You Made the Call
TRAINING and EDUCATION
You Make the Call
We asked , and you answered ! Here are a few responses from this month ’ s “ You Make the Call .”
For the full description of the clinical dilemma , and to see how the expert responded , turn to page 82 .
Clinical Dilemma :
I treated a young man with follicular lymphoma with four cycles of bendamustine / rituximab . He developed prolonged neutropenia ( presumed rituximab associated ) that lasted eight months . He now has diffuse large B-cell lymphoma . Would you restart rituximab as part of a new chemotherapy regimen ?
I would use rituximab retreatment and combine with ifosfamide , carboplatin , and etoposide , and try to reach an autologous bone marrow transplant .
Steven Fein , MD Baptist Health South Florida
Coral Gables , FL
Each month in “ You Make the Call ,” we ’ ll pick a challenging clinical question submitted through the Consult-a-Colleague program and post the expert ’ s response . But , what would YOU do ? We ’ ll also pose a submitted question and ask you to send your responses . See how your answer matches up to the experts in the next print issue .
This month , Arnold S . Freedman , MD , answers a question about restarting rituximab as part of a new chemotherapy regimen for a patient with diffuse large B-cell lymphoma ( DLBCL ).
Clinical Dilemma :
In 2012 , I treated a young man with follicular lymphoma with four cycles of bendamustine / rituximab . He developed prolonged neutropenia ( presumed rituximab associated ) that lasted eight months . He now has diffuse large B-cell lymphoma ( DLBCL ). Would you restart rituximab as part of a new chemotherapy regimen ? Is he at higher risk for recurrence of rituximab-associated neutropenia ?
Experts Make the Call
Arnold S . Freedman , MD Professor of Medicine Harvard Medical School ; Department of Medical Oncology Dana-Farber Cancer Institute Boston , MA
I would suspect that bendamustine is more likely the cause of the neutropenia . I would perform a bone marrow biopsy and send for cytogenetics . I think you have to use R-CHOP at this time for the DLBCL . IV IgG anecdotally helps reverse the neutropenia of rituximab .
ADDITIONAL RESOURCE
Saikia TK , Menon H , Advani SH . Prolonged neutropenia following anti CD20 therapy in a patient with relapsed follicular non-Hodgkin ’ s lymphoma and corrected with IVIG . Ann Oncol . 2001 Oct ; 12:1493-4 .
DISCLAIMER : ASH does not recommend or endorse any specific tests , physicians , products , procedures , or opinions , and disclaims any representation , warranty , or guaranty as to the same . Reliance on any information provided in this article is solely at your own risk .
Next Month ’ s Clinical Dilemma : A 31-year-old female , who had a recent miscarriage at six weeks of pregnancy , was participating in boot camp . She developed sudden onset left arm pain and numbness and was found to have brachial and axillary artery thromboses . She underwent an emergent thrombectomy . She was noted to have a dual brachial system , and a subacute thrombus was removed . An ECHO was negative for cardiac thrombus or defect . Her angiogram
Consult a Colleague Through ASH
Consult a Colleague is a service for ASH members that helps facilitate the exchange of information between hematologists and their peers . ASH members can seek consultation on clinical cases from qualified experts in 11 categories :
• Anemias
• Hematopoietic cell transplantation
• Hemoglobinopathies
• Hemostasis / thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“ colleagues ”) will respond to inquiries within two business days ( either by email or phone ).
Have a puzzling clinical dilemma ? Submit a question , and read more about Consult-a-Colleague volunteers at hematology . org / Clinicians / Consult . aspx or scan the QR code .
See more reader responses at ashclinicalnews . org / category / trainingeducation / you-make-the-call .
* If you have a request related to a hematologic disorder not listed here , please email your recommendation to ashconsult @ hematology . org so it can be considered for addition in the future . was negative for stenosis or dissection . A hypercoaguable workup was negative . The patient was placed on rivaroxaban ; she wants to conceive again as soon as she can . How long should she continue anticoagulation , and any recommendations regarding pregnancy ?
How would you respond ? Email us at ashclinicalnews @ hematology . org .
82 ASH Clinical News December 2016
Yes , he should get rituximab . His prolonged neutropenia is more likely due to the previous bendamustine than the rituximab , and I don ’ t think his risk will be increased much , if at all , if re-treated with rituximab in this scenario .
Kristie A . Blum , MD The Ohio State University Comprehensive Cancer Center Arthur G . James Cancer Hospital and Richard J . Solove Research Institute
Columbus , OH
MARKEY CANCER CENTER
Regarding the neutropenia , I believe it ’ s most likely due to bendamustine , not rituximab , which can cause prolonged lymphopenia . Therefore , I would indeed restart rituximab as part of the new chemo regimen .
A . Richard Adrouny , MD San Jose , CA
The prolonged neutropenia was more likely from the bendamustine , not the rituximab . I would have no hesitation in using rituximab again . Unlike bendamustine , rituximab is not a stem cell poison .
In a region where cancer is at its worst , it takes bold action to make a difference . That ’ s why the University of Kentucky Markey Cancer Center has set an ambitious goal : significantly reduce cancer incidence and mortality in our state , and the Appalachian region , by 2020 . With the momentum we ’ re building , we believe MARKEY CAN do it .
Follow our journey at ukhealthcare . com / lesscancer
Steve Perkins , MD Texas Oncology
Dallas , TX
We reported , as an abstract , our experience with close to two dozen cases of rituximab neutropenia . Several patients received rituximab again ( a couple again and again ), and every patient relapsed ( generally about 90 days ). I am not aware of whether or not there would be cross-reactivity of this reaction with other anti-CD20 antibodies , but I suspect there would be .
Larry Rice , MD Houston Methodist
Houston , TX
ASHClinicalNews . org