Patient is a 45 y/o female, ECOG PS 0, with no pmh, presents with diffuse lymphadenopathy and B-symptoms positive. Core needle biopsy showed High-grade B-cell lymphoma, Ki67 90%. FISH showed Gain of BCL2 or chromosome 18/18q, and Gain of BCL6 or chromosome 3/3q. No DH/TH. PET/CT was very concerning: disease is extensive. Right submandibular region / FOM intense mass, SUV max 23.4. Additional Deauville 5 right neck levels 2-4 involvement. Bilateral Deauville 5 mediastinal and hilar nodal involvement. Bilateral pulmonary involvement up to Deauville 5. Borderline splenomegaly. Bilateral Deauville 5 adnexal region lesions. Deauville 5 bilateral conglomerate retroperitoneal nodal involvement. Nonspecific moderate diffuse bone marrow activity. BMBx is pending path. My question is: with that kind of extensive disease and high Ki67 of 90%, would you still consider DA-R-EPOCH rather than R-CHOP? She is young with excellent performance status. Lastly, I think that patient will require IT chemo prophylaxis due to extra nodal involvement.
For a younger patient like her, if the clinical suspicion is high for HGBCL as a clinical phenotype then I would recommend REPOCH over RCHOP. We routinely use this approach as younger people tend to tolerate REPOCH better. Regarding CNS prophylaxis, none of our approaches have shown to be of benefit. Therefore many of us lymphoma physicians have completely stopped CNS prophlyaxis unless there is testicular or adrenal involvement. Having said this, if you do wish to proceed with prophylaxis, systemic methotrexate has better brain parenchyma penetration compared to IT. Therefore, this can be done after R_EPOCH x 6 cycles are completed. I do suggest to obtain an interim PET scan prior to cycle 4. If there is reduction of SUVmax > 70% of the most avid lesion then this suggestive of good response. Alternatively, if you have enough tissue, ctDNA by clonoseq is an FDA approved test which you can use to monitor more frequently than PET scans.
Oncologist Follow-up: Would you prefer R-CHOP if lymphoma is non-germinal center (I think I forgot to mention).
NHL Specialist: If non GCB I would treat with R-CHP-Pola. Adding polatuzumab has greater benefit in non GCB.
