Diffuse Large B Cell Lymphoma in Very Elderly Patients
Authors: Dhakal Ajay , Gohari Pouyan , Floudas Charalampos , Neupane Sanjay , Chandra Abhinav B 
Published: October 2019

Abstract
Background:
Incidence of Diffuse Large B-Cell Lymphoma (DLBCL), one of the most common lymphoid malignancies worldwide, increases with age. With improving life expectancy, its incidence among the elderly population is predicted to rise further. Elderly patients pose unique challenges- multiple co-morbidities, variable life expectancy, poor social support systems, and increased risk of therapy-related toxicity. Management decisions in geriatric patients are usually based on data obtained in younger patients. R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisone) is the standard chemotherapy for younger patients with DLBCL. Unfortunately, among the patients aged 80 or more, data on the use of R-CHOP and its comparison with other treatment regimens are meager. Also, new data on alternate chemotherapy regimens including R with Bendamustine (R-Benda) and R with low dose CHOP (R-miniCHOP) are emerging. Thus, there is a need for development and validation of treatment strategies for DLBCL in this patient population. Objective of this study is to provide a descriptive data including co-morbidity profile, chemotherapy regimen offered, tolerance of chemotherapy, and outcome of the treatment among the DLBCL patients aged 80 or more.
Methodology:
A retrospective chart review of 33 DLBCL patients (N) aged 80 or more treated in the last 4 years in a tertiary community hospital.
Results:
Table 1 Age Charlson Co-morbidity Index (CCI) Serum Lactate Dehydrogenase Serum Albumin Serum Beta2 Microglobulin Median Ki67 Valid N 33 30 23 24 9 11 Mean 83.33 2.87 611.91 2.85 6.77 0.70 Median 83.00 2.00 302 2.95 4.85 0.75 Standard Deviation 5.50 1.94 1033.15 0.78 5.79 0.19 Minimum 69 0 84 1.60 1.90 0.40 Maximum 93 9 5038 4.20 19.70 0.95
Table 2 ECOG Performance Score International Prognostic Index (IPI) BMI Hemoglobin Platelets WBC ANC Valid N 25 16 8 31 30 31 28 Mean 2.16 2.56 25.70 11.58 240.73 8.73 5971 Median 2.00 3.00 25.95 11.60 201 8.20 5400 Standard Deviation 1.17 1.03 2.910 1.94 129.64 3.47 2935 Minimum 0 1 20.98 8.20 62 3.60 1400 Maximum 4 4 29.40 15.10 716 16.10 12800
Table 3 Valid N Categories Percentage Sex 33 Male Female 54.5 45.5 Prior Malignancy 33 No Yes 81.8 18.2 Ann Arbor Staging 22 1 2 3 4 22.7 18.2 22.7 36.4 B symptoms 29 No Yes 62.1 37.9 Node Status 33 Nodal Extranodal Nodal and Extranodal 6.1 42.4 51.5 Chemotherapy offered 28 No Yes 17.9 82.1 Intent of Therapy 20 Curative Palliative 85 15 Chemotherapy regimen 22 R-miniCHOP R R-Bendamustine R-CHOP RCVP RCNOP 22.7 9 18.18 36.36 9 4.54 Adverse effect of Chemotherapy 16 No Yes 18.75 81.25 Hospital admission during Chemotherapy 19 No Yes 47.36 52.63 Growth factors required during Chemotherapy 20 No Yes 25 75 Dose delay 17 No Yes 70.58 29.42 Dose modification 17 No Yes 64.70 35.29 Chemotherapy stopped prior to completion 18 No Yes 66.67 33.33 Radiation therapy 19 No Yes 52.63 47.36 Result of chemotherapy 15 Complete Response (CR) Partial Response (PR)Progression 40 40 20 Relapse 7 No Yes 57.14 42.85 Death 10 No Yes 20 80
ANOVA was used for data analysis. A statistically significant difference in mean CCI between those who completed planned chemotherapy course (2.00) and those who did not (4.75) was observed (p= 0.017). Similarly, difference in the mean CCI among those achieving CR (2.00), PR (2.17) and Progression (7.00) was statistically significant (p= 0.005). There were significant differences in the mean pre-chemotherapy ECOG PS between those who completed planned chemotherapy course (1.27) vs. those who did not (2.75), (p= 0. 001) and those achieving CR (1.60), PR (1.00) and progression (3.00), (p=0.012). No significant association was found between CCI or pre-chemotherapy ECOG PS with various factors like type of chemotherapy offered, incidence of adverse effects, and dose delay/modification.
Conclusion:
Very elderly patients (≥80 years) with DLBCL having good ECOG PS or lower CCI are more likely to complete planned chemotherapy course and achieve remission. CCI might be a good marker for evaluation of co-morbidities in very elderly patients and could serve as a predictive tool for patient outcomes. We intend to analyze data of DLBCL patients aged 65 – 79 years and perform comparative study with existing cohort.

Disclosures
No relevant conflicts of interest to declare.