Here’s how readers responded to a You Make the Call question about rituximab maintenance after R-CHOP for a patient with stage 4B diffuse large B-cell lymphoma (DLBCL).
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I’d recommend continuing with rituximab maintenance and keeping the AHCT option for later.
Erden Atilla, MD
If at the end of the R-CHOP therapy the patient obtains a complete response, I would recommend adopting a watch-and-wait strategy, avoiding maintenance with rituximab. If the patient subsequently relapses, I would consider bispecific antibodies or CAR-T therapy.
Stefano Sacchi, MD
I would not recommend rituximab maintenance. If the disease relapses, which is perhaps likely, I would suggest either CAR-T therapy or polatuzumab vedotin. There are intriguing data on up-front use of rituximab plus lenalidomide plus ibrutinib.
Stephen Chandler, MD
I think the patient can benefit from consolidation with AHCT since he is clinically well and fit, has an aggressive disease with a high tumoral burden, and has demonstrated chemotherapy sensitivity. It’s not my clinical practice to use rituximab maintenance for transformed follicular lymphoma because of the lack of solid evidence that shows improved outcomes.
Larissa Lane Cardoso Teixeira
São Paulo, Brazil
Continued treatment with rituximab would be reasonable for 2 years. Consolidating with AHCT would also be a reasonable option after he recovers from initial treatment.
David T. Harrison, MD
I would favor giving the patient maintenance rituximab.
Subhash Proothi, MD, FRCP
I would advise maintenance therapy with rituximab 375 mg/m2 every 2 months, for a maximum of 2 years. I don’t see any indication for high-dose therapy with AHCT after completion of induction therapy.
Dirk Markus Niemann, MD
I would recommend R-CHOP followed by maintenance rituximab if a complete response is obtained.
William Johnson, DO
The treatment approach for patients with histologic transformation of FL to DLBCL is based on rituximab-containing chemotherapy. For anthracycline-naive patients, our first therapy choice is R-CHOP for 6 cycles. Consolidation with AHCT is recommended for younger and fit patients. Older or frail patients who obtain complete remission after R-CHOP may be approached with rituximab maintenance. Rituximab maintenance therapy improves outcomes for DLBCL with transformation and controls the follicular component.
João Tadeu Damian Souto Filho, MD, PhD
Rio de Janeiro, Brazil