Here’s how readers responded to a You Make the Call question about a patient with c-Myc positive diffuse large B-cell lymphoma.
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The jury is still out on the best therapy for double-hit lymphomas, but given his age and assuming a good performance status, I suggest dose-adjusted EPOCH-R.
Jorge David Korin, MD
Buenos Aires, Argentina
Dose-adjusted EPOCH-R plus radiation therapy.
Carmelo Carlo-Stella, MD
Humanitas Cancer Center
Martha Arellano, MD
Winship Cancer Institute
Robert K. Stuart, MD
Medical University of South Carolina
I would give dose-adjusted EPOCH-R to this patient.
Amir Steinberg, MD
Mount Sinai Hospital
New York, NY
R-CHOP x3-4 then radiation.
Juan M. Alcantar, MD
Los Angeles, CA
Cesar M. Campo, MD
Santa Fe, Argentina
Indu Sabnani, MD
I would be sure this is not double-hit lymphoma. If not, R-CHOP will do.
Achiel Van Hoof, MD
General Hospital St-Jan
Information about lactate dehydrogenase, BCL2, and BCL6 are missing. I would use the combined immunohistochemical (ICH) or fluorescent in situ hybridization/ICH score proposed by Horn, et al. (Blood. 2013;12:2253-63). A high c-Myc, high BCL2, and low BCL6 identifies patients with high-risk disease even in the low-risk IPI group. Specifically, if the patient has a sum score of 1 or more, he will have an inferior survival despite the low-risk IPI; in such a case, I recommend dose-adjusted EPOCH-R x6. If the score is 0, R-CHOP x6 would be safe.
Daniele Mattei, MD
Santa Croce Hospital
I would likely treat with a dose-adjusted EPOCH-R regimen. I would consider at least doing initial CSF analysis with flow cytometry as well. I would also ask for a radiation oncology opinion.
Mary E. Sheffield, MD
UAB Medicine Russell Medical Cancer Center
Alexander City, AL
I agree with the decision as presented. The c-Myc positivity contrasts with the limited nature of the disease.
Elias Anaissie, MD
What about BCL2 or BCL6 status? If positive, I recommend dose-adjusted EPOCH-R, otherwise R-CHOP.
Semra Paydas, MD
R-CHOP x4 plus radiation therapy and autograft while typing his sibs.
Luen Bik To, MD
Royal Adelaide Hospital