This month David Straus, MD, discusses treatment options for a patient with c-Myc positive diffuse large B-cell lymphoma.
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54-year-old previously healthy male with recent abdominal pain had a computed tomography (CT) scan that showed a 5 cm mesenteric mass. The CT core biopsy revealed diffuse large B-cell lymphoma of the germinal center B-cell phenotype that was c-Myc positive. A positron emission tomography scan showed this to be the only site of disease and the bone marrow is negative. Would you recommend R-CHOP x6 or x3-4 with radiation? Or a different regimen given the c-Myc positivity?
This is probably a high-grade diffuse large B-cell lymphoma. I would obtain fluorescence in situ hybridization to see if there is a c-Myc translocation as well as c-Myc overexpression by immunohistochemistry. Researchers from the National Cancer Institute (NCI) reported promising early results with dose-adjusted EPOCH-R for treatment of patients with aggressive B-cell lymphomas with MYC-rearrangement at the 2014 ASH Annual Meeting.1 This is being explored further in an NCI Cancer Therapy Evaluation Program clinical trial.2 If his lactate dehydrogenase is normal, he may be eligible for short course treatment with three cycles of RR-EPOCH-R. These regimens are described in the New England Journal of Medicine manuscript on Burkitt lymphoma treatment.3
- Dunleavy K, Fanale M, LaCasce A, et al. Preliminary report of a multicenter prospective phase II study of DA-EPOCH-R in MYC-rearranged aggressive B-cell lymphoma. Blood. 2014;124:395.
- ClinicalTrials.gov. Phase II study of dose-adjusted EPOCH-rituximab in adults with untreated Burkitt lymphoma and c-MYC+ diffuse large B-Cell lymphoma (NCT01092182).
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NEXT MONTH'S CLINICAL DILEMMA
A 30-year-old man with aplastic anemia presented with rapidly progressive exercise intolerance over a 2-week period. White blood cell (WBC) count is 2.2×109/L with an absolute neutrophil count of 450/µL. Hemoglobin is 5.5 g/dl, and platelet count is 3,000/µL. Lactate dehydrogenase is 180/µL and erythrocyte sedimentation rate is 89 mm/hr. Kidney and liver function is normal. A bone marrow (BM) biopsy shows scant lymphocytes and BM stromal cells. Hematopoietic elements are virtually absent. No signs of paroxysmal nocturnal hemoglobinuria by flow cytometry. The patient refuses packed red blood cells or platelet transfusions for religious reasons. We have started immunosuppressive treatment with anti-thymocyte globulin, steroids, and cyclosporine. Since the patient does not wish to receive transfusions, BM transplant is probably out of the question. Do you think it is reasonable to add erythropoietin, eltrombopag, or granulocyte colony-stimulating factor upfront? Is there anything else I am not thinking about?
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