A 77-Year-Old Woman with DLBCL - Episode 4

Frontline Treatment Approaches in DLBCL

John M. Burke, MD: This patient has a pretty straightforward diffuse large B-cell lymphoma. The standard practice remains using R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] chemotherapy as treatment. In a 77-year-old, as this patient was at presentation, certainly if her performance status was impaired or if she had comorbidities and one felt R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] might not be safe, then the treating physician needs to think about alternatives. There is no standard in that situation, although many physicians will reduce the doses of the CHOP [cyclophosphamide, doxorubicin, vincristine and prednisolone] in the form of R-miniCHOP therapy. Or if patients have inadequate cardiac function, you need to modify the CHOP [cyclophosphamide, doxorubicin, vincristine and prednisolone] and use something like etoposide in place of the doxorubicin. Various other regimens can be used in folks with impaired cardiac function. But for a straightforward large cell lymphoma case like this, R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] remains the standard of care.

For the double hit lymphomas, it’s a little less clear what exactly is the best regimen. It’s not 100% clear from phase 3 trials at least, that more aggressive regimens are better than R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone]. The data supporting these aggressive regimens in double hit lymphomas come from phase 2 trials where results appear to be better than they are with R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone]. Dose adjusted R-EPOCH [rituximab with etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin] is a commonly used regimen in community practices for patients with double hit lymphoma.

Again, the default is going to be R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] for most patients. If patients have comorbidities, that will impact the choice of first-line treatment. Knowing if the patient has a double or triple hit lymphoma will impact the choice of therapy. Those are the primary factors that impact the choice of treatment.

As for the success rates with R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] chemotherapy, most studies will indicate an overall response rate somewhere between 75% and 90%, a complete remission rate between 55% and 70%, and a 3-year progression-free survival on the order of 65% to 70%. We generally tell patients that long-term cure rates after R-CHOP [rituximab with cyclophosphamide, doxorubicin, vincristine and prednisolone] are in the ballpark of 60%.

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