TRAINING and EDUCATION
You Make the Call
Each month in “You Make the Call,” we’ll pick a challenging clinical question submitted through ASH’s Consult a Colleague
program and post the expert’s response, but we also want to know what you would do. Send in your responses to next month’s
clinical dilemma and see how your answer matches up to the experts’ in the next print issue.
This month, David Straus, MD, discusses treatment options for a patient with c-Myc positive diffuse large B-cell lymphoma.
Clinical Dilemma:
A 54-year-old previously healthy male with recent abdominal pain had a computed tomography (CT) scan that showed
a 5 cm mesenteric mass. The CT core biopsy revealed diffuse large B-cell lymphoma of the germinal center B-cell
phenotype that was c-Myc positive. A positron emission tomography scan showed this to be the only site of disease and
the bone marrow is negative. Would you recommend R-CHOP x6 or x3-4 with radiation? Or a different regimen given
the c-Myc positivity?
Consult a Colleague
Through ASH
Expert Opinion
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:
David Straus, MD
Internist and Hematologic Oncologist
Memorial Sloan Kettering Cancer Center
New York, New York
• Anemias
This is probably a high-grade diffuse
large B-cell lymphoma. I would
obtain fluorescence in situ hybrid-
ization to see if there is a c-Myc
translocation as well as c-Myc over-
expression by immunohistochemis-
try. Researchers from the National
Cancer Institute (NCI) reported
promising early results with dose-
adjusted EPOCH-R for treatment of
patients with aggressive B-cell lym-
phomas with MYC-rearrangement
at the 2014 ASH Annual Meeting. 1
This is being explored further in
an NCI Cancer Therapy Evaluation
Program clinical trial. 2 If his lactate
dehydrogenase is normal, he may be
eligible for short course treatment
with three cycles of RR-EPOCH-R.
These regimens are described in the
New England Journal of Medicine
manuscript on Burkitt lymphoma
treatment. 3
• 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.
References
1. Dunleavy K, Fanale M, LaCasce A, et al. Preliminary report
of a multicenter prospective phase II study of DA-EPOCH-R
in MYC-rearranged aggressive B-cell lymphoma. Blood.
2014;124:395.
2. ClinicalTrials.gov. Phase II study of dose-adjusted EPOCH-
rituximab in adults with untreated Burkitt lymphoma and
c-MYC+ diffuse large B-Cell lymphoma (NCT01092182).
3. Dunleavy K, Pittaluga S, and Shovlin M, et al. Low-intensity
therapy in adults with Burkitt’s lymphoma. N Engl J Med.
2013;369:1915-25.
Next Month’s Clinical Dilemma:
A 30-year-old man with aplastic anemia presented with
rapidly progressive exercise intolerance over a 2-week
period. White blood cell (WBC) count is 2.2×10 9 /L with
an absolute neutrophil count of 450/μL. Hemoglobin is
5.5 g/dl, and platelet count is 3,000/μL. Lactate de-
hydrogenase is 180/μL and erythrocyte sedimentation
rate is 89 mm/hr. Kidney and liver function is normal. A
bone marrow (BM) biopsy shows scant lymphocytes and
BM stromal cells. Hematopoietic elements are virtually
absent. No signs of paroxysmal nocturnal hemoglobinuria
36
ASH Clinical News
by flow cytometry. The patient refuses packed red blood
cells or platelet transfusions for religious reasons. We
have started immunosuppressive treatment with anti-
thymocyte globulin, steroids, and cyclosporine. Since
the patient does not wish to receive transfusions, BM
transplant is probably out of the question. Do you think
it is reasonable to add erythropoietin, eltrombopag, or
granulocyte colony-stimulating factor upfront? Is there
anything else I am not thinking about?
How would you respond? Email us at ashclinicalnews@
hematology.org. ●
*If you have a request related to a
hematologic disorder not listed here,
please email your recommendation to
[email protected] so it can be
considered for addition in the future.
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.
July 2017 Bonus Mid-Year Edition