Treatment of diffuse large B-cell lymphoma in elderly patients: Replacing doxorubicin with either epirubicin or etoposide (VP-16)

Diffuse large B-cell lymphoma (DLBCL) is the most common type of lymphoma. The standard therapy for DLBCL is R-CHOP. The current 5-year overall survival is 60% to 70% using standard frontline therapy. However, the use of doxorubicin and its cardiotoxicity is a major clinical problem and preexisting cardiac disease may prevent the use of doxorubicin. Age greater than 65years is a significant risk factor for anthracycline-induced cardiotoxicity, and therefore, the use of R-CHOP is often withheld from elderly patients. The feasibility of replacing doxorubicin with either epirubicin or etoposide in patients who have risk factors for heart complications is analyzed here. Clinical data of 223 DLBCL patients were retrospectively collected from hospital records. Fifty-five patients were treated with R-CHOP, 105 with R-CIOP (epirubicin instead of doxorubicin), 17 with R-CEOP (etoposide instead of doxorubicin), and 31 with R-CHOEP. Matched-pair analysis was carried out between 30 patients treated with R-CEOP and R-CHOP. For all patients, the 2-year progression-free survival (PFS) was 73.6%. In patients treated with R-CHOP, the 2-year PFS was 84.2%, with R-CIOP 64.4%, with R-CEOP 87.7%, and with R-CHOEP 83.2%. In matched-pair analysis, the 2-year PFS was 92.3% with R-CHOP and 86.2% with R-CEOP. The 2-year disease specific survival was 100% with R-CHOP and 86.2% with R-CEOP. In conclusion, R-CEOP offers reasonable PFS and disease specific survival in the treatment of DLBCL and good disease control can be achieved in elderly patients. Elderly patients with impaired cardiac function could benefit from the use of R-CEOP instead of R-CHOP. The results with R-CIOP were unsatisfactory, and we do not recommend using this protocol in elderly patients with cardiac disease.