Second Opinion

More documents

Recommendations

Info

Case 5 from the practice of Abraham B Schwarzberg, MDAn 80-year-old, very fit man with no major comorbidities presented with hematuria. A CTscan revealed pelvic lymphadenopathy (largest node 1.3 centimeters) and several splenicmasses (largest 2.2 centimeters). Splenic biopsy revealed DLBCL. His medical history wassignificant for a diagnosis of non-Hodgkin lymphoma 35 years ago for which he receiveda cumulative dose of 300 mg/m 2 of doxorubicin. An echocardiogram demonstrated anejection fraction of 45 percent. After two cycles of R-CHOP with a full dose of doxorubicinthat was divided over two days, he demonstrated a complete response and no change inhis ejection fraction. He received four more courses of a modified R-CHOP regimen, andhe has remained in complete remission for one year with a stable ejection fraction.SOURCE: Track 185.1Which systemic treatment would you most likelyrecommend for this patient?R-CNOP x 6 cycles15%R-CVP11%R-CHOP q2wk x 69%R-CHOP q3wk x 6 39%R-CHOP q3wk x 8 8%Other 15%No systemic therapy 3%0 10 20 30 40 50SOURCE: National Survey of Medical Oncologists, November 2008.Track 20DR LOVE: John, what are your thoughts regarding this case?DR LEONARD: The literature is scant and not useful for telling us what thebest approach is. It’s an individualized decision (5.1). The first thing is to besure that the patient’s cardiac function is truly compromised. We recentlyhad a patient in the middle of receiving R-CHOP whose ejection fraction16
appeared to decline. We repeated the study in a different way and spoke withhis cardiologist — it hadn’t dropped at all, so it’s helpful to have the cardiologistinvolved.For most of my patients with compromised cardiac function, I’ve administeredrituximab-cyclophosphamide/etoposide/procarbazine/prednisone (R-CEPP).This is a Stanford regimen from 10 or 15 years ago (Chao 1990) and we haveadded the rituximab. So it is different from the prednisone/etoposide/procarbazine-cyclophosphamide(PEP-C) regimen that we’ve occasionally used(Coleman 2008).Sometimes you can get away with R-CHOP for these patients. For an 80-year-old patient with an ejection fraction of 45 percent who has received aprior anthracycline, I would be hesitant about using R-CHOP, but I can’targue against using a dose reduction or doing it carefully.Few data are available for R-CNOP in this population. Certainly, someare using R-CVP. I don’t believe you’re giving up the ship by omitting theanthracycline, and for some patients that is reasonable. Most of the time, I endup starting with one regimen and cutting it down as time goes on, dependingon how the patient tolerates it.Obviously, we don’t watch and wait in DLBCL too often, but with a compromisedpatient who’s sick and has comorbidities, watching for a while withoutsymptoms might also be reasonable. However, in this case, I’d be hesitant todo that.DR MALONEY: It’s a mistake not to treat this patient aggressively. Every studythat has treated elderly patients with DLBCL using kinder and gentler therapyhas been associated with inferior survival or, at best, comparative survival.If you don’t use the correct dose of mitoxantrone or you drop the anthracycline,you have inferior survival. Your default position should be to try to cure thisman, despite the fact that he’s 80 years old and has received an anthracycline.I would use dose-adjusted EPOCH-R (Wilson 2008). You can administerinfusional anthracyclines without cardiac toxicity because they don’t reach thepeak levels that cause the toxicity. I’ve done it for several patients who hadalready received the maximum dose of anthracyclines. If I ran into problemswith toxicity, I would retreat to a more palliative approach.SELECT PUBLICATIONSChao NJ et al. CEPP(B): An effective and well-tolerated regimen in poor-risk, aggressivenon-Hodgkin’s lymphoma. Blood 1990;76(7):1293-8. AbstractColeman M et al. Prednisone, etoposide, procarbazine, and cyclophosphamide (PEP-C)oral combination chemotherapy regimen for recurring/refractory lymphoma: Lowdosemetronomic, multidrug therapy. Cancer 2008;112(10):2228-32. AbstractWilson WH et al. Phase II study of dose-adjusted EPOCH and rituximab in untreateddiffuse large B-cell lymphoma with analysis of germinal center and post-germinalcenter biomarkers. J Clin Oncol 2008;26(16):2717-24. Abstract17
Page 1 and 2: Second OpinionCase-Based Discussion
Page 3 and 4: Second OpinionCase-Based Discussion
Page 5 and 6: Case 1 from the practice of Michael
Page 7 and 8: of lenalidomide at a lower dose for
Page 9 and 10: How much more is not completely pro
Page 11 and 12: DR GREGORY: I’m impressed with th
Page 13 and 14: y RICE and ICE. These are well-tole
Page 15 and 16: SELECT PUBLICATIONSFeugier P et al.
Page 17: What can you expect from a patient
Page 21 and 22: EDUCATIONAL ASSESSMENT AND CREDIT F
Page 23 and 24: ModeratorManaging EditorScientific

Second Opinion

Create successful ePaper yourself

Delete template?

Save as template?