Primary mediastinal B-cell lymphoma

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Untreated

DA-R-EPOCH

DA-R-EPOCH: Dose Adjusted Rituximab, Etoposide, Prednisone, Oncovin, Cyclophosphamide, Hydroxydaunorubicin

Regimen, Dunleavy et al. 2013

Phase II

• Rituximab (Rituxan) 375 mg/m2 IV over 3 hours once on day 1
• Etoposide (Vepesid) 50 mg/m2/day IV continuous infusion over 96 hours on days 1 to 4 (total dose per cycle: 200 mg/m2)
• Prednisone (Sterapred) 60 mg/m2 PO BID on days 1 to 5
• Vincristine (Oncovin) 0.4 mg/m2/day IV continuous infusion over 96 hours on days 1 to 4 (total dose per cycle: 1.6 mg/m2; dose was not capped)
• Cyclophosphamide (Cytoxan) 750 mg/m2 IV over 2 hours once on day 5
• Doxorubicin (Adriamycin) 10 mg/m2/day IV continuous infusion over 96 hours on days 1 to 4 (total dose per cycle: 40 mg/m2)

Supportive medications:

• Filgrastim (Neupogen) 300 mcg SQ once per day, starting on day 6 and continuing until ANC >5,000/uL past nadir
• Trimethoprim/Sulfamethoxazole (Bactrim DS) 160/800 mg (or equivalent if allergic) PO once per day on 3 days per week
  • Note: It's assumed this is what the supplement for Dunleavy et al. 2013 meant by "Baxtrim (sulphametoxazole and trimethoprim)"
• Omeprazole (Prilosec) 20 mg (or equivalent) PO once per day
• Docusate (Colace) (dose not specified) and Sennosides (Senna) 2 tablets PO BID as needed for constipation
• Lactulose 20 g PO Q6H as needed for constipation
• Hepatitis B surface antigen positive patients received daily antiviral therapy until 8 weeks after completion of chemotherapy

21-day cycles x 6 to 8 cycles

Dose adjustments:

• Start cycle 1 as described above.
• Obtain CBCs twice per week for nadir measurements.
• If nadir ANC >500, increase etoposide, doxorubicin, and cyclophosphamide by one level (20%) compared to previous cycle.
• If nadir ANC <500, use same doses as last cycle.
• If nadir platelet count <25,000, decrease etoposide, doxorubicin, and cyclophosphamide by 20% compared to the previous cycle.

References

1. Dunleavy K, Pittaluga S, Maeda LS, Advani R, Chen CC, Hessler J, Steinberg SM, Grant C, Wright G, Varma G, Staudt LM, Jaffe ES, Wilson WH. Dose-adjusted EPOCH-rituximab therapy in primary mediastinal B-cell lymphoma. N Engl J Med. 2013 Apr 11;368(15):1408-16. link to original article link to supplementary appendix contains verified protocol PubMed