What is your approach to treating early stage EBV-positive diffuse large B-cell lymphoma of the elderly after a CR to systemic therapy?

This is a recently described entity with poor prognosis, so even with a CR after RCHOPx6 cycles, is your bias to push for ISRT due to EBV being poor prognosticator? If so, what dose would you recommend?

1 Answer

Mednet MemberInvited Expert

Radiation Oncology · Duke University Medical Center

Answered on

EBV+ diffuse large B-cell lymphoma of the elderly, which typically affects apparently immunocompetant individuals > 50 y/o, was a provisional diagnosis in the 2008 edition of the WHO classification system. EBV+ DLBCL has been recognized in younger patients which led to a revision in the 2016 classification. The new entity is termed "EBV+ DLBCL, NOS". Patients with EBV+ DLBCL appear to have a worse prognosis, especially older patients.

This is a rare entity and requires pathology to check EBV. Many institutions will check EBV in older patients with DLBCL or in younger patients when there is significant pleomorphism of the neoplastic cells, an anaplastic appearance, or when the histologic appearance has characteristics of Hodgkin lymphoma (the differential diagnosis of EBV+ DLBCL, NOS includes Hodgkin lymphoma and gray zone lymphoma).

Current recommendations are to treat this entity like DLBCL, NOS (Am J Hematol 2016;91:529). Therefore, I would use the same decision-making to utilize RT in these patients as I would in typical patients with DLBCL. If a CR is achieved by PET-CT, follow ISRT principles utilizing a total dose of 30 Gy for early-stage disease.