Diffuse large B-cell lymphoma (DLBCL)

When DLBCL doesn’t fall into another subtype category, it is classified as DLBCL NOS. It accounts for about a third of DLBCL cases.

T-cell/histocyte-rich large B-cell lymphoma is a rare and fast-growing subtype of DLBCL. It often involves the spleen, liver and bone marrow.

ALK-positive large B-cell lymphoma is a rare and fast-growing subtype of DLBCL. It is often diagnosed in advanced stages of disease and can be difficult to treat

Epstein-Barr virus (EBV) positive DLBCL is a fast-growing subtype of DLBCL. The EBV virus is present in the majority of the cancerous cells. It accounts for 5% to15% of all DLBCL cases.

Primary mediastinal large B-cell lymphoma is a rare and fast-growing subtype of DLBCL. It develops in the thymus gland in the chest. Symptoms can include severe chest pain, breathlessness and voice changes. It mostly affects adults in their 30s.

Primary central nervous system lymphoma (PCNSL) is a rare and fast-growing subtype of DLBCL. It starts in the central nervous system (CNS), which includes the brain and spinal cord. It usually affects people over 50, but can happen at any age.

If the lymphoma starts in another part of the body and spreads to the brain or spinal cord, it is called secondary CNS lymphoma (SCNSL). PCNSL is treated differently from other types of lymphoma. This is because regular treatments don’t easily reach the brain and spinal cord.

High grade B-cell lymphoma is a rare and fast-growing subtype of DLBCL. It can be difficult to treat because of specific genetic mutations. It has a high risk of spreading to the central nervous system. Your treatment plan will include medications that aim to prevent the lymphoma spreading to the central nervous system.

The best test to diagnose DLBCL is a biopsy. A biopsy is a procedure that involves taking a sample of tissue from a swollen lymph node, lump or skin and looking at it under the microscope.

Other tests you may have include:

• medical history and physical exam
• blood tests including full blood count (FBC), kidney and liver function, electrolytes
• genetic tests
• computed tomography (CT) scan
• positron emission tomography (PET) scan
• ultrasound
• bone marrow biopsy
• lumbar puncture
• magnetic resonance imaging (MRI).

Chemotherapy (often called chemo) is the most common treatment for DLBCL.

Chemotherapy kills cancer cells and stops them from growing. It also damages healthy cells which cause side effects, for example nausea, sore dry mouth and hair loss.

There is information on chemotherapy side effects and how to manage them on our chemotherapy webpage.

The type of chemotherapy recommended will depend on your subtype of DLBCL, the treatment goal, your age and medical history. Chemotherapy can be given in combination with targeted therapy. 

Treatment plans for DLBCL are shortened to letters like R-CHOP. The letters represent the name of the medicines in that plan. Your haematologist will provide you with information on your plan, including when and how often you will have it. 

There are several treatment plans for DLBCL. They can be found on the Cancer Institute NSW website.

Central nervous system (CNS) directed therapy

Your treatment team will discuss central nervous system (CNS) directed therapy if you have lymphoma in the CNS or if you are at risk of it spreading there. Intrathecal chemotherapy is given by an injection into the fluid around your spinal cord. This is done during a procedure called a lumbar puncture. 

Immunotherapy is a type of biological therapy. It uses the immune system to recognise cancer cells and destroy them. Your treatment team will give this to you via a drip into a vein (known as intravenous) or an injection under the skin (known as subcutaneous).

Immunotherapy works by:

• stimulating the immune system to find and attack cancer cells
• removing barriers that are stopping the immune system killing cancer cells.

Rituximab is an immunotherapy called a monoclonal antibody. It is used to treat DLBCL in combination with chemotherapy. Rituximab damages cancer cells and causes them to die by attaching to a protein called CD20 on the blood cancer cell. It is given as an intravenous infusion, usually in an outpatient unit. 

Bispecific T-cell engagers (BiTEs) are another type of immunotherapy used to treat some types of relapsed or refractory DLBCL. They work by attaching to a protein on a cancer cell and a protein on an immune cell. This brings the immune cell to the cancer cell to destroy it. Epcoritamab and Glofitamab are examples of BiTEs.

Side effects of immunotherapy are unique. You can read more on our immunotherapy webpage.

Radiation therapy (also called radiotherapy) is a type of treatment that:

• uses high energy X-rays to kill cancer cells
• is a local therapy because it only destroys cancer cells in the area it treats.

Radiation therapy can be used as part of a treatment plan for some types of DLBCL. It is normally given in combination with chemotherapy and immunotherapy.

You can read more on our radiation therapy webpage.

A bone marrow or blood stem cell transplant is a treatment that restores stem cells after high dose chemotherapy. Your treatment team might suggest a transplant if your DLBCL is aggressive, difficult to treat, or has come back after a period of remission.

There are 2 types of transplants:

• An autologous stem cell transplant is when your own stem cells are collected and then given back to you after high dose chemotherapy.
• An allogeneic stem cell transplant is when you receive stem cells from a donor, often a blood relative.

It is more common to receive an autologous transplant for DLBCL. There are some situations where an allogeneic transplant may be recommended.

CAR T-cell therapy is a type of treatment that uses your own immune cells to fight cancer. Your T cells are collected from your blood and changed in a laboratory so they can find and attack your blood cancer cells. After you have chemotherapy to prepare your body, the CAR T cells are returned to you through a drip into a vein.

Your treatment team may recommend CAR T-cell therapy if your DLBCL has relapsed or is refractory. Not everyone is eligible for CAR T-cell therapy. Your treatment team will discuss whether this treatment is suitable for you.

Clinical trials may be available for some types of DLBCL. They often compare new or combination therapies with current treatments, including side effects.

Many are randomised, meaning some patients receive the new treatment, and others receive standard care. Trials help improve future treatments and may offer access to costly new therapies not on the Pharmaceutical Benefits Scheme (PBS) in Australia.

If you are considering a clinical trial, your doctor will explain:

• the possible risks and benefits
• how it compares to standard treatment
• what is involved.

You will need to give informed consent before taking part. Read more on our clinical trials webpage.