A 74-Year-Old Man With Diffuse Large B-Cell Lymphoma - Episode 1

Presentation of a Patient With Diffuse Large B-Cell Lymphoma

Gilles Salles, MD: Hello, my name is Dr Gilles Salle. I’m a physician at the Memorial Sloan Kettering Cancer Center in New York, United States, and today I will discuss a 74-year-old patient who has been recently diagnosed with diffuse large B-cell lymphoma.

As I mentioned, this 74-year-old patient came to the clinic with a fever presenting for a couple of weeks. He had lost about 14 pounds, unintentionally, and had occasional chest pain in the axillary region. The previous medical history was diabetes mellitus, which was medically controlled, and on physical examination, he looked quite tired—this was the weight loss and a fever of a couple of weeks. He also had obvious palpable bilateral cervical lymph nodes that were not that big.

We started the clinical work-up of this patient. The LDH [lactate dehydrogenase] levels were elevated about 2-fold from normal values, hemoglobin level was slightly diminished to 10.8 g/dL, but everything was within normal range, and there was a slight elevation of creatinine value. Besides that, the other laboratory tests were within normal range.

The serological tests for hepatitis B and C, as well as HIV, were negative. The lymph node biopsy confirmed the large cells, which were CD20-positive, confirming the diagnosis of diffuse large B-cell lymphoma. Complementary examination with immunohistochemistry showed CD10-positive and CD19-positive on the report.

The patient went for a whole-body PET [positron emission tomography]-CT [computed tomography], and as a result, this exam showed activity on the cervical lymph node regions. The largest node was not big, about 2.5 cm, but he had evidence in other areas, such as the axillary region and thorax. He had some subcutaneous tissue involvement, which, because they were distant from the initial localization, classified this patient as stage IV. The performance status was 1, but this was a patient over 60 years old, with inoperable stage IV disease and elevated LDH, so he is in the high-risk category of patients.

What was decided for this patient was rather standard. The patient underwent immunochemotherapy with rituximab and CHOP [cyclophosphamide, doxorubicin, vincristine, and prednisone] and it was well tolerated. He went through 4 cycles. The physician had the impression that the lymph nodes had not fully disappeared after 4 cycles, so an additional PET was prescribed after the 4 cycles. Unfortunately, what was seen on this new PET-CT was progression of disease. Given the age and the comorbidities, and the wish of the patient, the patient was deemed transplant ineligible, and the physician’s decision was to start this patient with tafasitamab and lenalidomide.

Transcript edited for clarity.


Case: A 74-Year-Old Man with Diffuse Large B-Cell Lymphoma

Initial Presentation

  • A 74-year-old man presented with fever, 14-lb unintentional weight loss and occasional chest pain
  • PMH: DM, medically controlled
  • PE: tired-appearing man; palpable bilateral cervical lymphadenopathy

Clinical Work-up

  • Labs: LDH 2 times above normal; Hb 10.8 g/dL; bilirubin 2.3 mg/dL; creatinine 1.7 mg/fl; all others WNL
  • Hepatitis B, C and HIV negative
  • Lymph node biopsy; CD 20+ confirmed DLBCL; IHC panel: CD 10+, CD 19+
  • Imaging:
    • Whole body PET/CT scan showed activity the cervical lymph node region, largest node 2.5 cm; evidence of axillary and thoracic subcutaneous tissue involvement
  • Ann Arbor stage 4; IPI: high-risk; ECOG PS 1

Treatment

  • Treatment initiated with R-CHOP + RT; well-tolerated
    • Interim PET scan after 4 cycles; progressive diseases noted
  • Due to transplant ineligibility patient was treated with tafasitamab + lenalidomide