Lai N L, Bee P C
Hospital Kuala Lumpur, Department of Medicine, Kuala Lumpur, Malaysia.
Pusat Perubatan Universiti Malaya, Department of Medicine, Kuala Lumpur, Malaysia.
Med J Malaysia. 2025 May;80(3):307-312.
Diffuse large B-cell lymphoma (DLBCL) forms the bulk of non-Hodgkin lymphoma (NHL) cases encountered in clinical practice among the elderly. For the majority of cases of DLBCL, treatment comprising of Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone (R-CHOP) is suggested as first line chemotherapy. However, chemotherapy in the elderly population may be hampered by multiple factors, including reduced bone marrow reserves, significant comorbidities, and greater side effects from chemotherapy. Treatment as such aims to offer disease control and prolong life whilst minimising treatment related complications in this group of patients. Treatment with R-mini-CHOP, a reduced dose form of R-CHOP offers survival benefits and is recommended for treatment of elderly DLBCL patients and those who are frail. Our study examined local Malaysian experience of treating the newly diagnosed elderly DLBCL patient with R-mini- CHOP.
We retrieved retrospective data of all DLBCL patients aged >65 years old from the electronic medical records in Pusat Perubatan Universiti Malaya who received R-mini-CHOP. Treatment response was assessed by the overall response rate (ORR), defined as the proportion of patients attaining complete and partial remission after six cycles of treatment. We excluded patients with transformed lymphomas and relapsed refractory disease. For secondary analysis, we examined patients' treatment response according to their baseline demographic characteristics, development of complications during therapy as well as their survival in months from diagnosis.
Our study identified 33 patients in the period of January 2017 till June 2023. The mean age of the sample cohort was 78 years old (Range from 66 to 86 years old). Majority of the samples had advanced stage lymphoma at initial diagnosis with n=21/33 (63.6%) having stage III and IV disease. At the end of treatment, one patient did not have assessment scans and hence was excluded from analysis. n=16/32 patients (50.0%) had attained ORR when analysed by intention to treat, n=14/32 (43.7%) attained complete response and n=2/32 (6.25%) attained partial response. When analysed for treatment response, those who attained ORR were more likely to have Stage 1 or 2 disease (p value = 0.028) and had statistically significant increased progression free survival (28.5 vs 5.5 months, p value <0.01) and overall survival (28.5 vs 9.0 months, p value = 0.03) compared to those who did not attain ORR. In terms of treatment associated complications, n=9/32 (28.1%) of patients developed severe infection necessitating hospitalization, n=14/32 (43.7%) developed at least Grade 2 and above cytopenias, and n=13/32 (41.6%) developed some other adverse side effects, most of which were mild to moderate in terms of severity.
The ORR for our patients treated with R-mini- CHOP was lower than other cohorts. We hypothesise that Rmini- CHOP alone may not offer adequate lymphoma control in our sample, especially for treatment of advanced stage DLBCL. Age alone is not an objective assessment of suitability for treatment; therefore, we suggest the use of geriatric prognostication tools to better ascertain patient groups who would benefit from full dose R-CHOP chemotherapy to improve response and survival.
弥漫性大B细胞淋巴瘤（DLBCL）是临床实践中老年人非霍奇金淋巴瘤（NHL）的主要类型。对于大多数DLBCL病例，建议使用利妥昔单抗、环磷酰胺、多柔比星、长春新碱和泼尼松龙（R-CHOP）组成的方案作为一线化疗。然而，老年人群的化疗可能受到多种因素的阻碍，包括骨髓储备减少、严重合并症以及化疗的副作用更大。因此，治疗旨在在控制疾病和延长生命的同时，尽量减少该组患者与治疗相关的并发症。R-mini-CHOP是R-CHOP的减量剂型，其治疗可带来生存益处，推荐用于治疗老年DLBCL患者及身体虚弱者。我们的研究考察了马来西亚当地使用R-mini-CHOP治疗新诊断老年DLBCL患者的经验。
我们从马来亚大学医学中心的电子病历中检索了所有年龄>65岁接受R-mini-CHOP治疗的DLBCL患者的回顾性数据。通过总缓解率（ORR）评估治疗反应，ORR定义为接受六个周期治疗后达到完全缓解和部分缓解的患者比例。我们排除了转化型淋巴瘤和复发难治性疾病患者。为进行二次分析，我们根据患者的基线人口统计学特征、治疗期间并发症的发生情况以及从诊断开始的生存月数来考察患者的治疗反应。
我们的研究确定了2017年1月至2023年6月期间的33例患者。样本队列的平均年龄为78岁（范围为66至86岁）。大多数样本在初诊时为晚期淋巴瘤，n = 21/33（63.6%）为III期和IV期疾病。治疗结束时，1例患者未进行评估扫描，因此被排除在分析之外。按意向性分析，n = 16/32例患者（50.0%）达到ORR，n = 14/32例（43.7%）达到完全缓解，n = 2/32例（6.25%）达到部分缓解。在分析治疗反应时，达到ORR的患者更可能患有I期或II期疾病（p值 = 0.028），与未达到ORR的患者相比，无进展生存期（28.5个月对5.5个月，p值<0.01）和总生存期（28.5个月对9.0个月，p值 = 0.03）有统计学显著增加。在治疗相关并发症方面，n = 9/32例患者（28.1%）发生严重感染需要住院，n = 14/32例（43.7%）发生至少2级及以上血细胞减少，n = 13/32例（41.6%）发生其他一些不良副作用，其中大多数严重程度为轻度至中度。
我们使用R-mini-CHOP治疗的患者的ORR低于其他队列。我们推测，单独使用R-mini-CHOP可能无法在我们的样本中充分控制淋巴瘤，特别是对于晚期DLBCL的治疗。仅年龄不是治疗适用性的客观评估指标；因此，我们建议使用老年预后评估工具，以更好地确定能从全剂量R-CHOP化疗中获益的患者群体，从而改善反应和生存情况。
