Use of Rituximab with CHOP Chemotherapy Appears to Overcome Racial Disparities In Survival In Black Patients with Diffuse Large B Cell Lymphoma When Compared to CHOP Chemotherapy Alone.

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 1528-1528
Author(s):  
Uma Borate ◽  
Pareen J Shenoy ◽  
Will Donnellan ◽  
Kevin Bumpers ◽  
Tanyanika Douglas-Holland ◽  
...  
Keyword(s):  
Research Funding ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Chop Chemotherapy ◽  
Multivariate Models ◽  
Large B Cell Lymphoma ◽  
Black Patients ◽  
Younger Age ◽  
Male Sex ◽  
Large B Cell

Abstract Abstract 1528 Background: While black patients (pts) have a lower relative incidence of Diffuse Large B cell lymphoma (DLBCL),previous studies have shown that they tend to present at a younger age, with more advanced stage disease and have inferior 2 year and 5 year relative survival rates (ASH 2007 4430a; ASH 2009 898a). These studies have been limited by small numbers of black pts and by being single institution analyses. We performed a combined retrospective analysis of DLBCL pts treated at Emory & University of Alabama at Birmingham (UAB) to examine demographic, clinical, International Prognostic Index (IPI) score, socioeconomic, and treatment variables to determine their impact on survival in black (B) and white (W) pts. Methods: Clinical, pathology, and pharmacy records were reviewed and 862 pts were identified with DLBCL who were evaluated or received treatment at Emory and UAB from 1981–2010. Baseline demographic data, components of the IPI [age, stage, performance status (PS), LDH, number of extranodal sites (ES)], family history of lymphoma, insurance & employment status, as well as treatment and survival data were extracted. Pts with incomplete treatment and outcomes data or unknown race were excluded (n=87) as were n=157 who received treatments other than CHOP or R-CHOP. The primary outcome was overall survival (OS). Differences in baseline features and treatment category were analyzed using Chi-squared statistical analysis. Univariate & multivariate logistic regression analyses were performed for the entire population and cohorts matched by IPI, age, year of diagnosis and socioeconomic factors, to determine predictors of 2-year and 5-year survival. Results: A total of 618 pts with DLBCL (n=484 W, n=134 B) who received either CHOP (n=249) or R-CHOP (n=369) were included in the present analysis. Univariate analyses demonstrated that age >60 yrs, PS 32, ES32, presence of B symptoms, high LDH, and IPI score 32 but not race were each significantly associated with a poorer survival. In multivariate Cox analysis age >60 (Hazard Ratio (HR) 1.5, 95%CI 1.2–2.9), PS 32 (HR 2.6, 95%CI 2.0–3.5), and male sex (HR 1.2, 95%CI 1.0–1.5) (p=0.047) predicted significantly worse survival. Treatment with R-CHOP was associated with significantly better survival (HR 0.6, 95%CI 0.4–0.9). In multivariate models of pts treated with CHOP, white race was associated with significantly better survival (HR 0.6, 95%CI 0.4–0.9) (see Figure) while IPI scores 3–5 (HR 3.1, 95%CI 1.9–4.9) and male sex (HR 1.5, 95%CI 1.0–2.1) were associated with worse survival. However among pts treated with R-CHOP, IPI scores 3–5 (HR 3.2, 95%CI 1.8–5.7) and Medicaid insurance (HR 2.8, 95%CI 1.4–5.5) but not race or gender was associated with worse survival. In multivariate models of pts treated with CHOP, white race was associated with better survival (HR 0.6, 95% CI 0.4–0.9) while IPI scores 3–5 (HR3.1, 95% CI 1.9–4.9) and male sex (HR1.5, 95%CI 1.0–2.1) were associated with worse survival. Univariate & multivariate analysis of 2-yr OS and 5-yr OS also demonstrated that IPI scores 3–5, and all IPI components individually were associated with significantly worse survival. In both univariate and multivariate analysis, treatment with R-CHOP was associated with significantly better 2-yr (OR 2.9, 95%CI 1.8–4.6) and 5-yr OS (OR 1.8, 95%CI 1.2–2.9) irrespective of race or insurance status. Conclusion: Previous studies looking at racial differences in treatment of DLBCL showed that black pts present at a younger age,with more advanced disease and were less likely to be treated with combined immunochemotherapy. Our combined institutional study with a large cohort of black pts with DLBCL and detailed ascertainment of prognostic factors and therapy showed that treatment with CHOP is significantly associated with inferior survival in black pts. However, treatment with R-CHOP appears to overcome race as a prognostic factor and is associated with significantly improved survival in all pts subgroups irrespective of race and disease status. This suggests that potential biological differences in DLBCL biology may exist between W & B pts that are no longer prognostic with the addition of rituximab, which we are further exploring with DLBCL subtyping and a study of candidate single nucleotide polymorphisms. Disclosures: Flowers: Genentech/Biogen-Idec (unpaid): Consultancy; Celgene, Intellikine: Consultancy; Millennium: Research Funding. Foran:GlaxoSmithKline: Research Funding.

The Outcome of Primary Mediastinal Large B-Cell Lymphoma (PMBCL) in the R-CHOP Treatment Era

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 303-303 ◽  
Author(s):  
Kerry J. Savage ◽  
Paul R. Yenson ◽  
Tamara Shenkier ◽  
Richard Klasa ◽  
Diego Villa ◽  
...  
Keyword(s):  
B Cell ◽  
Fdg Pet ◽  
Research Funding ◽  
Who Classification ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Pet Scan ◽  
Chop Chemotherapy ◽  
Large B Cell Lymphoma ◽  
Large B Cell

Abstract Abstract 303 Background: Primary mediastinal large B-cell lymphoma (PMBCL) was distinguished from DLBCL in the REAL/WHO classification by virtue of distinct clinical and pathologic features. In DLBCL, R-CHOP has demonstrated a clear benefit over CHOP chemotherapy in randomized trials, some of which have included a small subset of PMBCL pts (pts). However, large studies evaluating R-CHOP in PMBCL are lacking. Further, the role of consolidative radiotherapy (RT) to the mediastinum remains unclear particularly with the more frequent use of FDG-PET. At the BCCA, from 2001–2005, R-CHOP with consolidative RT was recommended in all pts with PMBCL. After 2005, FDG-PET scan was used to guide RT usage following 6 cycles of R-CHOP. We evaluated: 1) the outcome of pts with PMBCL in R-CHOP vsCHOP treated pts; 2) prognostic factors in R-CHOP treated pts; 3) the impact of the introduction of PET based approach to guide RT compared to the use routine RT. Methods: Using the BC Cancer Agency Centre for Lymphoid Cancer database, we identified all pts with PMBCL by the REAL/WHO classification treated with R-CHOP in addition to an earlier group treated with CHOP chemotherapy. For R-CHOP treated pts, from 2001–2005, consolidative RT to the mediastinumwas routinely administered following R-CHOP (‘RT’ era). Since 2005, a PET was planned at the end of chemotherapy to guide RT (‘PET’ era). If the PET was negative, pts were observed and if the PET was positive, consolidative RT was given, if feasible. Results: In total, 176 pts were identified: 96 received R-CHOP; 80 received CHOP. Baseline clinical features were similar between the treatment groups. Compared to those treated with CHOP, R-CHOP pts had an improved time to progression (TTP) (5 y 78% vs 65%, p=0.018) and overall survival (OS) (5 y 88% vs 70%, p=0.015). Further, refractory disease (progressive disease (PD) on chemotherapy or relapse < 3 months after treatment completion) was more frequent in CHOP treated pts (16% vs 5%, p=0.016). There was no difference in the risk of central nervous system (CNS) relapse (3.2% vs2.1%, p=0.823). For the R-CHOP treated pts, 46 were treated in the ‘RT era’; 80% received consolidative RT; 50 were treated in the ‘PET era’; 38% received RT. In the RT era, there was a greater proportion of pts with extranodal sites > 1 (p=0.007) and the presence of a pleural/pericardial effusion (p=0.009). In an era to era outcome comparison, there was no difference in the 5 y TTP (RT era 76% vs PET era 83%, p=0.626) or 5 y OS (82% vs 89%, p=0.773). In univariate analysis, the presence of B symptoms was associated with an inferior TTP (5 y 67% vs 90%, p=0.014) and OS (5 y 83% vs 94%, p=0.047). An effusion at diagnosis was associated with an inferior TTP (p=0.017) but not OS (p=0.277). Using recursive partitioning, age > 38 y was identified as the optimal cut-off and was associated with an inferior OS (p=0.003) and there was a trend to a worse TTP (p=0.096). The aaIPI was not predictive of TTP (p=0.357) or OS (p=0.386). In multivariate analysis (including variables with p value<.1 and treatment era), B symptoms (HR 4.3 p=0.011), an effusion (HR 2.97, p=0.025) and age > 38 y (HR 2.98, p=0.025) were associated with an inferior TTP. For OS, age > 38 y (HR 6.7, p=0.003) and B symptoms (HR 4.5, p=0.023) were associated with an inferior outcome. Treatment era (RT vsPET) did not affect TTP or OS in MVA. In total, 59 pts treated with R-CHOP had a PET scan at the end of treatment, 50 in the PET era and 9 pts in the ‘RT era’ by self-pay: 35 (59%) were PET-negative (neg) (2 received RT) and 24(41%) were PET-positive (pos) (23 received RT). With a median follow-up of 5.4 y, there was no difference in the TTP (5 y 78% vs 83%, p=0.735) or OS (5 y 88.5% vs 95%, 0.271) for PET-neg and PET-pos cases, respectively. In total, there were 6 relapses in PET-neg cases: 2 CNS and 4 mediastinal. There were 4 relapses in the PET pos cases (PD in the mediastinum at PET scan n=1; within in RT field n=1; within and outside RT field n=1; outside RT field n=1). Conclusion: We confirm the superior outcome using R-CHOP compared to CHOP chemotherapy in PMBCL, however, rituximab does not appear to impact the rare risk of CNS relapse. The introduction of a PET-guided RT approach in R-CHOP treated PMBCL pts has maintained excellent outcomes in the majority of pts while reducing the use of RT. The presence of B symptoms at diagnosis was associated with an increased risk of relapse and may reflect more aggressive underlying disease biology. Disclosures: Savage: Roche: Research Funding. Klasa:F Hoffmann-La Roche (Roche Canada): Consultancy, Research Funding. Villa:F Hoffmann-La Roche (Roche Canada): Consultancy, Research Funding. Slack:F Hoffmann-La Roche (Roche Canada): Consultancy, Research Funding. Gascoyne:F Hoffmann-La Roche (Roche Canada): Consultancy, Research Funding. Connors:Roche: Research Funding. Sehn:F. Hoffmann-La Roche (Roche Canada): Research Funding.

10 Years Follow-up of the GELA LNH98.5 Study, First Randomized Study Comparing R-CHOP to CHOP Chemotherapy in Patients with Diffuse Large B-Cell Lymphoma.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 3741-3741 ◽  
Author(s):  
Bertrand Coiffier ◽  
Christian Gisselbrecht ◽  
Andre Bosly ◽  
Raoul Herbrecht ◽  
Reda Bouabdallah ◽  
...  
Keyword(s):  
Board Of Directors ◽  
Research Funding ◽  
Cell Lymphoma ◽  
Randomized Study ◽  
B Cell Lymphoma ◽  
Chop Chemotherapy ◽  
Advisory Committees ◽  
Large B Cell Lymphoma ◽  
Large B Cell

Abstract Abstract 3741 Poster Board III-677 LNH98.5 was the first randomized study with the addition of rituximab to CHOP in patients with diffuse large B-cell lymphoma. 399 patients were randomized, 197 in CHOP arm and 202 in R-CHOP arm. Patients were aged between 60 and 80 years (median 70 years), had disease stage II to IV, and no contra-indication to one of the drugs. 60% had poor risk lymphoma according to IPI. Response to treatment and early survival analyses were previously presented with 2 years and 5 years median follow-up (NEJM 2002;346:235 and JCO 2005;23:4117). With a median follow-up of 10 years, median age of surviving patients is 78 years, oldest patient being 91 years old. Only 4 patients were lost for follow-up, defined as not seen during the last 18 months, at 5, 7, 8, and 8 years. No event was observed in 105 of the 399 patients, 37 (19%) in CHOP arm and 68 (34%) in R-CHOP arm. Relapse was observed in 73 (59%) and 51 (34%) of CR patients, and death without progression in 16 and 33 patients, respectively. Death occurred in 71% and 56% of the patients, most of them from disease progression but 21 and 20 cancers were observed, representing half of the deaths without progression. Most frequent cancers were colon and lung; two MDS were observed in CHOP arm and one AML in R-CHOP arm. One patient with CHOP presented a multiple myeloma 10 years after DLBCL. During the last 3 years, 10 additional patients relapsed, 4 in CHOP arm and 6 in R-CHOP arm, these late relapses representing 4% of CR patients. Median overall survival was 37 months in CHOP arm and 7 y 9 m in R-CHOP arm with 10-y survival of 28% and 43%, respectively (p<0.001). Median survival from progression was 8 months in both arms. This analysis showed that the benefit of combining rituximab with CHOP chemotherapy persists with a median follow-up of 10 years and that over 40% of elderly patients are alive 10 years later confirming these patients could express long-term survival if treated like younger patients. However, late relapses do occur and new strategies should be developed to prolong the response of these patients. Disclosures: Coiffier: Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Gisselbrecht:Roche: Research Funding, Speakers Bureau. Bosly:Roche: Research Funding, Speakers Bureau. Herbrecht:Roche: Research Funding. Bouabdallah:Roche: Research Funding. Morel:Roche: Research Funding. Van Den Neste:Roche: Research Funding. Bordessoule:Roche: Research Funding. Haioun:Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Tilly:Roche: Research Funding, Speakers Bureau. Salles:Roche: Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.

scholarly journals Impact of Genetic Polymorphism of Myeloid Differentiation Primary Response Gene 88, Enhancer of Zeste Homolog 2, and B-cell Lymphoma 2 like 11 in Patients with Diffuse Large B Cell Lymphoma Treated with Rituximab, Cyclophosphamide, Doxorubicin, Vincristin

2021 ◽  
Vol 9 (A) ◽  
pp. 98-105
Author(s):  
Hussam Zawam ◽  
Noha E. Ibrahim ◽  
Rasha Salama ◽  
Mai Samir ◽  
Walaa Abdelfattah ◽  
...  
Keyword(s):  
B Cell ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Poor Response ◽  
Cell Of Origin ◽  
Bulky Disease ◽  
Large B Cell Lymphoma ◽  
Younger Age ◽  
Extranodal Disease ◽  
Large B Cell

BACKGROUND: Despite the growing landscape of genetic drivers in Diffuse Large B-cell Lymphoma, yet their clinical implication is still unclear and R-CHOP regimen remains a “one size fits all” therapy. We aimed in this study to examine the prevalence of EZH2, BCL211 and MYD 88 genetic polymorphisms in DLBCL patients and correlate the results with various clinical and survival outcomes. METHODS: Genotyping of MYD88 (rs387907272 T/C), EZH2 (rs3757441 C/T), and BCL2L11 (rs3789068 A/G) polymorphisms were conducted using real time polymerase chain reaction analysis in a total of 75 DLBCL patients. RESULTS: Most of our cases carried the wild TT genotype of MYD88 gene (64%), the mutant TT genotype of EZH2 gene (52%) and the wild AA genotype of BCL2L11 gene (48%). Regarding cell of origin, Germinal Centre (GC) phenotype was present in 56% of cases while 44% expressed the Post-GC (PGC) phenotype. Poor response outcome to first line R-CHOP was significantly correlated with the mutated CC genotype of MYD 88 (p=0.02), while better response to R-CHOP was significantly associated with younger age <50 years (p <0.0001), good PS (p=0.046), normal LDH level (p=0.003), earlier stage (p <0.0001), good IPI score (p=0.009), absence of extranodal disease (p <0.0001) and absence of bulky disease (p=0.004). The median PFS and the 2 year OS were significantly higher in younger age, earlier stage, good IPI score, absence of extranodal disease, absence of bulky disease and in GC phenotype. CONCLUSIONS: Our results emphasized that the mutated genotype of MYD 88 gene polymorphism is significantly associated with poor response to R-CHOP therapy.

scholarly journals Relapses after Achieving EFS24 in Patients with Diffuse Large B-Cell Lymphoma in the Rituximab Era

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 454-454 ◽  
Author(s):  
Yucai Wang ◽  
Umar Farooq ◽  
Brian K. Link ◽  
Mehrdad Hefazi ◽  
Cristine Allmer ◽  
...  
Keyword(s):  
B Cell ◽  
Cumulative Incidence ◽  
Research Funding ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Salvage Chemotherapy ◽  
Newly Diagnosed ◽  
Indolent Lymphoma ◽  
Large B Cell Lymphoma ◽  
Large B Cell

Abstract Introduction: The addition of Rituximab to chemotherapy has significantly improved the outcome of patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). Patients treated with immunochemotherapy for DLBCL who achieve EFS24 (event-free for 2 years after diagnosis) have an overall survival equivalent to that of the age- and sex-matched general population. Relapses after achieving EFS24 have been considered to be unusual but have been understudied. We sought to define the rate, clinical characteristics, treatment pattern, and outcomes of such relapses. Methods: 1448 patients with newly diagnosed DLBCL from March 2002 to June 2015 were included. Patients were enrolled in the Molecular Epidemiology Resource (MER) of the University of Iowa/Mayo Clinic Lymphoma SPORE, treated per physician choice (predominantly R-CHOP immunochemotherapy) and followed prospectively. An event was defined as progression or relapse, unplanned re-treatment after initial therapy, or death from any cause. Cumulative incidence of relapse and non-relapse mortality after achieving EFS24 were analyzed as competing events using Gray's test in the EZR software. Post-relapse survival was defined as time from relapse to death from any cause and analyzed using Kaplan-Meier method in SPSS (V22). Results: Among the 1448 patients, 1260 (87%) had DLBCL alone at diagnosis, and 188 (13%) had concurrent indolent lymphoma (follicular lymphoma 115, marginal zone lymphoma 18, chronic lymphocytic leukemia 14, lymphoplasmacytic lymphoma 4, unspecified 37) at diagnosis. After a median follow-up of 83.9 months, 896 patients achieved EFS24. For all 896 patients who achieved EFS24, the cumulative incidence of relapse (CIR) was 5.7%, 9.3% and 13.2%, respectively, at 2, 5 and 10 years after achieving EFS24. Patients with concurrent indolent lymphoma at diagnosis had a higher CIR compared to those with DLBCL alone at diagnosis (10.2 vs 4.8% at 2 years, 15.7 vs 8.0% at 5 years, 28.8 vs 9.7% at 10 years, P<0.001; Figure 1). There were a total of 84 patients who relapsed after achieving EFS24. The median age at initial diagnosis was 66 years (range 35-92), and 48 (57%) were male. At diagnosis, 11 (13%) had ECOG PS >1, 37 (50%) had LDH elevation, 62 (74%) were stage III-IV, 14 (17%) had more than 1 extranodal site, and 26 (31%) were poor risk by R-IPI score. There were 58 patients with DLBCL alone at diagnosis who relapsed after achieving EFS24, and 38 (75%) relapsed with DLBCL, 13 (25%) relapsed with indolent lymphoma (predominantly follicular lymphoma), and pathology was unknown in 7 patients. In contrast, there were 26 patients with concurrent indolent lymphoma at diagnosis who relapsed after achieving EFS24, and 9 (41%) relapsed with DLBCL, 13 (59%) relapsed with indolent lymphoma, and pathology was unknown in 4 patients. In the 47 patients who relapsed with DLBCL after achieving EFS24, 45% received intensive salvage chemotherapy, 19% received regular intensity chemotherapy, 9% received CNS directed chemotherapy, and 36% went on to receive autologous stem cell transplant (ASCT). In the 26 patients who relapsed with indolent lymphoma after achieving EFS24, 27% were initially observed, 54% received regular intensity chemotherapy, 4% received intensive salvage chemotherapy, and 19% received ASCT after subsequent progression. The median post-relapse survival (PRS) for all patients with a relapse after achieving EFS24 was 38.0 months (95% CI 27.5-48.5). The median PRS for patients who relapsed with DLBCL and indolent lymphoma after achieving EFS24 were 29.9 (19.9-39.9) and 89.9 (NR-NR) months, respectively (P=0.002; Figure 2). Conclusions: Relapses after achieving EFS24 in patients with DLBCL were uncommon in the rituximab era. Patient with DLBCL alone at diagnosis can relapse with either DLBCL or indolent lymphoma (3:1 ratio). Patients with concurrent DLBCL and indolent lymphoma at diagnosis had a significantly higher CIR, and relapses with DLBCL and indolent lymphoma were similar (2:3 ratio). Even with high intensity salvage chemotherapy and consolidative ASCT, patients who relapsed with DLBCL had a significantly worse survival compared to those who relapsed with indolent lymphoma. Late relapses with DLBCL remain clinically challenging, with a median survival of 2.5 years after relapse. Figure 1. Figure 1. Disclosures Maurer: Celgene: Research Funding; Nanostring: Research Funding; Morphosys: Research Funding. Witzig:Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Ansell:Takeda: Research Funding; Pfizer: Research Funding; Affimed: Research Funding; Regeneron: Research Funding; Seattle Genetics: Research Funding; Celldex: Research Funding; LAM Therapeutics: Research Funding; Trillium: Research Funding; Merck & Co: Research Funding; Bristol-Myers Squibb: Research Funding. Cerhan:Celgene: Research Funding; Jannsen: Other: Scientific Advisory Board; Nanostring: Research Funding.

scholarly journals Detection of the Incidence of HBV, HCV Infection and Febrile Neutropenia Associated With CHOP With or Without Rituximab in Diffuse Large B-Cell Lymphoma–Treated Patients

2017 ◽  
Vol 53 (3) ◽  
pp. 194-197 ◽  
Author(s):  
Kashif Ali ◽  
Ali Akbar Sial ◽  
Mirza Tasawer Baig ◽  
Nida Baig ◽  
Saqib Hussain Ansari ◽  
...  
Keyword(s):  
Hepatitis B ◽  
Febrile Neutropenia ◽  
B Cell ◽  
Cell Lymphoma ◽  
B Cell Lymphoma ◽  
Hcv Infection ◽  
Patient Records ◽  
Chop Chemotherapy ◽  
Large B Cell Lymphoma ◽  
Large B Cell

Background: Reactivation of hepatitis B virus (HBV) and hepatitis C virus (HCV) and febrile neutropenia (FN) are common in diffuse large B-cell lymphoma (DLBCL) patients undergoing cyclophosphamide, hydroxyrubicin, Oncovin, and prednisolone (CHOP) or cyclophosphamide, hydroxyrubicin, Oncovin, prednisolone - rituximab containing (R-CHOP) chemotherapy. This ultimately leads to delaying the therapy, increasing hospital stay, and raising the pharmacoeconomic burden on patients. Aim and Objective: The aim of this study was to determine the incidence of HBV and HCV infection and febrile neutropenia in DLBCL patients treated with R-CHOP and CHOP. Methodology: This was an institutional approved study in which patient records from a private hospital, specialized in hematology and oncology (Karachi, Pakistan), were reviewed retrospectively from 2014 to 2016. Patients aged above 18 years with known diagnosis of DLBCL who underwent CHOP-21 or R-CHOP-21 chemotherapy regimen were included. Baseline blood chemistry and liver function tests along with the data regarding HBV (hepatitis B surface antigen [HBsAg], hepatitis B surface antibody [anti-HBs]), HCV (antibody anti-HCV), and febrile neutropenia were collected from patient records. Results: In total, 35 cases of DLBCL were treated during a 3-year period (ie, from 2014 to 2016), of which 16 were on CHOP-21 regimen whereas 19 were treated with R-CHOP-21. Of the 19 patients who underwent R-CHOP chemotherapy, only 2 (10%) patients were HBsAg reactive. Before commencing the second cycle, 2 (10%) patients reported to hospital with fever and had hematological (low neutrophil count) and microbiological ( Escherichia coli) proven febrile neutropenia. The incidence of HBV infection post treatment was lower in group treated with CHOP (1 patient showed HBsAg reactivity).

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