How to treat a patient with c-Myc positive diffuse large B-Cell lymphoma?

Here’s how readers responded to a You Make the Call question about a patient with c-Myc positive diffuse large B-cell lymphoma.

Disclaimer: ASH does not recommend or endorse any specific tests, physicians, products, procedures, or opinions, and disclaims any representation, warranty, or guaranty as to the same. Reliance on any information provided in this article is solely at your own risk.

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
Milan, Italy

R-CHOP x6.

Martha Arellano, MD
Winship Cancer Institute
Atlanta, GA

R-EPOCH x6.

Robert K. Stuart, MD
Medical University of South Carolina
Charleston, SC

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
UCLA Health
Los Angeles, CA

R-CHOP x6.

Cesar M. Campo, MD
Santa Fe, Argentina

Dose-adjusted EPOCH-R.

Indu Sabnani, MD
Maplewood, NJ

I would be sure this is not double-hit lymphoma. If not, R-CHOP will do.

Achiel Van Hoof, MD
General Hospital St-Jan
Brugge, Belgium

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
Cuneo, Italy

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
UC Health
Cincinnati, OH

What about BCL2 or BCL6 status? If positive, I recommend dose-adjusted EPOCH-R, otherwise R-CHOP.

Semra Paydas, MD
Cukurova University
Adana, Turkey

R-CHOP x4 plus radiation therapy and autograft while typing his sibs.

Luen Bik To, MD
Royal Adelaide Hospital
Adelaide, Australia