Diffuse Large B-Cell Lymphoma (DLBCL)


Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL), accounting for about 30% of cases of NHL. DLBCL is an aggressive blood cancer characterized by abnormally large B cells, a type of white blood cell. DLBCL affects primarily the lymphatic system but may also involve other organs and tissues.1

One of the hallmark B symptoms of DLBCL is a patient’s unexplained weight loss of over 10% of their body weight within 6 months.2 After diagnosis, when treatments for DLBCL begin, including chemotherapy, radiation, monoclonal antibodies, and/or steroids, weight loss may be intensified with gastrointestinal side effects such as nausea, vomiting, loss of appetite, and changes in taste.3 

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This combination of factors makes it important to maintain a healthy weight, avoid losing muscle mass, and improve energy levels before, during, and after treatment. A registered dietitian may develop a meal plan with the right combination of foods to help patients with DLBCL maintain a healthy weight, tolerate treatment, and recover faster.3 However, common diet suggestions may include the following ideas.

High protein and calorie-dense foods

Because inherent disease and treatment may interfere with the ability to stay active, it is important for patients to consume enough protein to preserve muscle mass. A registered dietitian can calculate the required amount of protein according to the individual patient’s body mass index, kidney function, and other factors.3 Foods high in protein include meat, fish, eggs, dairy products, legumes, nuts, seeds, tofu, and hummus.6

To prevent weight loss and muscle atrophy during treatment, patients with DLBCL should also focus on consuming calorie-dense foods, including:

  • Eggs
  • Full-fat dairy products, such as yogurt, whole milk, and cottage cheese
  • Nuts, seeds, and nut butters
  • Whole grains such as oats, quinoa, and brown rice, whole-wheat bread and whole-wheat pasta3 

Raw fruits and vegetables

Additionally, fruits and vegetables are a source of vitamins, minerals, and fiber that can improve energy levels during treatment.3 In a study of 568 females living in Connecticut in whom NHL was diagnosed between 1996 and 2000, an increased intake of vegetables and fruits was associated with improved overall survival after a median follow-up of 7.7 years. Increased consumption of green leafy vegetables and citrus fruits in particular reduced the risk for death by 29% and 27%, respectively.8

Read more about DLBCL prognosis

Low Microbial Foods

Chemotherapy may decrease the number of white blood cells (neutropenia) to a level below 500/µL, which increases the risk for infection. Patients with neutropenia may therefore need to adopt a low microbial diet while their white blood cell count is low to reduce the likelihood of ingesting harmful bacteria.4

Read more about DLBCL complications

Frequent, Small Meals

Chemotherapy may cause appetite loss or taste changes, so eating frequent small meals or snacks during the day may be beneficial, with a timer set as a reminder. Avoiding a completely empty stomach may decrease the nausea that frequently accompanies treatment.3

Low Sodium

If steroids are included in DLBCL chemotherapy, it is recommended that patients restrict their salt intake to reduce fluid retention as a side effect of treatment.4,5 

Hydration

Chemotherapy and radiation can cause uncomfortable dehydration, so it’s important to intake around 2 liters of fluid daily. Alcohol or caffeine can increase dehydration, but liquids can mean more than water, including broths, fruit juices, nutritional supplement drinks, herbal teas, and even fluid-containing foods, such as soups or gelatins. Small, frequent sips or sucking on ice can also make water intake easier.7

Supplements

Selenium

Asfour and colleagues observed that patients with NHL who underwent chemotherapy and received supplementation with high-dose selenium (sodium selenite) were less likely to acquire an infection during treatment than were patients who underwent chemotherapy without receiving selenium (20% vs 67%, respectively). Additionally, the cardiac ejection fractions of patients who received selenium were better than those of patients who did not (69% ± 5% vs 62% ± 4%, respectively). Selenium supplementation may benefit patients with cardiovascular disease during chemotherapy.9

Vitamin D

Researchers analyzed the effects of vitamin D supplementation and the normalization of 25-hydroxyvitamin D levels on event-free survival in 155 patients with aggressive B-cell lymphomas, 128 of whom had DLBCL. Of the 155 patients, 105 presented with vitamin D deficiency, 32 with vitamin D insufficiency, and 18 with normal vitamin D levels. Vitamin D supplementation normalized the 25-hydroxyvitamin D levels of 56% of the patients. Event-free survival was better in the patients with normal vitamin D levels than in those with vitamin D deficiency.10

In another study, conducted by researchers at the Mayo Clinic, 119 of 390 patients with newly diagnosed chronic lymphocytic leukemia had vitamin D insufficiency, and time to treatment and overall survival were shorter in these patients after a median of 3 years of follow-up. The researchers observed a similar trend in a validation study with a longer median follow-up, 9.9 years. In the the validation cohort (153 patients), time to treatment and overall survival were shorter in the 61 patients with chronic lymphocytic leukemia who also had vitamin D insufficiency.11

In a recent study, low serum vitamin D levels were noted in all 34 patients with a new diagnosis of DLBCL, 32.3% of whom had severe vitamin D deficiency. Similar findings were noted in patients with a new diagnosis of chronic lymphocytic leukemia or multiple myeloma.12

These studies suggest that vitamin D supplementation is beneficial in patients with DLBCL.

Read more about DLBCL clinical trials

Vitamin C

A study showed that the intravenous administration of high-dose vitamin C reduced markers of inflammation such as pro-inflammatory cytokines and C-reactive protein. Lower levels of C-reactive protein correlated with lower levels of tumor markers.13

A Japanese study demonstrated the safety of the intravenous administration of 75 g of vitamin C/ascorbic acid concomitantly with chemotherapy in patients with relapsed or refractory B-cell NLH to normalize serum vitamin C levels. Future studies must assess the efficacy of the dose in this patient population.14

Omega-3 Fatty Acids

Low levels of plasma omega-3 fatty acids may predict a poor prognosis in patients with DLBCL, correlating with poor event-free survival after 24 months. Additional studies must confirm the beneficial effects of dietary supplementation with omega-3 fatty acids on event-free survival in patients with DLBCL.15

Foods to Avoid

Patients with a diagnosis of DLBCL should avoid or significantly reduce their consumption of sugar, processed or fatty meats, lard and butter, and refined grains such as white rice, pasta, and bread. A ketogenic diet high in fat and protein and low in carbohydrates should be avoided since it can cause kidney problems, unwanted weight loss, or other health issues for patients undergoing DLBCL treatment.3

Diets That May Reduce the Risk of DLBCL

A Mediterranean diet may reduce inflammation, possibly preventing the initial development or relapse of DLBCL in survivors; however, according to a systematic review, high-quality studies analyzing the effects of the Mediterranean diet in DLBCL survivors are notably lacking.3,16

One study reported that the risk for DLBCL tended to be lower in the patients with a high intake of total vegetables, particularly cruciferous vegetables over yellow, green leafy, or orange vegetables. The study also showed that a higher intake of leafy vegetables was related to higher lymphoma risk.17 

Another study echoed these findings, stating that an increased intake of vegetables or a combination of fruits and vegetables, but not of fruits alone, decreased the risk for non-Hodgkin lymphomas.18 

A third study reported that an increased intake of vegetables (especially green leafy or cruciferous vegetables), zinc, lutein, and zeaxanthin reduced the risk for NHL.19 Therefore, it may be important to implement a diet rich in vegetables, not only to prevent a first-time diagnosis of DLBCL but also to prevent relapse among patients in complete remission following successful treatment.

Read more about DLBCL risk factors

References

  1. Freedman AS, Friedberg JW. Patient education: diffuse large B-cell lymphoma in adults (Beyond the Basics). UpToDate. Updated July 22, 2022. Accessed August 18, 2022.
  2. Gandhi S. Diffuse large B-cell lymphoma (DLBCL) clinical presentation. Medscape. Updated May 6, 2021. Accessed August 18, 2022.
  3. A healthy diet for diffuse large B-cell lymphoma.  Cleveland Clinic Health Essentials. May 27, 2022. Accessed August 18, 2022. 
  4. Gandhi S. Diffuse large B-cell lymphoma (DLBCL) treatment & management: diet and activity. Medscape. Updated May 6, 2021. Accessed August 18, 2022.
  5. Steroids. Lymphoma Action. Accessed August 18, 2022. 
  6. Diet and nutrition. Lymphoma Action. Accessed August 18, 2022.
  7. Staying Hydrated. The Leukemia & Lymphoma Society. Accessed August 18, 2022. 
  1. Han X, Zheng T, Foss F, et al. Vegetable and fruit intake and non-Hodgkin lymphoma survival in Connecticut women. Leuk Lymphoma. 2010;51(6):1047-1054. doi:10.3109/10428191003690364
  2. Asfour IA, El Shazly S, Fayek MH, Hegab HM, Raouf S, Moussa MAR. Effect of high-dose sodium selenite therapy on polymorphonuclear leukocyte apoptosis in non-Hodgkin’s lymphoma patients. Biol Trace Elem Res. 2006;110(1):19-32. doi:10.1385/bter:110:1:19
  3. Hohaus S, Tisi MC, Bellesi S, et al. Vitamin D deficiency and supplementation in patients with aggressive B-cell lymphomas treated with immunochemotherapy. Cancer Med. 2018;7(1):270-281. doi:10.1002/cam4.1166
  4. Shanafelt TD, Drake MT, Maurer MJ, et al. Vitamin D insufficiency and prognosis in chronic lymphocytic leukemia. Blood. 2011;117(5):1492-1498. doi:10.1182/blood-2010-07-295683
  5. Graklanov V, Popov V. Vitamin D levels in patients with non-Hodgkin lymphoma/diffuse large B-cell lymphoma, chronic lymphocytic leukemia and multiple myeloma. J Int Med Res. 2020;48(7):300060520943421. doi:10.1177/0300060520943421
  6. Mikirova N, Casciari J, Rogers A, Taylor P. Effect of high-dose intravenous vitamin C on inflammation in cancer patients. J Transl Med. 2012;10:189. doi:10.1186/1479-5876-10-189
  7. Kawada H, Sawanobori M, Tsuma-Kaneko M, et al. Phase I clinical trial of intravenous L-ascorbic acid following salvage chemotherapy for relapsed B-cell non-Hodgkin’s lymphoma. Tokai J Exp Clin Med. 2014;39(3):111-115. 
  8. Thanarajasingam G, Maurer MJ, Habermann TM, et al. Low plasma omega-3 fatty acid levels may predict inferior prognosis in untreated diffuse large B cell lymphoma: a new modifiable dietary biomarker? Nutr Cancer. 2018;70(7):1088-1090. doi:10.1080/01635581.2018.1502328
  9. Minoia C, Gerardi C, Allocati E, et al. The impact of healthy lifestyles on late sequelae in classical Hodgkin lymphoma and diffuse large B-cell lymphoma survivors. A systematic review by the Fondazione Italiana Linfomi. Cancers (Basel). 2021;13(13):3135. doi:10.3390/cancers13133135
  10. Rohrmann S, Becker N, Linseisen J, et al. Fruit and vegetable consumption and lymphoma risk in the European Prospective Investigation into Cancer and Nutrition (EPIC). Cancer Causes Control. 2007;18(5):537-549. doi:10.1007/s10552-007-0125-z
  11. Chen GC, Lv DB, Pang Z, Liu QF. Fruits and vegetables consumption and risk of non-Hodgkin’s lymphoma: a meta-analysis of observational studies. Int J Cancer. 2013;133(1):190-200. doi:10.1002/ijc.27992
  12. Kelemen LE, Cerhan JR, Lim U, et al. Vegetables, fruit, and antioxidant-related nutrients and risk of non-Hodgkin lymphoma: a National Cancer Institute–Surveillance, Epidemiology, and End Results population-based case-control study. Am J Clin Nutr. 2006;83(6):1401-1410. doi:10.1093/ajcn/83.6.1401

Reviewed by Debjyoti Talukdar, MD, on 8/29/2022.

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