Edited excerpt from the discussion:

DR DRULLINSKY: I evaluated an 80-year-old woman who presented with vaginal bleeding. She went to see her gynecologist and was found to have endometrial hyperplasia. Incidentally, massive retroperitoneal adenopathy was noted. The largest nodal mass was 22 centimeters in diameter. Physical examination revealed a two-centimeter right axillary lymph node. She had many other medical problems, including severe peripheral vascular disease, coronary artery disease, hypertension and an anxiety disorder.

A staging CAT scan revealed small mediastinal lymph nodes, but most of the disease was in the abdomen. Bone marrow biopsy was negative, but immediately after the biopsy, she developed chest pain and was admitted to the hospital. Cardiac catheterization revealed mild coronary artery disease but it did not require emergency therapy.

Biopsy of the lymph node revealed a Grade I follicular lymphoma that was positive for CD20, CD10 and Bcl-2, negative for Bcl-1, and focally staining for Bcl-6. Her LDH and CBC were normal.

DR SMITH: I would want to leave this lady alone. She has a low grade lymphoma and presented incidentally with vaginal bleeding, which is presumably unrelated. Despite the size of her retroperitoneal nodes, the first question is always how much harm you’re going to do with any treatment.

So what are your choices? You could give her single-agent rituximab or an oral alkylator and some steroids. Chlorambucil/prednisone is not a bad treatment for an 80-year-old patient. I can think of the usual laundry list of things, but in patients who are as frail as this woman, my first decision is: Do I need to treat? And I don’t see any indication that she must be treated right away. You could wait a couple of months and see if it’s clearly progressing. I would probably start with an oral alkylater and prednisone to keep her in check as long as possible.

DR KAPLAN: I’m reluctant to leave a large retroperitoneal mass alone because the next thing you’ve got is either edema of one of the legs, which won’t go away, or renal shutdown. I think if you split the dose of rituximab and give her lots of premedication you’re not going to wind up with a lot of reaction, and you’ll probably achieve a better response than you would with an alkylating agent and prednisone.

DR SMITH: You have to make that decision based on the individual patient, and if I were going to administer rituximab, I would give her a small dose on day one and then the rest of the dose. I would certainly use premedication. Even a low grade lymphoma can be pretty large without causing a lot of the problems you mentioned. Obviously, I’m more comfortable if the mass seems to be pushing the arteries out of the way than if it’s encasing them.

If you repeat the scan in three months and the mass is bigger, you’re not going to be able to watch and wait, but at this point, you don’t know how long it has been growing. But I share your concern. This is not someone I’d say, “Come back in a year and we’ll see how you’re doing.” I think you have to monitor her closely for those problems.

Again, it’s always a balance with toxicity, but in the absence of any clear need to treat right away, I like to get a sense of the pace of a disease.

DR RADER: What’s her cardiac status?

DR DRULLINSKY: I think anxiety was more the cause of the atypical chest pain. Maybe it was false confidence, but after the cardiac catheterization, I felt that although she had coronary artery disease, it wasn’t left main disease and I didn’t think she was about to infarct.

DR LOVE: How did you end up treating this patient?

DR DRULLINSKY: I work in Long Island at a big hospital, and we have a disproportionate number of elderly patients. In our weekly meetings, we discuss the fact that in the main research centers, patients are 40 to 50 years old. We have 80-year-old patients, yet they want aggressive therapy.

This patient appeared younger than her actual age. We decided to treat her with rituximab/CVP (1.1) and up-front pegfilgrastim. She completed all six cycles, and the only complication was severe bone pain from the pegfilgrastim. She has had complete resolution of all adenopathy.

Where I work, people tend to want aggressive therapy. Patients are living longer and longer, into their eighties and nineties, and sometimes it’s difficult to determine how much therapy someone that age can tolerate. Treating 80- and 90-year-old patients can be anxiety provoking, but sometimes I’m surprised — especially in the new era with growth factor support. I’m just amazed at what you can do with pegfilgrastim and how well patients tolerate therapy.

DR L FARBER: I use a lot of pegfilgrastim — a lot of growth factors in general — but CVP is not a regimen I would automatically put in the category of requiring these. I just wonder if she could have gotten away without the pegfilgrastim. In an elderly person, I may start out with a reduced dose of cyclophosphamide and work my way up.

DR LEONARD: This treatment regimen is certainly reasonable and justifiable and it worked well. Part of this is the art of oncology — evaluating the patient and giving something a try. There will be times we will look at a patient and say, “This patient will do fine,” and often get surprised. Some people tolerate chemotherapy much better than others. I have treated elderly patients who tolerated R-CHOP, and other patients who said, “Don’t bother to do it.” I’ve also had patients whom I thought were going to tolerate chemotherapy but they didn’t because of the toxicities.

We’re not perfect and a lot of this is trial and error. You have to choose a treatment that agrees with your judgment and the patient’s wishes. If it works, just stick with it. In this case, it worked, but sometimes it doesn’t and you have to cut back. If she had not tolerated the CVP, you could have eliminated that and given her rituximab, or cut back to the oral alkylater with or without rituximab.

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