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Initial Clinical and Biological Evaluation of Patients and the Disease

Chapter 09 - Diffuse Large B-Cell Lymphoma in the Elderly: R-CHOP or Adapted Strategy?

Disease Evaluation

As for younger patients, the initial staging of the lymphoma includes clinical evaluation, relevant laboratory tests, bone marrow biopsy, positron emission tomography scans (whenever possible) and computed tomography scans. Electrocardiography and echocardiography must be performed to exclude a contraindication to anthracyclines, i.e. a left ventricular ejection fraction (LVEF) < 50%.

The International Prognostic Index (IPI) predicts survival better than the Ann Arbor (AA) staging system. The age adjusted IPI (aaIPI) (table below), a simplified score based on lactate dehydrogenase (LDH), AA stage and ECOG-performance status (PS), has been developed and is now currently used to stratify patients for therapeutic choice.

Age-adjusted IPI score

Age-adjusted International Prognostic Index (IPI)Score5-year relapse-free survival5-year overall survival
Low08683
Low-intermediate16669
High-intermediate25346
High35832

Adverse risk factors for age-adjusted IPI are: stage III or IV disease, elevated LDH, ECOG performance status ≥ 2.

IPI, international prognostic index; LDH, lactate dehydrogenase; ECOG, Eastern Cooperative Oncology Group.

Republished with permission of the American Society of Haematology, from: Sweetenham J. Diffuse Large B-Cell Lymphoma: Risk Stratification and Management of Relapsed Disease. Haematology Am Soc Haematol Educ Program. 2005: 252-259.

Patient Evaluation

Comorbidities should be evaluated using scales such as the Charlson Index or the Cumulative Illness Rating Scale (CIRS-G). Patients presenting with comorbidities are more likely to experience treatment toxicity. Alterations in kidney or liver function and other frequent concomitant medication modify drug pharmacokinetics, Pharmacodynamics and tolerance. Haematopoietic reserve capacity decreases with age and myelotoxicity increases.

Another consequence of aging is the possible alteration of functional capacity, which is a very heterogeneous phenomenon. The comprehensive geriatric assessment (CGA) is a multidimensional scoring process used to estimate the medical, psychological and functional status of older patients. It has been shown to predict survival and tolerance to chemotherapy independently from PS. The instrumental activities of daily living (IADL) and activity of daily living (ADL) scales evaluate the ability to perform the fundamental functions required to allow an individual to live independently in a community setting (termed “instrumental activities of daily living”). Among the alterations associated with aging, nutrition is one of the most important.

The presence of DLBCL is sufficient to alter the functional capacity of elderly patients and chemotherapy with intent to cure (in this case, R-CHOP) is the best way to improve this. It is often difficult to differentiate between alterations in functional capacity arising due to the lymphoma or as a secondary effect of diseases already present in the patient.

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