DA-EPOCH-R for Adult Burkitt’s Lymphoma: Pros and Cons

Burkitt’s lymphoma is a highly aggressive B-cell non-Hodgkin lymphoma characterized by translocation of the MYC gene on chromosome 8 to heavy or light chain immunoglobulin gene loci.1 This disease commonly presents with fast-growing extranodal tumors and is associated with high incidence rates of CNS involvement at presentation (10% to 40%) and at relapse (32%).1,2 Although Burkitt’s lymphoma is commonly seen in children, especially in the endemic areas, it also occurs in adults of all ages; approximately 60% of patients are older than 40 years. Burkitt’s lymphoma is a highly curable cancer in children, with cure rates higher than 80%.1,2 In adults, similar curability is reported in clinical trials; however, results outside of clinical trials seem to be worse.3 Treatment paradigms leading to successful eradication of Burkitt’s lymphoma were derived from pediatric therapeutic trials in acute lymphoblastic leukemia and are currently based on dose-intense combination chemotherapy, adequate CNS prophylaxis, and improvements in supportive care.3 In the United States, for adult patients with Burkitt’s lymphoma who can tolerate aggressive therapies, common treatment regimens include CODOX-M/IVAC (cyclophosphamide, doxorubicin, vincristine, methotrexate [CODOX-M]/ifosfamide, cytarabine, and etoposide [IVAC]) plus rituximab or R-Hyper CVAD (rituximab plus Hyper CVAD [hyperfractionated cyclophosphamide, vincristine, adriamycin, and dexamethasone]), based on similar outcomes reported in phase II studies. One of the main concerns about these therapies is treatment-related toxicity, especially in elderly patients. Consequently, dose-modified CODOX-M/IVAC was investigated. This regimen did not markedly reduce clinical efficacy but reduced toxicity. Furthermore, routine incorporation of initial cytoreduction with cyclophosphamide, prednisolone, and vincristine before more intensive chemotherapy further decreased the risk of adverse effects and increased drug tolerability. However, no randomized therapeutic trials have been reported for adult Burkitt’s lymphoma, thus preventing evidence-based selection of the most effective and least toxic treatment approach. The article by Dunleavy that accompanies this commentary provides a concise review of the biology, diagnosis, and treatment of adult Burkitt’s lymphoma.4 Dunleavy recommends the implementation of dose-adjusted (DA) EPOCH-R (etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab) in patients with low- and high-risk Burkitt’s lymphoma. DA-EPOCH-R was first implemented at the National Cancer