This information is about a specific type of non-Hodgkin lymphoma (NHL) known as diffuse large B-cell lymphoma. It should ideally be read with our general information about non-Hodgkin lymphoma.

Diffuse large B-cell lymphoma is a common type of NHL, accounting for about 2 in 5 of all cases. It is a cancer of the B-lymphocytes. Diffuse B-cell lymphoma can occur at any time between adolescence and old age. It is slightly more common in men than in women.

The causes of diffuse large B-cell lymphoma are unknown. Diffuse large B-cell lymphoma, like other cancers, is not infectious and cannot be passed on to other people.

Often, the first sign of the condition is a painless swelling in the neck, armpit or groin, caused by enlarged lymph nodes. Sometimes more than one group of nodes is affected. The lymphoma may spread to various organs in the body, such as the liver, lungs or the bones. Some people experience a loss of appetite and tiredness.

Other symptoms may include night sweats, unexplained high temperatures, and weight loss. These are known as B symptoms.

A diagnosis is made by removing an enlarged lymph node, or part of it, and examining the cells under the microscope (biopsy). It is a very small operation and may be done under local or general anaesthetic. Biopsies may also be taken from other body tissues.

Additional tests, including blood tests, x-rays, scans, and bone marrow samples, are then used to get more information about the type of lymphoma, and how far it has spread in the body. This information is used to help to decide which treatment is most appropriate for you.

Staging

The stage of non-Hodgkin lymphoma describes how many groups of lymph nodes are affected, where they are in the body, and whether other organs such as the bone marrow or liver are involved.

• Stage 1 The lymphoma is only in one group of lymph nodes, in one particular area of the body.
• Stage 2 More than one group of lymph nodes is affected, but all the affected nodes are contained within either the upper half or the lower half of the body. The upper half of the body is above the sheet of muscle underneath the lungs (the diaphragm), and the lower half is below the diaphragm.
• Stage 3 The lymphoma is in lymph nodes above and below the diaphragm. The spleen is considered a lymph node in this staging system.
• Stage 4 The lymphoma has spread beyond lymph nodes – for example, to sites such as the bones, liver or lungs.

The stage usually includes the letter A or B, which describes whether or not any B symptoms are present (eg stage 2B). Sometimes the lymphoma can start in areas outside the lymph nodes, and this is represented by the letter E, which stands for extranodal (eg stage 3AE).

Grading

For practical purposes, non-Hodgkin lymphomas are also divided into one of two groups: low- and high-grade. Low-grade lymphomas are usually slow-growing, and high-grade lymphomas tend to grow more quickly.

Diffuse large B-cell lymphoma is a high-grade lymphoma and needs prompt treatment.

Chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. It is the main treatment for diffuse large B-cell lymphoma. The type of chemotherapy depends on the extent of the lymphoma and other factors, such as your age and general health.

The two drugs that are usually given to treat diffuse large B-cell lymphoma are called doxorubicin and cyclophosphamide. They are commonly given together with other anti-cancer drugs.

Currently, the most widely used combination treatment is called the R-CHOP regimen. As well as doxorubicin and cyclophosphamide, this includes the chemotherapy drug vincristine, the steroid prednisolone, and rituximab, which is a monoclonal antibody (see below). The chemotherapy can usually be given to you as an outpatient at hospital, and continues for 4–6 months.

Chemotherapy will lead to a cure in a large number of people with diffuse large B-cell lymphoma. Even when a cure is not possible, treatment can still usually control the disease for a number of years. Further chemotherapy can often be given if the lymphoma comes back after initial treatment. Chemotherapy regimes that are used in this situation, include ICE, ESHAP and DHAP, all of which can be given with or without rituximab.

High-dose treatment with stem cell support

High-dose chemotherapy with bone marrow or stem cell infusions has been effective in some people whose lymphoma has come back. This type of treatment involves very intensive chemotherapy, and sometimes radiotherapy.

As the side effects can be severe, some types of high-dose treatment are not given to people over the age of 45–50, while others can be given to people of up to 65 years who are fit enough. The intensity of the treatment increases the risk of serious side effects for people over this age.

Radiotherapy

Radiotherapy is the use of high-energy rays to destroy cancer cells, while doing as little harm as possible to the healthy cells. It may be used when the lymphoma is confined to one or two areas of lymph nodes in the same part of the body (stage 1 or 2). It may also be given in addition to chemotherapy. Radiotherapy is also sometimes given to improve symptoms, such as pain.

Steroid therapy

Steroids are drugs which are often given with chemotherapy to help treat lymphomas. They also help you feel better and can reduce feelings of sickness.

Monoclonal antibody therapy

Monoclonal antibodies are drugs that recognise, target, and stick to specific proteins on the surface of cancer cells, and can stimulate the body’s immune system to destroy these cells. Rituximab (Mabthera®) is a monoclonal antibody that is commonly used to treat diffuse large B-cell lymphoma. It is usually given with chemotherapy, as part of the R-CHOP regimen.

More types of monoclonal antibodies are being researched. Some are attached to low doses of radioactivity, to see whether they make it more effective in treating the lymphoma. The most commonly used radioactive monoclonal antibodies are 90Y-ibritumomab tiuxetan (Zevalin®) and Iodine131 tositumomab (Bexxar®).

New treatments for diffuse large B-cell lymphoma are being researched all the time, and you might be invited by your doctor to take part in a clinical trial to compare a new treatment against the best available standard treatment. Your doctor must discuss the treatment with you, and have your informed consent before entering you into any clinical trial.

The need for practical and emotional support will of course be individual. For some people with diffuse large B-cell lymphoma, life may seem largely unaffected; for others the diagnosis of cancer may be a cause of great fear and distress. If you would like to discuss the condition, its treatment, or the practical and emotional problems of living with diffuse large B-cell lymphoma, please contact our cancer support service.

This section has been compiled using information from a number of reliable sources, including:

• Oxford Textbook of Oncology (2nd edition). Eds Eds Souhami et al. Oxford University Press, 2002.
• Wintrobe’s Clinical Haematology (11th edition). Eds Eds Lee et al. Williams and Wilkins, 2004.
• Full Guidance On Rituximab For Aggressive Non-Hodgkin Lymphoma. National Institute for Clinical Excellence, September 2003.

For further references, please see the general bibliography.