In a nutshell
The author describes his treatment approach to “double hit” lymphoma. The author concludes that patients with “double hit” lymphoma should be treated aggressively with high intensity treatment.
Some background
A new category of diffuse large b-cell lymphoma (DLBCL) was classified in 2016. This type of DLBCL involved abnormalities at the myc and bcl-2 or bcl-6 genes. This type of DLBCL is referred to as “double hit” lymphoma (DHL). DHL can only be diagnosed with advanced genetic testing, called fluorescence in situ hybridization (FISH) testing.
Patients with DHL have poor outcomes when treated with standard chemotherapy compared to patients with DLBCL. Previous retrospective studies have suggested that aggressive treatments are more effective. More research is needed about effective treatments for DHL.
Methods & findings
This study looks at the evaluation and treatment of DHL.
Evaluation: Patients should undergo routine tests and scans to establish baseline measurements of brain, heart, kidney, and liver function. The author suggests that patients with DHL should have a baseline lumbar puncture (spinal tap) as well. The author does not perform regular brain scans unless patients show neurological symptoms.
Treatment: Patients with DLBCL are commonly treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone). DHL is often treated with R-EPOCH (rituximab, etoposide phosphate, prednisone, vincristine, cyclophosphamide, and doxorubicin). The author recommends treatment with R-EPOCH. This chemotherapy combination is well-tolerated in patients under the age of 80. The author also suggests four cycles of methotrexate (Trexall or Rheumatrex Dose pack) for patients at higher risk for neurological involvement. Patients who already show nervous system involvement are often treated more aggressively.
Patients who are older than 80 or have other medical conditions may not be able to tolerate R-EPOCH. The author recommended the use of lower intensity chemotherapy combinations.
Future clinical trials are planned to evaluate the effectiveness of R-EPOCH and other chemotherapy regimens for the treatment of DHL. It is also recommended that patients with relapsed DHL join a clinical trial of new treatments. Trials are examining the use of targeted therapies and the use of CAR-T cells. Targeted therapies are treatments that block the activity of proteins involved in cancer growth. CAR-T cells make use of the immune system to fight the cancer cells. T-cells are removed from the blood and are then genetically modified in a laboratory to produce CAR. CAR is a protein that helps the T-cells recognize cancer cells as something to attack. The CAR-T cells are reintroduced into the patient and will then attack cancer cells.
The bottom line
The author concluded that DHL should be treated much more aggressively than DLBCL. More research is needed to determine the effectiveness of current and newer treatments.
The fine print
This study is one doctor’s expert opinion on diagnosis and treatment of “Double Hit” lymphoma. It may not be representative of the full range of options for treatment, and may not match the expert opinions shared by other physicians.
What’s next?
If you or a family member has been diagnosed with diffuse large B-cell lymphoma and are not responding well to initial chemotherapy treatment, consider talking to your doctor about advanced genetic testing (FISH or other) to identify whether the cancer is a high grade B-cell lymphoma with translocations involving myc and bcl-2 or bcl-6 genes (“double hit” lymphoma).
