The first 60 days: EBV-positive diffuse large B-cell lymphoma

What happens now

Staging tests establish exactly what and where the cancer is. Everything else follows from the answers.

Biomarkers your report may list

Epstein-Barr virus in the tumour cells by EBER in situ hybridisation, which is the only reliable way to find it A non-germinal-centre phenotype in most cases: CD10 negative, MUM1 positive LMP1, the viral membrane protein, expressed in most positive cases CD30, expressed in about half of cases and not specific The immune setting: transplant, HIV, immunosuppressive therapy or none identified, which decides whether the diagnosis is this entity or a lymphoma of immune deficiency

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 PET Histopathology & immunohistochemistry

Weeks 1 to 3

Who is on your team

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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.

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.

Weeks 2 to 6

Decisions coming up

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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.Finding it WHO Classification of Haematolymphoid Tumours, 5th edition (2022), with the International Consensus Classification (2022) where they differ
In situ hybridisation for Epstein-Barr-encoded RNA on the biopsy. The European series that put the frequency at 3.1 per cent found that no morphological or immunohistochemical feature reliably identified the positive cases, and recommended running the stain on every new diffuse large B-cell lymphoma in a person over 50. Necrosis and CD30 expression are common in positive cases but neither is specific enough to select who to test.
Epstein-Barr virus (EBV) in cancer Histopathology & immunohistochemistry CD30
2.Treatment NCI PDQ: adult non-Hodgkin lymphoma treatment
The same immunochemotherapy as diffuse large B-cell lymphoma without the virus; the presence of Epstein-Barr virus does not currently change the regimen. Where there is an identifiable cause of immune suppression, reducing it is part of the treatment, as it is for the post-transplant lymphoproliferative disorders. The regimens are on the diffuse large B-cell lymphoma page and in the treatment layer of this family.
Diffuse large B-cell lymphoma Rituximab R-CHOP (lymphoma chemoimmunotherapy)Post-transplant lymphoproliferative disorder (PTLD)The lymphoma regimen alphabet: R-CHOP, pola-R-CHP, DA-EPOCH-R, ABVD, BEACOPP and the rest

Every visit

Questions to ask at each visit

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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 Epstein-Barr virus in the tumour cells by EBER in situ hybridisation, which is the only reliable way to find it, A non-germinal-centre phenotype in most cases: CD10 negative, MUM1 positive, LMP1, the viral membrane protein, expressed in most positive cases, CD30, expressed in about half of cases and not specific, The immune setting: transplant, HIV, immunosuppressive therapy or none identified, which decides whether the diagnosis is this entity or a lymphoma of immune deficiency), 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 Polymorphic type, which contains a mixture of cell sizes, Monomorphic type, which looks like ordinary diffuse large B-cell lymphoma.
Is germline (inherited) genetic testing recommended for me or my family?Inherited variants can change treatment and matter for relatives.

Finding it

For my situation (finding it), which of the standard options do you recommend and why?Guideline options include: In situ hybridisation for Epstein-Barr-encoded RNA on the biopsy. The European series that put the frequency at 3.1 per cent found that no morphological or immunohistochemical feature reliably identified the positive cases, and recommended running the stain on every new diffuse large B-cell lymphoma in a person over 50. Necrosis and CD30 expression are common in positive cases but neither is specific enough to select who to test.

Treatment

For my situation (treatment), which of the standard options do you recommend and why?Guideline options include: The same immunochemotherapy as diffuse large B-cell lymphoma without the virus; the presence of Epstein-Barr virus does not currently change the regimen. Where there is an identifiable cause of immune suppression, reducing it is part of the treatment, as it is for the post-transplant lymphoproliferative disorders. The regimens are on the diffuse large B-cell lymphoma page and in the treatment layer of this family.
Am I a candidate for Rituximab, and what side effects should I expect?Knowing the expected toxicities helps you plan work, family, and supportive care.

Any stage

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 “The classification itself says the boundary between this entity and a lymphoma arising from an ageing immune system is arbitrary, and nobody has defined immune senescence in a way that could settle it”. How does that affect my plan?Open problems are where trials and second opinions matter most.
I read that “The virus is present in the tumour and no treatment aims at it. Virus-specific T cells and other approaches used after transplant have not been tested here”. How does that affect my plan?Open problems are where trials and second opinions matter most.

From day one

Help that costs nothing

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Much of what helps in the first weeks is free if you know to ask: testing, helplines, rides and lodging, second opinions, trial travel.

Any time

What to read next

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Words this page and the cancer page use

B-cell, T-cell and NK-cell lymphoma: The first thing a lymphoma report says is which kind of lymphocyte the cancer came from.
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.
Epstein-Barr virus (EBV) in cancer: The common glandular-fever virus, carried lifelong by most adults, which in a minority of people drives nasopharyngeal cancer, some stomach cancers and several lymphomas.
The two lymphoma classifications of 2022 (WHO-HAEM5 and ICC): Since 2022 there have been two reference classifications of lymphoma rather than one, published within months of each other by overlapping groups of experts.
The lymphoma regimen alphabet: R-CHOP, pola-R-CHP, DA-EPOCH-R, ABVD, BEACOPP and the rest: Lymphoma treatment is written in acronyms, one letter per drug.

Every term links to the glossary.