TRAINING and EDUCATION
You Make the Call
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, Jane Winter, MD, talks about how she would treat a young patient
with a rare composite lymphoma diagnosis.
Clinical Dilemma:
I have an 18-year-old female patient who presented with syncope. A comprehensive workup showed a bulky right
lung mass invading into the right atrium with an intra-atrial mass, as well as liver and kidney lesions. She also has
severe vena cava syndrome due to the mass. A lung biopsy was performed; it showed “composite lymphoma with
primary mediastinal lymphoma and focal involvement of classical Hodgkin lymphoma.” The pathology report
was also reviewed by physicians at the National Institutes of Health who confirmed the diagnosis.
We started her on DA-EPOCH-R, and she finished the first cycle last week. I wanted to get your thoughts
about the treatment of this rare entity and also any recommendations.
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
Experts Make the Call
Jane N. Winter, MD
Professor of Medicine
Feinberg School of Medicine, Robert H.
Lurie Comprehensive Cancer Center
Northwestern University
Division of Hematology/Oncology
Chicago, IL
What a challenging case! Whereas primary mediastinal
B-cell lymphoma (PMBCL) and Hodgkin lymphoma share
many features and are biologically similar, I agree with your
strategy of DA-EPOCH-R. It has been shown to be effective
therapy in PMBCL as well as in grey zone lymphomas,
part of the spectrum of disease to which your case belongs.
Although there aren’t published data on this regimen in
classical Hodgkin lymphoma, given its activity in grey zone
lymphomas and PMBCL, I am hopeful it will be effective
for your patient. CNS prophylaxis will be important because of the many extranodal sites and renal involvement.
It’s always problematic to combine CNS prophylaxis with
• Lymphoproliferative disorders
• Leukemias
DA-EPOCH-R, and it generally comes down to IT methotrexate (MTX) with each cycle, although the risk of parenchymal brain disease persists. I’ve contemplated adding a
few cycles of high-dose MTX at 3.5 gm/m2 at the completion of therapy or after achievement of a remission, but I
haven’t yet pursued that strategy. There is the concern that
integrating high-dose methotrexate with DA-EPOCH-R
could compromise the “dose adjustments,” if it is scheduled
on day 15 as we do when combining it with R-CHOP.
If you do achieve a CR based on PET/CT after three or
four cycles, I’d strongly consider integrating some highdose MTX at some point.
Expert’s Note: A group from the Department of Lymphoma/Myeloma at MD Anderson published a letter to the
editor giving mid-cycle high-dose methotrexate in a small
number of patients with secondary CNS involvement (Chihara D, Fowler NH, Oki Y, et al. Dose-adjusted EPOCH-R
and mid-cycle high dose methotrexate for patients with
systemic lymphoma and secondary CNS involvement. Br J
Haematol. 2016 August 9. [Epub ahead of print]).
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 45-year-old woman presented with a
painful 11 cm ovarian mass. It was surgically resected and found to be a myeloid
sarcoma. Several surrounding lymph
nodes were noted to contain similar
ASHClinicalNews.org
findings. A bone marrow biopsy was
negative for acute myeloid leukemia.
Cytogenetics and molecular markers
were not obtained due to tissue fixation. The patient has completed chemotherapy with standard daunarubicin/
cytarabine and has pancytopenia. A
bone marrow biopsy was repeated and
remains normal. How do I follow/assess
this patient’s response? What treatment should I give after induction?
• Multiple myeloma & Waldenström
macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned vo