A Multidisciplinary Team (MDT) Meeting on Diffuse Large B-cell Lymphoma (DLBCL)

MDT meetings, sometimes known as “Tumor Boards”, are occasions when the entire team of health professionals meets to discuss specific patients. They provide learning experiences for all team members and improve overall patient care. INCTR has introduced MDTs into its annual meeting to demonstrate their value to those unfamiliar with the concept.

Case History

A 59-year-old man presented with generalized lymphadenopathy and weight loss of six months' duration.

Diagnosis

Several discussants pointed out that in regions where tuberculosis is prevalent, it should be considered in the differential diagnosis. Professor Wright stressed that to establish the histological subtype of lymphoma, an excision (or cutting needle) biopsy is mandatory. Dr. Ngoma and Dr. Nkegoum (from Tanzania and Cameroon, respectively) agreed, but pointed out that for the diagnosis of African Burkitt lymphoma, an F.N.A. would suffice.

Pathology

Professor Wright demonstrated the importance of immunophenotyping in differentiating B from T cell lymphomas and identifying subtypes. In this case, Bcl-2 was strongly expressed in the cytoplasm, typical of many cases of DLBCL, whilst Bcl-6, surprisingly, was negative. He discussed the morphological variants that comprise DLBCL in the WHO classification: centroblastic, immunoblastic, T-cell/histiocyte-rich and anaplastic, and mentioned the intravascular large B-cell and mediastinal (thymic) large B-cell subtypes. He also discussed the pathogenesis of DLBCL in light of recent advances in gene expression profiling. Patients in whom the lymphoma cells express a germinal center B-cell signature appear to have a better prognosis than those with an activated B-cell profile when treated with CHOP or similar regimens. Such lymphomas also appear to be the predominant subtype in children.

Staging Investigations

The bone marrow aspirate and biopsy revealed no lymphoma cells and CT scans showed intra-abdominal lymphadenopathy; thus, the disease stage was IIIB. The group consensus was that CT scanning should be mandatory for all patients with lymphoma. Dr. Khan discussed the role of gallium and MRI scanning, the latter being reserved for lesions involving the brain and spinal cord. PET scanning (where available) is particularly useful in identifying viable tumor in residual mediastinal or abdominal masses after treatment.

Treatment

It was agreed that CHOP regimen (Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) remains the standard regimen (given with Rituximab, if possible) for DLBCL. In the eventuality of recurrence, a second-line regimen, e.g. ‘ICE’ (Ifosphamide, Cytosine Arabinoside and Etoposide), could be used with a view to high-dose treatment, supported by autologous peripheral progenitor cells, in patients who have a partial response. The session was interactive and generated lively debate.

Anita Chandra and T.G. Sagar, Chennai, Dennis Wright, Southampton, Ali Khan, Manchester and Ama Rohatiner, London.