Guidelines for Diagnosis and Immediate Management of Aggressive Diffuse Large B‑Cell Lymphoma with Bone‑Marrow or Hepatosplenic Involvement

Diagnostic Work‑up

Core needle biopsy can be used as the sole diagnostic procedure when rapid treatment is required, avoiding delay for excisional biopsy. 1, 2, 3
Immunohistochemistry must include CD45, CD20, and CD3 to confirm B‑cell lineage and CD20 positivity, which is required for rituximab eligibility. 4, 2
A complete blood count is essential to document cytopenias (anemia, thrombocytopenia, neutropenia). 4, 2, 3
A comprehensive metabolic panel that includes lactate dehydrogenase (LDH) and uric acid should be obtained; elevated LDH is a prognostic marker and uric acid guides tumor‑lysis‑syndrome (TLS) risk assessment. 4, 2, 3
Screening for HIV, hepatitis B, and hepatitis C is required because these infections influence therapeutic decisions. 4, 2, 3
Serum protein electrophoresis is recommended as part of the baseline work‑up. 4, 2

Contrast‑enhanced CT of the chest and abdomen is the minimum imaging requirement for patients considered for curative therapy. 4, 2
PET‑CT is strongly recommended to delineate disease extent and to serve as a reference for subsequent response evaluation. 2, 3

Performance status (ECOG) and cardiac function (left‑ventricular ejection fraction) must be evaluated before initiating therapy. 4, 2
The International Prognostic Index (IPI) and age‑adjusted IPI should be calculated using age, LDH level, ECOG status, Ann Arbor stage, and number of extranodal sites. 4, 2

In patients with high tumor burden, administer oral prednisone 100 mg daily for several days as a “pre‑phase” before starting chemotherapy to reduce TLS risk. 1, 2

R‑CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) is the standard regimen for all patients, irrespective of age or risk category.
- Patients ≤ 60 years: 6–8 cycles of R‑CHOP every 21 days (R‑CHOP‑21) combined with eight rituximab doses. [4, 1]
- Patients > 60 years: 8 cycles of R‑CHOP‑21 is the current standard. [4, 1]

Chemotherapy dose reductions due to hematologic toxicity should be avoided; prophylactic hematopoietic growth‑factor support should be used to preserve planned dose intensity. 1, 2

Do not postpone therapy for complete staging; a core biopsy provides sufficient diagnostic information to start treatment urgently in emergency situations. 1, 2, 3
Avoid reducing chemotherapy doses because of cytopenias; instead, employ growth‑factor support, as dose reductions have been shown to compromise survival. 1, 2