Postsplenectomy Therapy in Diffuse Large B-cell Lymphoma?

Joseph A. Sparano, MD

Disclosures

December 11, 2001

Question

What is the best treatment for a 51-year-old woman with diffuse large B-cell lymphoma of the spleen who underwent splenectomy? There was no other localization of disease.

Response from Joseph A. Sparano, MD

Although the spleen is commonly involved in non-Hodgkin's lymphoma, primary splenic diffuse large B-cell lymphoma is an unusual presentation of diffuse large B-cell lymphoma. There are few clues in the literature regarding how to approach this problem.

Kraus and colleagues[1] reviewed the medical records of 1280 patients who underwent splenectomy for therapy (44%), staging (20%), or diagnosis (9%) of disease, or for other reasons incidental to another procedure (26%). Lymphoid proliferations were present in 200 cases; the most common diagnoses included small lymphocytic lymphoma (28%), diffuse large B-cell lymphoma (21%), follicular center cell lymphoma (10%), and marginal zone lymphoma (7%). More important, diffuse large B-cell lymphoma was the most common lymphoma to go undiagnosed until the time of surgery.

Although the study provided no information regarding the natural history of splenic lymphoma, it indicates that primary splenic diffuse large cell lymphoma is one of the more common lymphomas to be confined to the spleen at the time of diagnosis. The most common presentation was splenic masses.

Miller and colleagues[2] reported 1 of the few randomized trials that evaluated early-state intermediate-grade lymphoma. Four hundred and one eligible patients with stage I or II intermediate- or high-grade non-Hodgkin's lymphoma were randomized to receive either 8 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or 3 cycles of CHOP followed by involved field irradiation. The median age was 59 years; 67% of patients had stage I disease, 75% had large cell or immunoblastic histology, and 90% to 95% had low- or low-to-intermediate-risk disease as classified by the International Prognostic Index. It is noteworthy that approximately 30% of patients in each group were rendered disease-free by the diagnostic biopsy prior to the initiation of therapy, a situation analogous to a patient with primary splenic diffuse large B-cell lymphoma diagnosed at splenectomy. The estimated 5-year progression-free survival was 77% for combined modality therapy vs 64% for CHOP alone, giving some indication of the prognosis expected for the patient in question if treated with CHOP alone.

Therefore, although there is little information upon which to base a firm conclusion, 6-8 cycles of "adjuvant" CHOP would seem to be a reasonable alternative. The role of irradiation to the splenic bed and regional nodes in this setting is unknown.

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