I have a patient in 60s, good PS, with rapidly enlarging bilateral cervical LAD and mediastinal LAD , suv 25 on recent PET scan, size roughly 5 cm in conglomerate of LN in neck, presenting uric acid of 9, with mild pancytopenia, bm involvement 5% by lymphoma. CD 5 and cd 10 negative, b cell lymphoma, high ki67 on core biopsy from cervical node , 11,14 negative on fish , waiting for excisional biopsy from cervical LN. In this kind of scenario, is it advisable to start empiric treatment with RCHOP while inpatient or wait for full results of biospy to make sure it is not double hit or some other aggressive b cell lymphoma? Also if there is mild cytopenia with wbc of 2k with neutrophil of 1.2k and platelet about 75, during 1st cycle of chemo , do we need to dose reduce based on pancytopenia or do the full dose?
If the excisional cervical LN biopsy was done and you are waiting on results you could give dexamethasone 40 mg daily for 4 days for palliation until the results are back. If the patient needs chemo urgently you could give R-CHOP and then change to dose adjusted R-EPOCH for the second and subsequent cycles if it turns out to be double-hit lymphoma. You could start with mini-R-CHOP given the low counts and then escalate to full dose if counts improve with subsequent cycles
