Etoposide e dexametasona como primeira linha em idosos com comorbidades portadores de Linfoma Difuso de Grandes Células B

Abstract

A third of non-Hodgkin lymphoma (NHL) patients are diagnosed at over 75 years of age and the predominance of the Diffuse Large B-cell Lymphoma (DLBCL) sub-type is found in 40% of the cases. 1 In spite of this, the number of aged patients in clinical trials is rather small with the median age being about 50 years old. Three DLBCL patients, including one suffering from a severe heart comorbidity, who were treated with an alternative oral chemotherapeutic regimen at the Hematology Service of HC-FMUSP are described. Case 1An 86-year-old woman with dilated myocardiopathy taking digitals, with 40% ejection fraction measured by echocardiography, history of several hospitalizations due to heart complications was referred to the Hematology Service of the HC-FMSP and diagnosed as DLBCL, ECIIB with low intermediate IPI. Therapy used etoposide (50 mg/day) for 5 days plus dexamethasone (20 mg/day) for 5 days during 6 cycles. After the 2 nd cycle the patient presented with complete remission but did not suffer from clinical toxicity during the treatment. Complete remission was maintained to the last evaluation with overall survival and disease-free survival rates of 35.1 and 31.9 months, respectively. The patient died of heart failure. Case 2A 90-year-old female Jehovah's Witness, with no pathological records, was referred to the Hematology Service of the HC-FMSP and diagnosed as DLBCL, Ki 67 ranging from 80 to 90%, ECIIx A, (bulky cervical tumor of 15 cm) with low intermediate IPI. Prescribed treatment involved etoposide (100 mg/day) for 21 days and dexamethasone (20 mg/day) for 7 days, although 250 mg/day for 8 days was incorrectly used. The patient evolved to Grade 3 non-febrile neutropenia with no clinical evidence of infection, which was reverted by using GCSF, obtaining a 60% mass tumor reduction soon after the 1 st cycle. After the 2 nd cycle the patient achieved complete remission and was submitted to 3 cycles in total when, in a joint decision, consolidation with radiotherapy was chosen. Complete remission was kept up to the last evaluation, with overall survival and diseasefree survival rates of 39.4 and 38.2 months, respectively.Case 3 A 94-year-old woman was referred the Hematology Service of the HC-FMUSP and diagnosed as DLBCL, EC IIIsxA (x = bulky cervical tumor of 13 cm) with high risk IPI. Treatment was started using etoposide (50 mg/day) and dexamethasone (12 mg/day) in both alternate and continuous schemes. She achieved complete remission after the 4 th cycle, with a total of 8 cycles being performed. She kept complete remission up to the last evaluation with overall survival and disease-free survival rates of 20.3 and 17.1, respectively.In Brazil 49.9% of deaths among over 65-year-old patients are with malignant tumors proving to be the third most common cause of death in this group. Data from IBGE (Brazilian Institute of Geography and Statistics) show an increase in the aged population from the current 7.8% to 13% by 2020. An increased life expectancy will thus require clinical trials directed at the elder...