Transcript Journal reading

Diffuse large B cell lymphoma in
elderly patients(>80 years old)
British Journal of Haematology, 2012, 157, 159–170
Annals of Oncology 23: 1280–1286, 2012
R4 簡聖軒
指導老師: 蕭樑材大夫
Characteristic in elderly patient
 Evaluation of elderly patient
 Prognostic factor
 Treatment strategy

圖1. 歷年0歲平均餘命及死亡率
0歲平均餘命
(歲)
100年國人零歲平均餘命，男性為76.0歲，女性為82.7歲
每十萬人口
死亡率

80
79.2 79.2 9
810.2
76
74.5
72.0
655.5
72
625.3
647.7
6
68
554.6
462.4
479.7
455.6
64
60
3
70
71
72
73
74
75
76
77
78
79
80
平均餘命
81
82
83
84
85
86
粗死亡率
87
88
89
90
91
92
標準化死亡率
93
94
95
96
97
98
99 100年
圖2.死亡人數年齡結構比
100%
100年65歲以上死亡數占全體死亡數之68.5%
12.9
25.7
37.2 38.3
80%
34.0
60%
38.8
31.3 30.2
40%
53.1
20%
35.5
31.5 31.5
0%
70
71
72
73
74
75
76
77
78
79
80
0-64 歲
81
82
83
84
85
86
65-79 歲
87
88
89
90
91
92
80 歲以上
93
94
95
96
97
98
99 100年
公開類
年 報
編製機關
每年終了第3年4月底前填報
表
號
行政院衛生署國民健康局
1631-08-01
十大惡性腫瘤申報發生人數及發生率
中華民國 97 年
總
順 位
國際疾病分類
腫瘤學代碼
ICD-O-3
計
男
發生率
部 位
發生人數
(每10萬人口)
(C00～C80)
單位：人
國際疾病分類腫
瘤學代碼ICD-O3
性
女
發生率
部 位
發生人數
國際疾病分
類腫瘤學代
碼ICD-O-3
性
發生率
部 位
發生人數
(每10萬人
(C00～C80)
口)
(C00～C80)
(每10萬人
口)
C22
肝及肝內
膽管
7,401
63.66
C50
女性乳房
8,136
71.30
47.77
C18-C21
結腸及直
腸
6,277
53.99
C18-C21
結腸及直
腸
4,727
41.43
10,565
45.86
C33,C34
肺、支氣
管及氣管
6,194
53.28
C33,C34
肺、支氣
管及氣管
3,322
29.11
肺、支氣
管及氣管
9,516
41.31
C00-C06,C09,
C10,C12-C14
口腔、口
咽及下咽
5,349
46.01
C22
肝及肝內
膽管
3,164
27.73
攝護腺
3,603
30.99 (2)
C61
攝護腺
3,603
30.99
C53
子宮頸
1,725
15.12
口腔、口
咽及下咽
5,781
25.09
C16
胃
2,303
19.81
C73
甲狀腺
1,561
13.68
C16
胃
3,578
15.53
C15
食道
1,849
15.90
C54
子宮體
1,424
12.48
8
C53
子宮頸
1,725
15.12 (1)
C67
膀胱
1,476
12.70
C16
胃
1,275
11.17
9
C54
子宮體
1,424
12.48 (1)
C44
皮膚
1,380
11.87
C44
皮膚
1,205
10.56
10
C44
皮膚
2,585
11.22
C11
鼻咽
1,162
9.99
卵巢、輸
卵管及寬
韌帶
1,110
9.73
45,171
388.52
34,647
303.64
1
C50
女性乳房
8,136
2
C18-C21
結腸及直
腸
11,004
3
C22
肝及肝內
膽管
4
C33,C34
5
C61
6
C00-C06,C09,
C10,C12-C14
7
全癌症
79,818
71.30 (1)
346.48
全癌症
C56,C57.0C57.4
全癌症
公開類
年
報
編製機關
每年終了第3年4月底前填報
表
行政院衛生署國民健康局
號
1631-08-01
十大惡性腫瘤申報發生人數及發生率
中華民國
總
順
位
國際疾病分類
腫瘤學代碼
ICD-O-3
位
發生人數
(每10萬人口)
(C00～C80)
女性乳房
單位：人
男
發生率
部
98 年
計
國際疾病分類
腫瘤學代碼
ICD-O-3
性
女
發生率
部
位
發生人數
(C00～C80)
國際疾病分類
腫瘤學代碼
ICD-O-3
(每10萬人口)
(C00～C80)
C22
肝及肝內膽
管
7,747
66.57
C50
54.01
C18-C21
結腸及直腸
7,151
61.45
11,080
47.92
C33,C34
肺、支氣管
及氣管
6,737
10,643
46.03
C00-C06,C09,
C10,C12-C14
口腔、口咽
及下咽
1
C50
2
C18-C21
結腸及直腸
12,488
3
C22
肝及肝內膽
管
4
C33,C34
肺、支氣管
及氣管
5
C61
6
C00-C06,C09,
C10,C12-C14
7
8,926
77.73 (1)
性
發生率
部
位
發生人數
(每10萬人口)
女性乳房
8,926
77.73
C18-C21
結腸及直腸
5,337
46.48
57.89
C33,C34
肺、支氣管
及氣管
3,906
34.02
5,927
50.93
C22
肝及肝內膽
管
3,333
29.03
攝護腺
4,013
34.49 (2)
C61
攝護腺
4,013
34.49
C73
甲狀腺
1,846
16.08
口腔、口咽
及下咽
6,480
28.03
C16
胃
2,404
20.66
C53
子宮頸
1,796
15.64
C16
胃
3,848
16.64
C15
食道
1,898
16.31
C54
子宮體
1,496
13.03
8
C53
子宮頸
1,796
15.64 (1)
C44
皮膚
1,589
13.66
C16
胃
1,444
12.58
9
C54
子宮體
1,496
13.03 (1)
C67
膀胱
1,419
12.19
C44
皮膚
1,339
11.66
10
C44
皮膚
2,928
12.66
非何杰金氏
淋巴瘤
1,205
10.36
C56,C57.0-C57.4
卵巢、輸卵
管及寬韌帶
1,113
9.69
87,189
377.12
49,022
########
38,167
########
全癌症
M959-976
全癌症
全癌症
Multiple co-morbid illness
 Decreased portal/renal perfusion flow
 Altered pharmacokinetics
 Decreased bone marrow hematopioetic reserve
 Poor compliance and tolerance
 Exclude in clinical trial, no available guideline

NHL 3 hematology centers
Israel
1984-2004
age 80 years or older at diagnosis.
Annals of Oncology 17: 928–934, 2006
Annals of Oncology 17: 928–934, 2006
Annals of Oncology
17: 928–934, 2006
Aggressive lymphoma increase with age,
especially in patient age > 85 years
 Complete response : 50 %,
 In aggressive lymphoma, short survival
median survival : 18 months
3 year survival rate: 35%

Prognostic parameter: IPI and PS
 Aggressive chemotherapy had a significantly
longer median survival than no or mild therapy
 For with aggressive lymphoma, age alone should
not be a contraindication for treatment

Five regional Dutch cancer registries
From 1997-2004 (N:419)
After adjustment other variable, age and
performance was independently associated with
receiving CHOP like chemotherapy
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Grade 3-4 toxicity occurred in 67 % in CHOP
like therapy , 40 % in milder regimen
Age
75-79
80-85
>85
Toxicity
62%
73%
85 %
Tx
>6 CHOP like
<6CHOP like
Sub-optiamal
CR
67
29
11
Recurrence
38
33
63
Mean time
from diagnosis
to recurence
20 months
16 months
16
Tx
>6 CHOP
like
<6CHOP
like
Suboptiamal
Nil
5 yr
survivial
38
22
12
4
After correction aaIPI, The effect of therapy (in four
subgroups) was independently associated with survival
N Engl J Med 2002; 346:235-242
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60 - 80 years of age with diffise large B cell lymphoma ,
randomization mainly in France
stage II, III, or IV disease
ECOG of 0 to 2 (good to fair)
No history of indolent lymphoma
central nervous system involvement,
active cancer
Excluded if cardiac contraindication to doxorubicin
therapy
Excluded neurologic contraindication to vincristine
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G-CSF in grade 4 neutropenia
C+H decreased 50 % in > 2 x grade 4 neutropenia
C+H decreased 50 % Grade 3- 4 thrombocytopenia
If neutrophil < 1500 or platelet < 10000, hold Tx
If hold Tx > 2 wks, DC treatment plan
The doses of rituximab were not modified, but rituximab
was discontinued when CHOP was stopped.
Treatment was stopped if lymphoma progressed
Lancet Oncol 2011; 12: 460–68
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Prospective, multicentre, single-arm, phase 2 study
GELA ran the study in 38 centers in France and Belgium
Age > 80 years with diffuse large B-cell lymphoma. ECOG< 2
Rituximab + CHOP (R-miniCHOP) at 3-week intervals.
375 mg/m2 rituximab,
400 mg/m2 cyclophosphamide,
25 mg/m2 doxorubicin,
1 mg vincristine
40 mg/m2 prednisone on days 1–5.
G-CSF or erythropoietin support was left to the
discretion of the treating physician.
 Recommend G-CSF SC used on day 6-day13 if
severe neutropenic fever until neutrophil >1000
 Hold theray if neutrophil < 1000, if neutophil
still < 1000 for more than 28 days, treatment
DC
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108/149 complete 6 X R-miniCHOP
Median survival was 21 months
2 year prgoression free survival 47%
58 death report:
33 lymphoma progression
12 toxicities of treatment
Most frequently side effeict : hematological toxicity
>3 grade neutropenia : 59
Febrile neutropenia : 11
Median overall survival was 29 months
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29 months median survival
62% complete response rate (CR+uCR)
The only parameter associated with poor outcome
is low serum albumin
Death from toxicity in previous study: 9%-23%,
but 5 death in first cycle in this study
Despite absence of a control arm. This study
suggest selected patient older than 80 years with
DLBCL in good performance, R-miniCHOP is
considered
Treatment in very elderly patient is no more
rare pratice
 As age increased, aggressive lymphoma is more
popular
 Adequate evaluation is essential for treatment
decision, suitable for elderly tool
 Performance, LDH, albumin are most import
prognostic factor

Age would not be contraindication for therapy
 Median survival: 18-20 months and complete
response: 50 % in treatment population
 Treatment with Rituximab and reduced dose of
chemotherapy would be acceptable strategy
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Thanks