Dr. Pagel on Determining Treatment Based on Genetic Risk in Double- and Triple-Hit Lymphoma

John M. Pagel, MD, PhD, chief of the Hematologic Malignancies Program, and director of the Hematopoietic Cell Transplantation Program at Swedish Cancer Institute in Seattle, Washington, discusses the utility of rituximab (Rituxan) with etoposide, doxorubicin, cyclophosphamide, vincristine, and prednisone (R-EPOCH) in double- and triple-hit lymphoma.

A variety of up-front regimens have been examined in DLBCL, says Pagel. Most recently, investigators have examined dose-adjusted R-EPOCH in this patient population. While the regimen plays a significant role in the treatment of patients with primary mediastinal diffuse large B-cell lymphoma, the standard of care for the vast majority of patients is still frontline rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), according to Pagel.

Patients do poorly because of genetic risk, particularly those who have double-hit or triple-hit lymphoma, adds Pagel. As such, genetic risk factors should be screened for. The FISH test, for example, looks for gene rearrangements between the MYC gene, BCL-2, or BCL-6, says Pagel. If these gene rearrangements are identified, the disease is often determined to be a very aggressive large cell lymphoma. A regimen of dose-adjusted R-EPOCH may be an appropriate approach for those patients, according to Pagel. A patient who has double- or triple-hit lymphoma without those gene rearrangements but an overexpression of those genesis determined to have intermediate-risk disease and as such, is often treated with R-CHOP, concludes Pagel.