Table 1.

Special situations

High CNS-IPI

MRI and liquor assessment using cytology and flow cytometry in patients with CNS-IPI >10% to exclude CNS involvement is recommended. Consider CNS-directed treatment followed by consolidative autologous stem cell transplant in patients with cerebral involvement.

Leg-type lymphoma

Consolidative radiotherapy after systemic treatment is recommended, avoid extensive surgery.

Frail patients

Off-label use of bendamustine, rituximab and polatuzumab vedotin and tafasitamab with lenalidomide should be considered in patients not eligible for anthracycline-based chemotherapy.

Patients with high-volume and symptomatic disease

In patients highly symptomatic due to high-volume disease, we often consider immediate start of polychemotherapy instead of a pre-phase treatment with corticosteroids. Strict prophylaxis of tumor lysis syndrome and close monitoring of the serum parameters are mandatory in these patients.

Patients with HIV-associated DLBCL

It is important to start (or continue) an effective ART, watching drug–drug interactions. In patients with CD4 <50/μl, the use of rituximab is individualized to lymphoma and infection risks. In patients with CD4 count >50/μl, our former standard regimens R-CHOP or R-EPOCH are now challenged due to the better efficacy of polatuzumab vedotin.

ART, antiretroviral therapy; CNS, central nervous system; DLBCL, diffuse large B-cell lymphoma; HIV, human immunodeficiency virus; IPI, international prognostic index; MRI, magnetic resonance imaging; R-CHOP, rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone; R-EPOCH, rituximab, etoposide, prednisone, vincristine, cyclophosphamide and doxorubicin.