Impact of Concurrent Indolent Lymphoma on the Clinical Outcome of Newly Diagnosed Diffuse Large B-Cell Lymphoma

Yucai Wang, Brian K. Link, Thomas E. Witzig, Matthew J. Maurer, Cristine Allmer, Rebecca L. King, Andrew L. Feldman, Thomas M. Habermann, Stephen M. Ansell, Susan L. Slager, James R. Cerhan and Grzegorz S. Nowakowski

Key Points

  • Concurrent DLBCL and FL have similar outcome to that of GCB DLBCL. Concurrent other indolent lymphoma does not worsen outcome of DLBCL.

  • Inclusion of patients with concurrent DLBCL and indolent lymphoma should be considered in clinical trials of newly diagnosed DLBCL.


Approximately 10-15% of patients with diffuse large B-cell lymphoma (DLBCL) present with a concurrent indolent lymphoma at initial diagnosis. Their outcomes in rituximab era are not fully defined. Using a prospectively followed cohort of 1,324 newly diagnosed DLBCL patients treated with immunochemotherapy, we defined the prevalence, characteristics and outcome of DLBCL with concurrent indolent lymphoma. Compared to patients with DLBCL alone (n=1,153, 87.1%), patients with concurrent DLBCL and FL (n=109, 8.2%) had fewer elevations in LDH (36 vs 58%, P<0.01), lower IPI (P<0.01) and were predominantly GCB subtype (93 vs 62%, P<0.01), while patients with concurrent DLBCL and other indolent lymphomas (n=62, 4.7%) had more stage III-IV disease (92 vs 62%, P<0.01) and a trend towards higher IPI (P=0.09) and non-GCB subtype (52 vs 38%, P=0.06). After adjusting for IPI, patients with concurrent DLBCL and FL had similar EFS (HR=0.95, 95% CI=0.71-1.27) and a trend of better OS (HR=0.75, 95% CI=0.52-1.09) compared to patients with DLBCL alone, but nearly identical EFS (HR=1.00, 95% CI=0.73-1.36) and OS (HR=0.84, 95% CI=0.56-1.23) compared to patients with GCB DLBCL alone. Patients with concurrent DLBCL and other indolent NHLs had similar EFS (HR=1.19, 95% CI=0.86-1.66) and OS (HR=1.09, 95% CI=0.74-1.60) compared to patients with DLBCL alone. In conclusion, DLBCL patients with concurrent FL predominantly had the GCB subtype with outcomes similar to that of GCB DLBCL patients. Patients with concurrent other indolent lymphoma had similar outcomes compared to patients with DLBCL alone. These patients should not be summarily excluded from DLBCL clinical trials.

  • Submitted March 29, 2019.
  • Revision received July 25, 2019.
  • Accepted July 4, 2019.