Dose adjusted R-EPOCH and other etoposide-containing regimens in first-line treatment of diffuse large B-cell lymphoma

Abstract

Etoposide is a well-known cytotoxic agent effective in the treatment of B-large cell lymphoma (B-LCL). Currently, there is no consensus regarding the place of etoposide-containing regimens (R-CHOEP, R-ACVBP and DA-R-EPOCH) in front-line treatment of B-LCL. This paper summarizes published data and our own experience regarding the activity and toxicity of these regimens, especially DA-R-EPOCH. Most non-randomized, real-life and retrospective studies suggest that, compared to R-CHOP, DA-R-EPOCH, similarly to other etoposide-containing regimens, has superior antitumor efficacy but is also more toxic. The most important severe side-effects are hematological and infectious, making the regimen unfeasible in unfit patients. However, in fit patients with high-risk features, progression-free survival rates seem improved by 15–20% compared to R-CHOP. In our series of high-risk [age-adjusted International Prognostic Index (aaIPI) 2–3] fit [Eastern Cooperative Oncology Group (ECOG) performance status 0–2]) B-LCL patients older than 60 treated with DA-R-EPOCH, PFS at 2 years was 70%, while it was 53% in a comparable historical cohort treated with R-CHOP. DA-R-EPOCH resulted in more hematological and infectious toxicity, but no treatment-related mortality. In our opinion, DA-R-EPOCH should be considered in newly diagnosed, fit, high-risk patients with B-LCL who are older than 60, provided that there is adequate outpatient supervision, supportive care, and prompt hospital admittance in case of neutropenic fever or other severe toxicities.