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Research Letter |

Combined Treatment With Rituximab and Anthracycline-Containing Chemotherapy for Primary Cutaneous Large B-Cell Lymphomas, Leg Type, in Elderly Patients FREE

Alexis Guyot, MD; Nicolas Ortonne, MD; Laurence Valeyrie-Allanore, MD; Martine Bagot, MD, PhD
Arch Dermatol. 2010;146(1):89-91. doi:10.1001/archdermatol.2009.345.
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Published online

Primary cutaneous large B-cell lymphoma, leg type (PCLBCL,LT), mainly affects the elderly population. Nevertheless, to our knowledge, no specific studies are available on the outcomes in patients 80 years or older. Herein, we aim to evaluate the efficacy and tolerance of a modified R-CHOP regimen (rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisone) in this particular population.

Four patients aged 81 to 96 years (mean age, 91 years) were treated and followed up for PCLBCL,LT. Their general condition in all cases was good prior to treatment, and pretherapeutic echocardiography showed no severe ventricular dysfunction, thus allowing anthracycline therapy. All patients had multiple lesions; the lesions were confined to 1 inferior limb in 3 patients and were disseminated in the fourth case. Whole-body computed tomographic scans showed extracutaneous involvement in only 1 patient, who had a laterotracheal lymphadenopathy. An osteomedullar biopsy was performed in 1 patient, and no medullar involvement was found.

All patients received a modified R-CHOP treatment with reduced doses of the following drugs: doxorubicin, 25 mg/m2; vincristine, 1 mg/m2; and cyclophosphamide, 400 mg/m2. Rituximab and prednisone were given at standard doses (ie, 375 mg/m2 and 40 mg/m2 for 5 days, respectively). A prophylactic injection of pegfilgrastim was administered the day after chemotherapy. Cycles were administered every 3 or 4 weeks.

All patients achieved a partial or complete remission. Three patients experienced severe infections requiring hospitalization. Two patients had congestive heart failure: one had decreased ventricular function and myocardial infarction, and the other experienced worsening of a preexisting chronic atrial fibrillation. None of our patients experienced severe cytopenias, mucitis, or renal or neurologic toxic effects. In 2 cases, the treatment had to be discontinued, and these patients died of adverse effects. The other 2 completed 6 cycles of treatment and at last follow-up (15 and 21 months) remained alive and in complete remission. Clinical data and outcomes are summarized in the Table.

Table Graphic Jump LocationTable Clinical Data and Treatment Outcomes

In the overall population, the outcome of PCLBCL,LT is improved by R-CHOP, which is now considered the standard first-line treatment.1,2 Alternative treatments such as radiotherapy or rituximab as single-agent therapy are proposed only if the condition of the patient does not allow R-CHOP treatment because these regimens have a lower complete response rate and a higher relapse rate.2 Furthermore, radiotherapy is possible only for localized lesions.

Nevertheless, doxorubicin use is limited by cardiac toxic effects, which are known to be more frequent in elderly patients at lower cumulative doses.3 Moreover, elderly patients can have a lower tolerance of other chemotherapy toxic effects such as cytopenias, mucitis, and digestive adverse effects. In clinical practice, a reduction in doses can be made in consideration of the age of the patient, the presence of cardiopathy, and/or a poor general condition. Nevertheless, there is no consensus on the precise indications or amounts for this dose reduction.

In our patients, the doses were reduced based only on the age criterion. While we observed serious infectious and/or cardiac adverse effects in our 3 oldest patients, and 2 patients died of these complications, the other 2 achieved prolonged complete remission.

In our geriatric series, the expected efficacy of the treatment was counterbalanced by a poor tolerance of adverse effects, emphasizing the need for a pretherapeutic comprehensive geriatric assessment, which includes an evaluation of physiologic age, function, comorbidities, and nutritional, social, and economic needs.4 If this assessment shows that the patient is too fragile to receive standard treatment, less aggressive treatments should be discussed, such as radiotherapy or rituximab as single-agent therapy. Liposomal doxorubicin must also be evaluated in this indication.

Further clinical studies are needed to evaluate more precisely the outcomes of dose-reduced anthracycline-containing chemotherapy plus rituximab in elderly patients treated for PCLBCL,LT and to determine accurately its indications with regard to less aggressive treatments in this particular population.

ARTICLE INFORMATION

Correspondence: Dr Guyot, Hôpital Bichat, Service de Dermatologie, 46 rue Henri Huchard, 75877 Paris CEDEX 18, France (alexis.guyot@bch.aphp.fr).

Accepted for Publication: June 10, 2009.

Author Affiliations: Departments of Dermatology (Drs Guyot, Valeyrie-Allanore, and Bagot) and Pathology (Dr Ortonne), Henri-Mondor Hospital, APHP, Créteil, France; and Université Paris XII (Drs Guyot, Valeyrie-Allanore, and Bagot), Créteil.

Author Contributions: All authors had full access to all of the data in the study and take full responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Guyot, Ortonne, Valeyrie-Allanore, and Bagot. Acquisition of data: Guyot, Ortonne, and Bagot. Analysis and interpretation of data: Guyot, Ortonne, Valeyrie-Allanore, and Bagot. Drafting of the manuscript: Guyot, Ortonne, Valeyrie-Allanore, and Bagot. Critical revision of the manuscript for important intellectual content: Bagot. Study supervision: Bagot.

Financial Disclosure: None reported.

Grange  FBeylot-Barry  MCourville  P  et al.  Primary cutaneous diffuse large B-cell lymphoma, leg-type: clinicopathologic features and prognostic analysis in 60 cases. Arch Dermatol 2007;143 (9) 1144- 1150
PubMed
Senff  NJNoordijk  EMKim  YH  et al. European Organization for Research and Treatment of Cancer; International Society for Cutaneous Lymphoma, European Organization for Research and Treatment of Cancer and International Society for Cutaneous Lymphoma consensus recommendations for the management of cutaneous B-cell lymphomas. Blood 2008;112 (5) 1600- 1609
PubMed Link to Article
Swain  SMWhaley  FSEwer  MS Congestive heart failure in patients treated with doxorubicin: a retrospective analysis of three trials. Cancer 2003;97 (11) 2869- 2879
PubMed Link to Article
Balducci  LCohen  HJEngstrom  P  et al. National Comprehensive Cancer Network, Senior adult oncology clinical practice guidelines in oncology. J Natl Compr Canc Netw 2005;3 (4) 572- 590
PubMed

Figures

Tables

Table Graphic Jump LocationTable Clinical Data and Treatment Outcomes

References

Grange  FBeylot-Barry  MCourville  P  et al.  Primary cutaneous diffuse large B-cell lymphoma, leg-type: clinicopathologic features and prognostic analysis in 60 cases. Arch Dermatol 2007;143 (9) 1144- 1150
PubMed
Senff  NJNoordijk  EMKim  YH  et al. European Organization for Research and Treatment of Cancer; International Society for Cutaneous Lymphoma, European Organization for Research and Treatment of Cancer and International Society for Cutaneous Lymphoma consensus recommendations for the management of cutaneous B-cell lymphomas. Blood 2008;112 (5) 1600- 1609
PubMed Link to Article
Swain  SMWhaley  FSEwer  MS Congestive heart failure in patients treated with doxorubicin: a retrospective analysis of three trials. Cancer 2003;97 (11) 2869- 2879
PubMed Link to Article
Balducci  LCohen  HJEngstrom  P  et al. National Comprehensive Cancer Network, Senior adult oncology clinical practice guidelines in oncology. J Natl Compr Canc Netw 2005;3 (4) 572- 590
PubMed

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