Imaging studies to start, then biopsy
Many imaging modalities can aid in the diagnosis of DLBCL and help determine the extent of involvement for staging of the disease. These modalities include plain radiograph; CT, magnetic resonance imaging, and positron emission tomography (PET) scans; and lymphangiograms. Confirmatory diagnosis of DLBCL is best made by excisional tissue biopsy. Bone marrow biopsy is also used to help determine staging and management after initial diagnosis.8
Survival hinges on chemotherapy
Survival without treatment in patients with aggressive DLBCL can be measured in months. Combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (the CHOP regimen) increases the disease-free survival rate to between 35% and 45% at 4 years.9 The addition of rituximab has further increased survival in adult patients.10 While the optimal number of treatment cycles remains unclear, 6 to 8 cycles are typically given prior to PET imaging to assess for response.
Consider radiation. Some patients benefit from the addition of radiation to their chemotherapy regimen—particularly those with bulky disease.1 After completion of the planned treatment of DLBCL, a one-month follow-up physical exam with labs and a 2-month follow-up PET/CT scan should be obtained to evaluate response.
It took many scans and tests to arrive at a Dx
The patient’s CT scan showed a large anterior mediastinal mass with central necrosis, diffuse lymphadenopathy, a large left-sided pleural effusion, and multiple pulmonary nodules. Cytologic evaluation of pleural fluid did not show evidence of carcinoma. A fine needle aspiration of the substernal mass under radiologic guidance was performed, and histology was consistent with DLBCL. Further testing confirmed that disease was present both above and below the diaphragm, leading to the diagnosis of Stage IV-B DLBCL.
Our patient. The patient was treated with a chemotherapy regimen of rituximab-cyclophosphamide, vincristine, prednisone, and doxorubicin every 2 weeks for a total of 5 cycles.
Vincristine was discontinued after 2 weeks when the patient developed a Grade 2 peripheral neuropathy at her fingertips. The patient is currently in remission.
CORRESPONDENCE
Larissa Buccolo, MD, Naval Hospital Family Practice Clinic, 2080 Child Street, Jacksonville, FL 32214; larissa_buccolo@yahoo.com