Diffuse Large B-Cell Lymphoma (DLBCL)

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma (NHL) in adults. The disease is usually aggressive, involving clonal proliferation of a germinal or post-germinal malignant B cell. Surgery in patients with DLBCL is performed for diagnostic purposes or to relieve symptoms if a cancerous mass is pressing on an organ, causing obstruction, or posing a risk for perforation.¹

Excisional Surgery for DLBCL Diagnosis

After clinical examination and radiographic imaging, the final diagnosis of DLBCL is often based on the histological examination of an excisional biopsy specimen that has been removed from an abnormally enlarged lymph node or an extranodal tumor. Histology usually shows replacement of the normal architecture by sheets of large cells that stain positive for pan-B-cell antigens, such as CD20 and CD79a. This method allows a large amount of tissue to be reviewed by pathology and reduces the risks for sampling errors and false negatives associated with fine-needle aspiration and core biopsy.²

Read more about DLBCL testing

In addition to lymph nodes, DLBCL frequently involves extranodal sites, including the kidneys, adrenal glands, brain, bones, and other soft tissues. Positron emission tomography/computed tomography (PET-CT) can be used to determine the disease sites with the highest uptake value and identify the preferred site of biopsy.²

Read more about DLBCL diagnosis

Surgical Resection as DLBCL Treatment Strategy

In some cases, such as limited-stage DLBCL of the small bowel and limited-stage ileocecal DLBCL, initial surgical resection of the involved area is often performed because of the risk for obstruction or perforation of the bowel. It is recommended to follow this surgical resection with full cycles of chemotherapy or combined treatment with chemotherapy and radiotherapy. Although the surgery may slightly decrease patient quality of life, the effectiveness of this treatment strategy may require this as an acceptable disadvantage.³

Read more about DLBCL treatment

Clinical Studies Related to DLBCL Surgery

In a clinical trial called PETAL (Positron Emission Tomography-guided therapy of aggressive non-Hodgkin lymphomas; NCT00554164),⁴ most of the patients with fully resected stage 1 disease according to baseline PET received 6 cycles of R-CHOP (Rituxan® [rituximab] combined with cyclophosphamide, hydroxydaunorubicin [sold as Lipodox® or Doxil®], Oncovin® [vincristine], and prednisone). Among the patients younger than 60 years, 2-year progression-free survival (PFS) was better in those with completely resected disease than in those with incompletely resected disease (100% vs 92%), as was 2-year overall survival (OS; 100% vs 96%); among the patients older than 60, no statistically significant differences were noted between these groups.^5,6

Read more about R-CHOP

In a retrospective study of 250 patients with limited-stage intestinal (mainly ileocecal) DLBCL treated with 6 cycles of CHOP or R-CHOP with or without surgical debulking, surgery in combination with chemotherapy was associated with significantly better rates of complete remission (85% vs 64%), 3-year PFS (82% vs 52%), and 3-year OS (91% vs 62%) in comparison with chemotherapy alone. However, no survival benefit of surgical resection was observed in patients with advanced-stage intestinal disease. This study suggests that surgical resection provides a survival benefit in patients with limited-stage disease but not advanced-stage disease. One of the most common reasons for surgery was primary mass resection for both diagnostic and therapeutic purposes. Presentation as bowel obstruction was a common cause for surgery compared to bowel perforation or bleeding.​​^3,7

Read more about DLBCL clinical trials

Another study, by Bairey, et al, showed the benefit of splenectomy at diagnosis in 87 patients with splenic DLBCL who received chemotherapy with or without radiotherapy. In this trial, splenectomy was associated with significantly better 5-year PFS (85% vs 55%) and OS (91% vs 68%) in patients with early-stage (stage I/II) disease. However, this benefit was not observed in patients with more advanced stages of disease.⁸

Read more about DLBCL prognosis

References

1. Susanibar-Adaniya S, Barta SK. 2021 Update on diffuse large B cell lymphoma: a review of current data and potential applications on risk stratification and management. Am J Hematol. 2021;96(5):617-629. doi:10.1002/ajh.26151
2. Liu Y, Barta SK. Diffuse large B-cell lymphoma: 2019 update on diagnosis, risk stratification, and treatment. Am J Hematol. 2019;94(5):604-616. doi:10.1002/ajh.25460
3. Kim SJ, Kang HJ, Kim JS, et al. Comparison of treatment strategies for patients with intestinal diffuse large B-cell lymphoma: surgical resection followed by chemotherapy versus chemotherapy alone. Blood. 2011;117(6):1958-1965. doi:10.1182/blood-2010-06-288480
4. Positron emission tomography guided therapy of aggressive non-Hodgkin’s lymphomas. ClinicalTrials.gov. November 6, 2007. Updated May 5, 2017. Accessed August 21, 2022.
5. Dührsen U, Müller S, Hertenstein B, et al. Positron emission tomography-guided therapy of aggressive non-Hodgkin lymphomas (PETAL): a multicenter, randomized phase III Trial. J Clin Oncol. 2018;36(20):2024-2034. doi:10.1200/JCO.2017.76.8093
6. Schmitz C, Rekowski J, Müller SP, et al. Impact of complete surgical resection on outcome in aggressive non-Hodgkin lymphoma treated with immunochemotherapy. Cancer Med. 2020;9(22):8386-8396. doi:10.1002/cam4.3448
7. Rojek AE, Smith SM. Evolution of therapy for limited stage diffuse large B-cell lymphoma. Blood Cancer J. 2022;12(2):33. doi:10.1038/s41408-021-00596-z
8. Bairey O, Shvidel L, Perry C, et al. Characteristics of primary splenic diffuse large B-cell lymphoma and role of splenectomy in improving survival. Cancer. 2015;121(17):2909-2916. doi:10.1002/cncr.29487

Reviewed by Debjyoti Talukdar, MD, on 8/31/2022.

---

Erum Naqvi, PhD

Erum Naqvi obtained her Ph.D. in Molecular Medicine from Hannover Medical School (Germany) after completing her Masters in Biomedical Science and Bachelors in Microbiology from University of Delhi (India). She has several years of experience as a science writer.