Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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Rapid lymphoma with organ compromise
Airway, superior vena caval, bowel, ureteric, cord or CNS compression, tumour lysis, haemophagocytic inflammation or neutropenic sepsis requires immediate stabilisation alongside accelerated tissue diagnosis.
Action: Use ABCDE assessment, obtain lysis, FBC, coagulation, cultures and group samples, involve the anatomical and lymphoma teams, start hydration and risk-adapted urate lowering, secure blood, effusion or core tissue before steroids when possible, and begin subtype-appropriate cytoreduction once essential diagnostic material is protected.
Synopsis
Recognise rapidly progressive lymphoma, secure adequate tissue and defining genetics before treatment, stabilise lysis and compression and deliver subtype-specific curative immunochemotherapy with response and relapse planning.
Aggressive NHL is an umbrella: diffuse large B-cell lymphoma is common, but Burkitt, high-grade B-cell, primary mediastinal and peripheral T-cell lymphomas need different protocols.
First-line diagnostic procedure is excision biopsy; if unsafe, obtain multiple large cores and preserve tissue for morphology, flow, immunohistochemistry, FISH and molecular tests.
In newly presenting high-grade B-cell lymphoma, test MYC rearrangement; if present, add BCL2 and BCL6 FISH and identify the MYC partner as recommended by NICE.
Key red flags
A mass doubling over days, LDH rise, spontaneous lysis, cytopenias or extranodal organ failure suggests highly aggressive biology and needs same-day haemato-oncology review.
Lysis pattern
Rising urate, phosphate, potassium, LDH and creatinine with falling calcium can precede treatment in a bulky highly proliferative lymphoma.
Investigation priorities
01
Reference standard: excision or adequate core biopsyFirst stepReference standard
Establish architecture, lineage and exact aggressive lymphoma entity.
02
First-line staging: FDG PET-CTFirst line
Map nodal and extranodal burden and establish response baseline.
Management branches
Suspected aggressive lymphomaStabilise and secure adequate tissue
A rapidly progressive nodal or extranodal mass, lysis or organ compromise is present.
Assess airway, vascular, cord, bowel, renal and CNS threat and begin lysis and sepsis management.
Obtain excision or multiple large cores before steroids when possible, allocating tissue for flow, histology, genetics and microbiology.
New DLBCLDeliver curative first-line immunochemotherapy
Integrated pathology confirms DLBCL without a subtype-specific alternative pathway.
Key medicines
R-CHOP-21Give rituximab 375 mg/m² IV, cyclophosphamide 750 mg/m² IV, doxorubicin 50 mg/m² IV and vincristine 1.4 mg/m² IV capped at 2 mg on day 1, plus prednisolone 100 mg orally daily on days 1–5, every 21 days.
Polatuzumab vedotin with R-CHPGive polatuzumab vedotin 1.8 mg/kg IV every 21 days with protocol rituximab, cyclophosphamide, doxorubicin and prednisolone for six cycles; omit vincristine and follow the commissioned additional rituximab schedule.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.