ESMO guidelines for treatment of elderly patients with malignant lymphomas

This is a European Society for Medical Oncology (ESMO) review of the treatment guidelines for elderly patients with malignant lymphoma. 

The treatment for elderly patients (aged 70 or older) must be carefully adjusted to reduce side effects while still being effective. Many elderly patients may not be able to tolerate the same intensity of treatment as younger patients. 

The EMSO gathered a group of 25 experts to determine the best treatment options for elderly patients with malignant lymphoma. Malignant lymphoma includes diffuse large B-cell lymphoma (DLBCL), peripheral T-cell lymphoma (PTCL), mantle cell lymphoma (MCL), follicular lymphoma (FL), and chronic lymphocytic leukemia (CLL).

Before beginning treatment, all elderly patients should have a “geriatric assessment”. These assessments ensure that patients are getting the right kind of treatment. Quality of life should also be a factor.

Chronic lymphocytic leukemia: After being diagnosed, CLL patients should be tested for gene mutations Del(17p) and TP53mut. Mutations in these genes lead to different treatment strategies.

For fit older patients, low-dose FCR (fludarabine, cyclophosphamide, rituximab) or BR (bendamustine plus rituximab) are recommended. For more vulnerable older patients, chlorambucil in combination with obinutuzumab (G-CLB), ofatumumab (O-CLB), or rituximab (R-CLB) is recommended. Low-dose FCR or BR may be effective for more vulnerable patients as well.

Patients with Del(17p) or TP53mut mutations should be treated with ibrutinib. Ibrutinib or idelalisib plus rituximab are effective treatments for patients with relapsed CLL.

Follicular lymphoma: For patients without symptoms, a watch-and-wait strategy is recommended. Chemotherapy is not recommended in elderly patients with mild symptoms. Rituximab as a single agent is recommended for patients with mild symptoms. Patients with more severe symptoms or a higher tumor burden should be treated with BR.

Patients with relapsed FL should be treated with R-CVP (rituximab plus cyclophosphamide, vincristine, prednisone) or other rituximab plus chemotherapy combinations. Idelalisib is also an option, but the side effects may be significant.

Mantle cell lymphoma: R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, prednisone) is considered the standard first line treatment for fit elderly patients. Patients can also be treated with BR, VR-CAP (rituximab, plus cyclophosphamide, doxorubicin, bortezomib, prednisone) or R-BAC (rituximab plus bendamustine, cytarabine).

Elderly vulnerable patients are recommended to be treated with lower doses of chemotherapy treatments, including BR, R-CVP, or R-CLB. For patients with relapsed MCL, ibrutinib, lenalidomide, temsirolimus, and bortezomib have been shown to be effective.

Peripheral T-cell lymphoma: The first line standard of care for elderly patients is CHOP chemotherapy. For patients with relapsed PTCL, gemcitabine or platinum-containing agents are recommended. Brentuximab has shown to be effective. It is strongly recommended that all PTCL patients seek to be enrolled in a clinical trial if possible.

Diffuse large B-cell lymphoma: R-CHOP is considered the standard of care for first line treatment in elderly patients. For patients older than 80, a lower dose of R-CHOP is recommended.

An autologous stem cell transplantation (auto-SCT; using stem cells from the patient’s own body) following high-dose chemotherapy is recommended for eligible patients with relapsed DLBCL. For patients who cannot receive an auto-SCT, R-DHAP (rituximab plus etoposide, methylprednisolone, cytarabine, cisplatin), R-ESHAP (rituximab plus gemcitabine, dexamethasone, cisplatin), or R-ICE (rituximab plus ifosfamide, carboplatin, etoposide) chemotherapy are recommended. Treatment with R-Gem-Ox (rituximab, gemcitabine, oxaliplatin), bendamustine, and pixantrone have also been effective.

This study reviewed the recent ESMO guidelines for the treatment of elderly patients with malignant lymphomas. 

Not every patient will meet the criteria for “standard” treatment. Your doctor may recommend a different treatment based on your individual situation.