You Make the Call
Each month in “ You Make the Call ,” we ’ ll pick a challenging clinical question submitted through ASH ’ s Consult a Colleague program and post the expert ’ s response , but we also want to know what you would do . Send in your responses to next month ’ s clinical dilemma and see how your answer matches up to the experts ’ in the next print issue .
This month , Carol Portlock , MD , discusses neurologic toxicity following R-CHOP ( rituximab , cyclophosphamide , doxorubicin , vincristine , prednisone ).
TRAINING and EDUCATION
Clinical Dilemma :
A 73-year-old woman has stage III diffuse large B-cell lymphoma . I did not do a bone marrow biopsy , but she had a normal LP and normal brain MRI . She has had two courses of R-CHOP with a great response . However , she has developed pronounced short-term memory loss . She can no longer care for herself and does not remember events from the previous hour . Is this chemo brain ? If so , what regimen would be safe to use ?
Expert Opinion
Carol S . Portlock , MD Attending Lymphoma Service Department of Medicine Memorial Sloan Kettering Cancer Center New York , NY
“ Chemo brain ” is a diagnosis of exclusion . The information provided in the clinical description , though limited , implies that the patient had no relevant preexisting medical history of significance and that no clear etiology could be identified for the onset of memory loss ( negative LP and brain MRI ).
R-CHOP is a standard regimen rarely associated with such devastating toxicity . Etiologies to consider would be progressive multifocal leukoencephalopathy , which is recognized as a rare complication of rituximab therapy , or some other viral / infectious disease ( HIV or cytomegalovirus ) that might emerge during therapy and can present with dementia .
In older patients , steroid withdrawal and vincristine toxicity can cause excess fatigue , orthostatic hypotension , etc ., which can cause memory loss without invoking transient ischemic attack or cerebrovascular accident . A simple way to handle steroid withdrawal is to add hydrocortisone maintenance between cycles ( 20 mg in the morning and 10 mg at night ), and a simple way to address vincristine toxicity is to keep the dosing low or discontinue if warranted . Cardiovascular disease is a well-recognized complication of R-CHOP in older patients . Another rare cause of memory problems or confusion is hyponatremia from either cyclophosphamide / syndrome of inappropriate antidiuretic hormone or , more commonly , from hyperglycemia in the setting of steroid use .
Whatever the etiology , it is a medical necessity to define the cause , if possible , and to treat it accordingly . Based on the information provided , it is hard to justify continuing R-CHOP until an etiology is identified and improved . Two cycles of R-CHOP are most likely insufficient to result in a curative outcome , but continuing therapy in this devastating scenario may only precipitate more neurologic toxicity .
REFERENCES
• Hua Q1 , Zhu Y , Liu H . Severe and fatal adverse events risk associated with rituximab addition to B-cell non-Hodgkin ’ s lymphoma ( B-NHL ) chemotherapy : a meta-analysis . J Chemother . 2015 ; 27:365-70 .
• Sarkozy C , Coiffier B . Diffuse large B-cell lymphoma in the elderly : a review of potential difficulties . Clin Cancer Res . 2013 ; 19:1660-9 .
• Coiffier B , Thieblemont C , Van Den Neste E , et al . Long-term outcome of patients in the LNH-98.5 trial , the first randomized study comparing rituximab-CHOP to standard CHOP chemotherapy in DLBCL patients : a study by the Groupe d ’ Etudes des Lymphomes de l ’ Adulte . Blood . 2010 ; 116:2040-5 .
Next Month ’ s Clinical Dilemma :
An otherwise fit 92-year-old who presented with pancytopenia was diagnosed with Philadelphia chromosome negative B-cell acute lymphocytic leukemia . I am worried about using anthracyclinebased chemotherapy because of his age . I am considering vincristine plus prednisone ( lowintensity therapy ). However , would you consider alternative therapies ( i . e ., inotuzumab ozogamicin or blinatumomab ) in the upfront setting ?
How would you respond ? Email us at ashclinicalnews @ hematology . org . ●
Consult a Colleague Through ASH
Consult a Colleague is a service for ASH members that helps facilitate the exchange of information between hematologists and their peers . ASH members can seek consultation on clinical cases from qualified experts in 11 categories :
• Anemias
• Hematopoietic cell transplantation
• Hemoglobinopathies
• Hemostasis / thrombosis
• Lymphomas
• Lymphoproliferative disorders
• Leukemias
• Multiple myeloma & Waldenström macroglobulinemia
• Myeloproliferative disorders
• Myelodysplastic syndromes
• Thrombocytopenias
Assigned volunteers (“ colleagues ”) will respond to inquiries within two business days ( either by email or phone ).
Have a puzzling clinical dilemma ? Submit a question , and read more about Consult a Colleague volunteers at hematology . org / Clinicians / Consult . aspx or scan the QR code .
* If you have a request related to a hematologic disorder not listed here , please email your recommendation to ashconsult @ hematology . org so it can be considered for addition in the future .
DISCLAIMER : ASH does not recommend or endorse any specific tests , physicians , products , procedures , or opinions , and disclaims any representation , warranty , or guaranty as to the same . Reliance on any information provided in this article is solely at your own risk .
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