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

Rapidly progressive disease in the third-line setting presents a clinical challenge. While CAR T-cell therapy provides the most effective option for patients who have progressed after two or more prior therapies, treatment may be delayed to an unacceptable extent for patients with rapidly progressing disease, particularly those with impending organ compromise. In addition to the time required to produce the therapy, organizational and process-related problems, such as obtaining insurance coverage, can also extend the time to treatment.

Therefore, CAR T-cell therapy, with the addition of a bridging therapy (typically a chemoimmunotherapy regimen), is recommended in eligible patients in order to control the patient's disease while waiting for the CAR T cells to be produced and ready for administration.

Involved-site radiation therapy  is another option for bridging therapy, either alone or in combination, sequentially with systemic therapy. It may also be considered as a palliative therapy.

Chemotherapy-free options, including a BTK inhibitor (ibrutinib) and the immunomodulator (lenalidomide) ± rituximab, have demonstrated activity in transplantation-ineligible patients with non-GCB DLBCL and may be considered as well, but they are not typically recommended in the third-line setting.


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