Is Dose-adjusted EPOCH-R Enough in Burkitt Lymphoma?

A diagnosis of Burkitt lymphoma (BL) typically causes a fair bit of anxiety for affected patients and their providers. But with appropriate therapy, the proportion of patients cured is quite high; in fact, higher than other aggressive B-cell lymphomas. The problem is getting there. Historically, the regimens considered acceptable for BL included R-hyper-CVAD (rituximab with hyper cyclophosphamide, vincristine, adriamycin, and dexamethasone) with alternating R-cytarabine/methotrexate; CODOX-M (cyclophosphamide, vincristine, doxorubicin, high-dose methotrexate) with alternating IVAC (ifosfamide, etoposide, high-dose cytarabine), or “Magrath”; and the “modified” Magrath regimen. The modified Magrath regimen is a spin-off of the original, with some key dose modifications to improve tolerability in adults. Even with these modifications, the regimen is a significant challenge to administer to patients older than 40 years, as is hyper-CVAD, which is really a childhood acute lymphoblastic leukemia regimen. With this in mind, investigators from the National Cancer Institute tested the dose-adjusted (DA) EPOCH-R (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab) regimen in adult patients with BL and reported highly encouraging results.¹  As with any single-institution study, however, patient selection issues may bias results. With that in mind, these investigators conducted a multicenter trial (22 sites) testing the DA-EPOCH-R regimen in adults with BL.

One hundred thirteen patients were enrolled, with a median age of 49 years (range, 18-86 years). The treatment plan was tailored to the patient’s risk category (Figure 1). Patients with low-risk disease could receive as little as three cycles of therapy with no central nervous system (CNS) –directed therapy. With a median follow up of 59 months, the event-free survival for the whole population is 85 percent. When analyzing by risk category, 100 percent of the low-risk patients (n=15) and 82 percent of the high-risk patients were cured (n=98; Figure 2). The toxicities were typical for the EPOCH-R regimen, and 4 percent of patients died during therapy due to treatment toxicity. Patients with either CNS involvement or bone marrow involvement (n=29) did decidedly less well, with cure rates arounds 60 percent.