A 77-Year-Old Woman with DLBCL - Episode 1

Case Overview: 77-Year-Old Woman With DLBCL

September 25, 2020
John M. Burke, MD

John M. Burke, MD: We’re going to start with a case of a 77-year-old woman who presents with anorexia, fatigue, and shortness of breath. Her past medical history is notable for having diabetes that is medically controlled. On physical examination, she has palpable inguinal lymphadenopathy and splenomegaly, and we assess her ECOG performance status to be 1. Her laboratory evaluation is notable for anemia, with a hemoglobin of 9.8 [g/dL], and she has an elevated LDH [lactate dehydrogenase]. By pulmonary function test, she has an FEV1 [forced expiratory volume in the first second of expiration] of 45%. Hepatitis B, C, and HIV tests are all negative.

You proceed with a core needle biopsy of the inguinal lymph node. That demonstrates a CD20-positive diffuse large B-cell lymphoma [DLBCL], nongerminal center B-cell [GCB] subtype. You get a FISH [fluorescence in situ hybridization] panel back that demonstrates a translocation between chromosomes 14 and 18, consistent with a BCL2 rearrangement, but she does not have a rearrangement of MYC or BCL6.

A staging PET [positron emission tomography]/CT scan demonstrates FDG [fluorodeoxyglucose]-avid inguinal lymphadenopathy measuring up to 3.3 cm, FDG-avid splenomegaly, and a small—1 cm—suspicious lesion in the lung. A bone marrow examination confirms involvement with diffuse large B-cell lymphoma.

In conclusion, we have a patient with stage IV diffuse large B-cell lymphoma, nongerminal center B-cell subtype. It is not a double hit. You assess her IPI [International Prognostic Index] score to be high risk, and her CNS [central nervous system] relapse score to be intermediate risk, meaning that she does not require prophylactic intrathecal or high-dose methotrexate therapy.

She’s 77 years old. You treat her with 6 cycles of R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] chemotherapy. At the end of treatment, a PET/CT scan demonstrates a Deauville 2 score complete remission.

One year later, while she’s in surveillance, she presents with new onset of diffuse lymphadenopathy involving cervical, axillary, mediastinal, and abdominal regions. A core needle biopsy of an axillary node confirms a relapse of her original DLBCL, non-GCB subtype. Based on her age, 78 years at this point, and performance status, you consider her to be transplant ineligible. You elect to initiate therapy with tafasitamab plus lenalidomide.

Transcript edited for clarity.


Case: A 77-Year-Old Woman With DLBCL

Initial Presentation

  • A 77-year-old woman presented with loss of appetite, fatigue and shortness of breath
  • PMH: post-menopausal; DM, medically controlled
  • PE: palpable inguinal lymphadenopathy; splenomegaly
  • ECOG PS 1

Clinical Work-up

  • Labs: Hb 9.8 g/dL; all others WNL
  • FEV1 45 %
  • Hepatitis B, C and HIV negative
  • Core needle biopsy of the inguinal node: CD20-positive diffuse large B-cell lymphoma, non-GCB subtype. FISH panel: t(14;18) with a BCL2 rearrangement; no MYC or BCL6 rearrangement
  • Imaging:
    • Whole body PET/CT scan showed FDG avidity the inguinal lymph node region, largest node 3.3 cm; splenomegaly; and a small suspicious lung lesion
  • Bone marrow biopsy: involvement with DLBCL
  • Conclusion: stage IV DLBCL, non-GCB subtype
  • IPI score high-risk; CNS relapse score intermediate risk

Treatment

  • Treated with R-CHOP for 6 cycles
  • End-of-treatment PET/CT demonstrates a Deauville 2 complete remission
  • 1 year later while in surveillance she presents with new cervical, axillary, mediastinal, and abdominal lymphadenopathy
  • Core needle biopsy of an axillary node confirms a relapse of DLBCL, non-GCB subtype
  • Based on her age of 78 years and performance status, you consider her to be transplant-ineligible
  • You elect to initiate tafasitamab + lenalidomide