Skill Checkup: A 74-Year-Old Woman With a History of Treated Diffuse Large B-Cell Lymphoma Has Fatigue and Splenomegaly

Zachary Cohn, MD


March 30, 2023

Although a plethora of options are available to patients in the third-line setting, CAR T-cell therapy is preferred following two previous lines of therapy, as it has demonstrated curative potential in patients who have not responded to autologous stem cell transplantation as well as those who are transplantation ineligible; approximately one third of patients achieve durable disease control. Patient criteria include adequate organ function, sufficient lymphocyte reserve and platelet counts, no active infections, and lack of CNS involvement. However, acute toxicities requiring inpatient management and potential long-term toxicities should be considered in the decision-making process. Logistical issues and delays to treatment are often concerns as well.

Several bispecific T-cell engagers are under investigation, and promising results have been seen in phase 1 and 2 studies.

Allogeneic stem cell transplantation is not appropriate in this patient. According to the NCCN guidelines, it may be considered in select cases in the second-line setting for fit patients, such as those with stem cell mobilization failure and persistent bone marrow involvement or lack of adequate response to second-line therapy, though patients should be in CR or near CR at the time of transplantation. Although allogeneic transplantation is potentially curative, the relatively high treatment-related mortality and the emergence of alternative therapies have limited its use.

A selective BCL2 inhibitor has been studied but it did not demonstrate efficacy in this disease.


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