Case Study 5

For each question, choose the answer you think is correct. See the end of this page for the answers.

D.G. is an 81-year-old female diagnosed with stage 4a diffuse B-cell lymphoma, scheduled to receive 6 cycles of LYCHOPR.

Weight: 52 kg Height: 159 cm

Lab results (taken 24 hours prior to first treatment)

WBC 6.1
ANC 3.7
Platelets 175
Creatinine 77
Bilirubin 12
AST 23
ALT 31
LDH 110
HBsAg - negative
HBCoreAb - negative

1. Which of the following best describes the doses of LYCHOPR that D.G. should receive for her first cycle?

Cyclophosphamide 855 mg, DOXOrubicin 57 mg, vinCRIStine 2.1 mg, riTUXimab 570 mg, and predniSONE 75 mg PO daily × 5 days
Cyclophosphamide 1140 mg, DOXOrubicin 76 mg, vinCRIStine 2.1 mg, riTUXimab 570 mg, and predniSONE 75 mg PO daily × 5 days
Cyclophosphamide 1290 mg, DOXOrubicin 86 mg, vinCRIStine 2.4 mg, riTUXimab 645 mg, predniSONE 75 mg PO daily × 5 days
Cyclophosphamide 968 mg, DOXOrubicin 65 mg, vinCRIStine 1.8 mg, riTUXimab 483 mg, predniSONE 50 mg PO daily × 5 days

2. D.G. will be receiving the CHOP portion (i.e. cyclophosphamide, DOXOrubicin, vinCRIStine, and predniSONE) of the protocol on a different day than riTUXimab. Which drugs does she have to receive first? How much time can elapse between the CHOP and riTUXimab treatment?

Treatment can be scheduled at the patient’s convenience, as long as CHOP is started on the first day and the predniSONE is taken in the morning before receiving riTUXimab
The CHOP portion should be given on Day 1 and the riTUXimab on Day 2
The CHOP portion should be given on Day 1 and the riTUXimab within 48 hours of Day 1
The CHOP portion should be given on Day 1 and the riTUXimab may be given on Day 1 or Day 2, but no later than 72 hours after CHOP. The patient must start her predniSONE on Day 1, and must make sure a dose of predniSONE is taken on the morning before receiving riTUXimab

3. D.G. should be monitored for hypersensitivity reactions during administration of which of the following drug(s)?

PredniSONE and vinCRIStine
PredniSONE and riTUXimab
VinCRIStine and riTUXimab
RiTUXimab

Answer 1

The correct answer is 1.

Rationale:

Based on the LYCHOPR protocol "Dose Modifications" section, DOXOrubicin and cyclophosphamide doses in Cycle 1 should be reduced to 75% for patients greater than 75 years old. The doses can be escalated to 100% in subsequent cycles, depending on the patient’s tolerance to the reduced dose. Doses are calculated as follows:

Cyclophosphamide dose = 750 mg/m² x 0.75 x 1.52 m²
= 855 mg

DOXOrubicin dose = 50 mg/m² x 0.75 x 1.52 m²
= 57 mg

VinCRIStine dose = 1.4 mg/m² x 1.52 m²
= 2.1 mg

RiTUXimab dose = 375 mg/m² x 1.52 m²
= 570 mg

Prednisone dose = 45 mg/m² x 1.52 m²
= 68.4 mg (rounded to nearest 25 mg = 75 mg) daily x 5 days

Answer 2

The correct answer is 4.

Rationale: The LYCHOPR protocol states that cyclophosphamide, DOXOrubicin, vinCRIStine and predniSONE (the "CHOP" portion of the protocol) are to be given on day 1. RiTUXimab may be given on either day 1 or 2 whenever possible, but no later than 72 hours after "CHOP", with the daily dose of predniSONE taken on the morning of the riTUXimab day (i.e. before the riTUXimab administration).

Answer 3

The correct answer is 4.

Rationale: Under the LYCHOPR protocol "Precautions" section, point 4 indicates the need to monitor for hypersensitivity reactions to both etoposide and riTUXimab. However, this particular patient is receiving riTUXimab and DOXOrubicin, (not etoposide in place of DOXOrubicin), so riTUXimab is the only drug monitored for hypersensitivity. This does not preclude the fact that the patient could have hypersensitivity reactions to the other drugs in this protocol, but a higher percentage of patients react to riTUXimab and thus it is anticipated and monitored for.