Managing Relapsed DLBCL

Cyrus Khan, MD, reviews the management of DLBCL after relapse on frontline therapy.

John Leonard, MD: Cyrus, I want to now move back to more standard diffuse large B-cell lymphoma [DLBCL] and systemic scenario. For much of the rest of our time we’re going to focus on relapse patients. I think we have covered the upfront setting pretty well. What is your take on the data of how many patients…what percent of patients relapse in your practice? And obviously we have referral centers and particularly if you’re doing transplant, you’re going to see a decent proportion of the relapse patients finding their way to you. But how do you approach a patient with large cell lymphoma typically speaking as far as prognosticating for them? And then in a minute I’ll ask you, Loretta, your take on second-line therapy for some of these groups. Cyrus, what’s your view of this second-line population?

Cyrus Khan, MD: Sure. Naturally as you mentioned at the beginning you get about 60% of the patients with a cure. Sixty to seventy percent rather. And then you’d be left with about 30% to 40% of the patients who either relapse or be refractory. Obviously, most of those patients are going to be in that 2-year window after completion of frontline chemotherapy. What I do, of course, what all of us do generally is a re-biopsy and then other things can happen. We can confuse it with sarcoidosis or other carcinomas. I’ve certainly seen other issues crop up concerning a relapse setting. Once that happens and depending on what kind of workup the patient had in the past, I might do further studies to really look at whether it’s an active B-cell subtype, center subtype, whether it’s double or triple previously called. Then we hone in on what are the prognostic markers for those patients. We don’t do it yet, but I know that genetic profiling has looked at previous subsets among active B-cell subtype to look at whether there’s MYD88 mutation or whether there is CARD11 mutation. Whether there’s mutation in those, have prognostic bends, and now we have novel treatments that can be used in those settings. More appropriate for later lines of therapy, obviously. Once we establish a relapse patient then obviously one wants to look at whether the patient is transplant eligible or ineligible. Obviously, the standard of care is to go for an autologous transplant after salvage chemotherapy. If the patient is eligible that’s our standard approach. Usually RISE or the standard of care as far as salvage patients are concerned. The CR [complete response] or close to CR, that patient would go on for autologous transplant. If the patient is ineligible for an autologous transplant, then either a clinical trial or, to be honest, I am looking at CAR T [chimeric antigen receptor T-cell therapy] now in a second-line setting, providing that the patient is ineligible for an autologous transplant for a variety of reasons. Just because of age or comorbidities that the patients would be excluded from auto transplant does not mean that they would be excluded from going for CAR T. Certainly a viable option for those patients.


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