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
Clinical Work-up
Treatment
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