I have a 39 yr old male ECOG 0 with pmh of HTN, HLD who presented with progressive left inguinal LN swelling since early 2022. S/P U/S guided core biopsy with path report high-grade B-cell lymphoma Ki-67 80%. FISH: positive for gain of BCL-6 and BCL2 [not re-arranagement]. Polysomy 8 including gain [not re-arrangement] of MYC and "gain or re-arranagement" of IgG. Negative for translocations for (8;14) and (14;18) Echo normal EF. LDH WNL's. CBC normal. PET/CT showed: Right groin LN 4 cm with SUV max 29/9 and separate right external LN 1.5 cm SUV 25.7. No other evidence of disease. BM Biopsy negative. Wanted to ask: 1. would you label this to be a double expressor DLBCL? 2. How would you treat? 3 cycles of R-CHOP followed by re-staging PET/CT? 3. Based on re-staging PET/CT results how would you decide how many additional cycles of treatment vs. consolidative radiation?
MYC/BCL2/BCL6 gains are not well understood as with DHL. They do not have their own WHO classification or designation. Data have not confirmed the poor prognostic nature of those so I treat them as NON DHL. Also, in stage 2 disease, even DHL have not shown to have worse prognosis. In this particular case I would treat the patient with 3 cycles of RCHOP followed by radiation. While the SWOG trial showed that you can consider 3 cycles of RCHOP followed by iPET and if negative can give one more cycle for a total of 4, it was a single arm study. So for a young patient with a field of low risk for radiation complications (inguinal region), I think going with the more proven route of rchop x3 followed by radiation is better.
