Frontline Treatment Approaches in DLBCL

EP: 1.Case Overview: 77-Year-Old Woman With DLBCL

EP: 2.Approaching DLBCL: Risk Assessment and Prognosis

EP: 3.DLBCL: Cytogenetic Testing and Treatment Initiation

Now Viewing

EP: 4.Frontline Treatment Approaches in DLBCL

EP: 5.Current Treatment Approaches for R/R DLBCL

EP: 6.Implications for Treating R/R DLBCL With the L-MIND Regimen

EP: 7.R/R DLBCL: Observations From the Re-MIND Study

EP: 8.R/R DLBCL: Treating With Tafasitamab Plus Lenalidomide

EP: 9.Progress Made in Treating R/R 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