Lymphomas in the elderly

The elderly patients with lymphoma suffer from a relevant excess mortality, both during treatment and in the course of follow-up: various causes contribute, including: 1) "generational" mortality; 2) iatrogenic mortality due to unexpected organ/system fragility; 3) low remission rates, due to low tolerated doses and, 4) a high prevalence of second tumors. The difficulty in achieving high cure rates begins after age 50 and steadily increases for patients over 60, 70 and 80. Less aggressive staging procedures are justified, and the modern visualizing techniques provide alternatives to lymphangiography and laparosplenectomy. In HD, local radiation instead of Total Nodal Irradiation, and doses of 30 or even 20 Gy may be administered for stages I and II; for stages III and IV the ChlVPP and the NOVP or the "ABVD without D" regimens may be adopted. After chronological and/or biological age 80, sequentially administered single agents produce an effective palliation, allowing for a good quality of life during treatment, and often obtain a reasonable prolongation of survival. Many NHL of elderly patients are indolent in their course, and a "watch and wait" policy is often in the true interest of the patient; when local aggressiveness only is apparent, a local low dose radiation may be considered. For advanced stage, treatment-requiring low-grade-NHL, oral chlorambucil plus or minus low dose steroids (or prednimustine) should be considered in alternative to watch and wait. For high grade, aggressive NHL, chemotherapy with short, non-Methotrexate-containing programs like POCE, NOSTE, P-VABEC, or other variations of MACOP-B are acceptable. Beyond age 80, or when other factors deteriorate the chances for survival, single agents like VM 26, or simple combinations of VP 16 + Prednimustine or VP 16 and Mitoxantrone may be adopted.