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Diffuse large B-cell lymphoma, advanced stage

Diffuse large B-cell lymphoma →

Six 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.

061 yr182 yr303 yrMonths from diagnosis · solid bar = shortest typical duration, hatched = up to the longest · arrow = continues for yearsPhaseDiagnosis and stagingDiagnosis and tests · 2-3 wkR-CHOP or pola-R-CHP × 6Systemic therapy · 18 wkEnd-of-treatment PETDiagnosis and tests · 4-8 wkSurveillanceSurveillance · yearsCAR-T if relapse within 12 monthsCell therapy · 8-10 wkComplete metabolic response on PET?decision 1Diagnosis and testsSystemic therapySurveillanceCell therapy
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Typical sequence for Advanced stage (III-IV), first line disease; durations are protocol values (cycle counts and lengths, fraction schedules, guideline follow-up intervals), not averages of real patients. Your team's plan will differ in detail.

Phase by phase

  1. 1. Diagnosis and staging
    weeks 0-3

    Excisional or core biopsy with immunohistochemistry and FISH (MYC, BCL2, BCL6), PET-CT, bloods; cell-of-origin and double-hit status change the plan.

    Source
  2. 2. R-CHOP or pola-R-CHP × 6
    weeks 2-20

    Six 3-week cycles of rituximab with cyclophosphamide, doxorubicin, prednisolone and either vincristine (R-CHOP) or polatuzumab vedotin (pola-R-CHP, POLARIX).

    Source
  3. 3. End-of-treatment PET
    weeks 20-28

    PET-CT 6-8 weeks after the last cycle; a complete metabolic response (Deauville 1-3) ends treatment.

    Source
    Decision: Complete metabolic response on PET?
    • Yes: surveillance
    • No, or relapse within 12 months: CAR-T (ZUMA-7); later relapse: salvage chemotherapy and transplant, or CAR-T
    • Not fit for CAR-T: bispecific antibodies (glofitamab, epcoritamab)
  4. 4. Surveillance
    from week 24, continues for years

    Visits every 3 months for 2 years, then every 6 months to 5 years; no routine scans after remission is confirmed.

    Source
  5. 5. CAR-T if relapse within 12 months
    weeks 128-138

    Axicabtagene ciloleucel beat salvage chemotherapy and transplant in ZUMA-7: apheresis, 3-4 weeks of manufacturing (bridging therapy if needed), 3 days of lymphodepleting chemotherapy, infusion, then about 4 weeks of monitoring for cytokine release syndrome and neurotoxicity.

    Source

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