Diffuse large B cell lymphoma: first-line and salvage treatment

Background. Diffuse large B cell lymphoma (DLBCL) represent a heterogeneous group of diseases with respect to biology and prognosis. Objective. This article summarizes the current strategies and rationales in the treatment of DLBCL, in first-line as well as in salvage therapy. Results and conclusion. Currently, no therapeutic consequences result from biological stratification factors. The best validated assessment of the prognosis is achieved by the clinical international prognostic index (IPI). In the majority of patients curative first-line treatment relies on systemic chemotherapy with CHOP-based protocols, which always include rituximab. Beyond the initial uniform treatment with R-CHOP-21, a risk-adapted approach has evolved where, stratification is done by IPI risk groups. This concept emerged from randomized clinical trials, which have been performed in distinct prognostic risk groups. After relapse the prognosis, which is predominantly determined by the time period of occurrence (i.e. early vs. late relapse), is poor. Salvage treatment mostly consists of regimens containing platinum derivatives. The low rate of long-term remission necessitates a consolidating high-dose chemotherapy followed by autologous stem cell transplantation in eligible patients. Especially, in early relapse and availability of a fully HLA-matched donor, high-dose treatment and allogeneic stem cell transplantation can induce long-term remission in some patients. Recently, autologous T-cells with genetically modified chimeric antigen receptors (CAR T-cells) represents an important innovation and long-term disease control has partially been achieved after multiple recurrences.