cel), NCCN 2026
CD19 CAR-T (axi-cel or liso-cel) preferred over salvage chemotherapy and transplant (ZUMA-7, TRANSFORM); bridging therapy while manufacturing; bispecific ± chemotherapy if CAR-T unavailable.
Salvage chemotherapy (R-ICE, R-DHAP, R-GemOx) → high-dose therapy and autologous transplant if chemosensitive; CAR-T if not.
CD20×CD3 bispecific (glofitamab, epcoritamab) or mosunetuzumab-polatuzumab (SUNMO); pola-BR; tafasitamab-lenalidomide; loncastuximab tesirine.
CAR-T if not yet given; bispecific after CAR-T (active in CD19-negative relapse if CD20 retained); loncastuximab; zilovertamab vedotin (trial); allogeneic transplant in selected fit patients; clinical trials.
Decision points in the recorded journey, Advanced stage (III-IV), first line
- Complete metabolic response on PET?
Generated from this cancer's standard of care, biomarkers and open problems. Take the group that matches where you are. To tick, add your own and print, open the one-page appointment sheet.
Newly diagnosed
- What is my exact diagnosis, stage, and grade, and which tests established them?Everything else follows from an accurate stage and subtype.
- Which biomarkers have been tested on my tumour (for example Cell of origin, Double-hit, CD19/CD20, ctDNA MRD, IPI / NCCN-IPI), and what were the results?These results decide eligibility for targeted therapy, immunotherapy, and trials.
- Which subtype is my cancer, and does that change the recommended treatment?Recognised subtypes for this cancer include Germinal-centre B-cell-likevs activated B-cell-like, High-grade B-cell lymphoma with MYC and BCL2 rearrangements, LymphGen genetic subtypes: MCD, BN2, N1, EZB, ST2, A53.
- Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.
Frontline
- For my situation (frontline), which of the standard options do you recommend and why?Guideline options include: R-CHOP or Pola-R-CHP.
Early relapse
- For my situation (early relapse), which of the standard options do you recommend and why?Guideline options include: CD19 CAR-T.
- Am I a candidate for Axicabtagene ciloleucel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Later
- For my situation (later), which of the standard options do you recommend and why?Guideline options include: CD20×CD3 bispecifics, loncastuximab, tafasitamab.
- Am I a candidate for Glofitamab, Loncastuximab tesirine, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Limited stage (I-II, non-bulky)
- For my situation (limited stage (i-ii, non-bulky)), which of the standard options do you recommend and why?Guideline options include: R-CHOP × 4 with PET-guided omission of radiation (FLYER, S1001): 4 cycles if interim PET negative; involved-site radiotherapy if PET positive.
- Am I a candidate for Doxorubicin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Advanced stage, IPI 0-1
- For my situation (advanced stage, ipi 0-1), which of the standard options do you recommend and why?Guideline options include: R-CHOP × 6 (or Pola-R-CHP); consider 4 cycles plus 2 rituximab in young low-risk patients (FLYER).
- Am I a candidate for Doxorubicin, Polatuzumab vedotin, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Advanced stage, IPI 2-5
- For my situation (advanced stage, ipi 2-5), which of the standard options do you recommend and why?Guideline options include: Pola-R-CHP × 6 (POLARIX) or R-CHOP × 6; tafasitamab + lenalidomide + R-CHOP (frontMIND) pending approval for IPI 3-5; DA-EPOCH-R for double-hit lymphoma; CNS prophylaxis for high CNS-IPI (contested).
- Am I a candidate for Polatuzumab vedotin, Tafasitamab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of POLARIX and frontMIND apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Frail or elderly
- For my situation (frail or elderly), which of the standard options do you recommend and why?Guideline options include: R-mini-CHOP; epcoritamab-based regimens in trials for the elderly (EPCORE NHL-2 cohorts); tafasitamab-lenalidomide where transplant is never an option.
- Am I a candidate for Epcoritamab, Tafasitamab, Lenalidomide, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
Primary refractory or relapse within 12 months
- For my situation (primary refractory or relapse within 12 months), which of the standard options do you recommend and why?Guideline options include: CD19 CAR-T (axi-cel or liso-cel) preferred over salvage chemotherapy and transplant (ZUMA-7, TRANSFORM); bridging therapy while manufacturing; bispecific ± chemotherapy if CAR-T unavailable.
- Am I a candidate for Axicabtagene ciloleucel, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of ZUMA-7 and TRANSFORM apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Late relapse (>12 months), transplant-eligible
- For my situation (late relapse (>12 months), transplant-eligible), which of the standard options do you recommend and why?Guideline options include: Salvage chemotherapy (R-ICE, R-DHAP, R-GemOx) → high-dose therapy and autologous transplant if chemosensitive; CAR-T if not.
Relapse, transplant-ineligible
- For my situation (relapse, transplant-ineligible), which of the standard options do you recommend and why?Guideline options include: CD20×CD3 bispecific (glofitamab, epcoritamab) or mosunetuzumab-polatuzumab (SUNMO); pola-BR; tafasitamab-lenalidomide; loncastuximab tesirine.
- Am I a candidate for Glofitamab, Epcoritamab, Mosunetuzumab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of SUNMO apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Third line and beyond
- For my situation (third line and beyond), which of the standard options do you recommend and why?Guideline options include: CAR-T if not yet given; bispecific after CAR-T (active in CD19-negative relapse if CD20 retained); loncastuximab; zilovertamab vedotin (trial); allogeneic transplant in selected fit patients; clinical trials.
- Am I a candidate for Axicabtagene ciloleucel, Glofitamab, Epcoritamab or related drugs, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.
- How do the results of waveLINE-003 apply to someone like me?Trial populations differ from individual patients; ask how closely you match.
Any stage
- Are there clinical trials I could join, for example of Zilovertamab vedotin, Abexinostat, DZD8586, Rocbrutinib?Trials are how the next standard of care is set; asking early keeps options open.
- Would a second opinion at a high-volume centre change anything, and can you help arrange it?Rare or high-stakes decisions benefit from a centre that treats many similar patients.
- What supportive care (symptom control, nutrition, exercise, mental health, financial help) is available from the start?Supportive care improves quality of life and helps patients complete treatment.
- I read that “Primary refractory disease”. How does that affect my plan?Open problems are where trials and second opinions matter most.
- I read that “CAR-T access and cost”. How does that affect my plan?Open problems are where trials and second opinions matter most.
Trials open now for this cancer in OnCo, largest phase first. Joining a trial is a decision like any other: ask what the comparison arm is, whether a placebo is used, and what happens if you leave. The cancer page searches ClinicalTrials.gov live for more.
- A Combination of Acalabrutinib With R-CHOP in Subjects With Previously Untreated Non-GCB DLBCL (ACE-LY-312)Phase 3 · active · NCT04529772Phase 3, Randomized, Double-Blind, Placebo-Controlled Study of Acalabrutinib in Combination With Rituximab, Cyclophosphamide, Doxorubicin, Vincristine, and Prednisone (R-CHOP) in Subjects ≤75 Years With Previously Untreated Non-GCB DLBCL
- A Long-term Extension Study of PCI-32765 (Ibrutinib)Phase 3 · recruiting · NCT01804686PCI-32765CAN3001: A Phase 3b, Multicenter, Open-label, PCI-32765 (Ibrutinib) Long-term Extension Study
- A Phase 3 Clinical Study of SHR-A1912 Combined With R-GemOx Versus R-GemOx in Diffuse Large B-cell LymphomaPhase 3 · recruiting · NCT06929624A Phase 3, Open-label, Randomized Study of SHR-A1912 Combined With Rituximab + Gemcitabine + Oxaliplatin (R-GEMOX) Versus R-GEMOX in Patients With Relapsed or Refractory Diffuse Large B-cell Lymphoma
- A Phase III Clinical Study of Purinostat Mesylate for Injection in Patients With Diffuse Large B-cell LymphomaPhase 3 · recruiting · NCT07011056A Randomized, Controlled, Multicenter Phase III Clinical Study Evaluating the Efficacy and Safety of the Purinostat Mesylate for Injection (PM) Compared to Selinexor in Patients With Relapsed/Refractory Diffuse Large B-cell Lymphoma (R/R DLBCL)
- A Phase III Study of HMPL-760 Plus R-GemOx VS Placebo Plus R-GemOx in Relapsed/Refractory DLBCLPhase 3 · recruiting · NCT07409428A Phase III Randomized, Double-Blind, Positive Controlled Study to Evaluate the Efficacy, Safety, and Pharmacokinetics of HMPL-760 in Combination With R-GemOx Versus Placebo in Combination With R-GemOx in Patients With Relapsed/Refractory Diffuse Large B-Cell Lymphoma (DLBCL)
Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.
- Diffuse large B-cell lymphoma: the full pageDiffuse large B-cell lymphoma (DLBCL) is an aggressive but curable lymphoma. CAR-T cures about 40% of relapsed patients, and off-the-shelf bispecifics are now approved.
- One-page appointment sheetYour questions, the words you may hear, what to bring, and space for the answers. Print it.
- Treatment journey: Advanced stage (III-IV), first lineSix cycles of immunochemotherapy over about four months, a PET scan to confirm the lymphoma has gone, then two years of close follow-up; if it comes back early, CAR-T cell therapy is the next step.
- Guidelines comparedNCCN, ESMO and NICE side by side for this cancer.
- Treatment sequencingWhich treatment tends to follow which, line by line.
- NavigatorStandard of care for your stage, what you have tried, and trials near you.
Words this page and the cancer page use
- International Prognostic Index (IPI): A five-point score (age, stage, performance status, LDH, extranodal sites) that predicts how risky a lymphoma is before treatment.
- R-CHOP (lymphoma chemoimmunotherapy): R-CHOP is the standard first treatment for diffuse large B-cell lymphoma: rituximab (an antibody against CD20) plus four chemotherapy drugs (cyclophosphamide, doxorubicin, vincristine, prednisone), given every three weeks for six cycles with curative intent.
- Richter transformation: When slow CLL suddenly turns into an aggressive lymphoma.
- Double-hit / high-grade B-cell lymphoma: Double-hit lymphoma is a large B-cell lymphoma with rearrangements of two oncogenes (MYC plus BCL2 and/or BCL6), which behaves aggressively and often escapes R-CHOP.
- ICANS (neurotoxicity): ICANS is confusion, speech difficulty, and rarely seizures after CAR-T or bispecific therapy.
- Deauville score and PET-adapted therapy: A 1-to-5 scale for how brightly a lymphoma lights up on a PET scan, compared with the liver and the middle of the chest.
- Deauville five-point scale: A 1-to-5 score for how bright a lymphoma looks on PET compared with the liver; 1-3 is considered a complete metabolic response.
- Cell of origin (GCB vs ABC): Whether a large B-cell lymphoma resembles a germinal-centre B cell or an activated B cell; the activated type does worse and depends on different pathways.
- Lymphoma (tissue type): Cancer of lymphocytes, the white blood cells of the immune system, usually growing as masses in lymph nodes, spleen or other organs.
- B cell: The immune cells that make antibodies.
Every term links to the glossary.