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Managing PN in PTCL
How I Assess and Manage Peripheral Neuropathy in Patients With PTCL

Released: August 27, 2019

Expiration: August 25, 2020

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The rare and aggressive non-Hodgkin lymphoma peripheral T-cell lymphoma (PTCL) is treated in the frontline setting with standard first-line chemotherapy regimens such as CHOP or other chemotherapy combinations and now with brentuximab vedotin plus CHP, which was recently approved by the FDA based on efficacy and safety results from the ECHELON-2 trial vs standard CHOP therapy.

One of the PTCL adverse events I find most challenging to assess in my clinical practice, and one of the most common ones associated with PTCL treatment, is peripheral neuropathy (PN), a degeneration of the peripheral nerves. In the ECHELON-2 trial, PN rates were similar between treatment arms (52% all grades with brentuximab vedotin plus CHP vs 55% with CHOP (4% grade ≥ 3 in both cohorts), with > 90% sensory PN. PN can affect both motor and sensory nerves, with symptoms including pain, numbness, tingling, or weakness, particularly in the hands and feet.

Assessing PN
To properly assess and manage PN, it is essential to establish a baseline, starting with a few key questions:

  • Does the patient have diabetes or multiple sclerosis? Both are associated with PN.
  • Does the patient currently have any motor or sensory difficulties?
    • For example, does the patient have any difficulties carrying out activities of daily living (eg, zipping or buttoning clothing, difficulties with walking, episodes of dizziness, or tingling or pain in hands or feet)?
  • Is the patient receiving any medications that can cause or contribute to PN (eg, cardiovascular drugs such as amiodarone or other drugs such as the antibiotic isoniazid)?

The next step is the physical examination. As there is no national standardized approach to PN, there are variations of the Total Neuropathy Score (TNS) assessment tool that one can apply in clinical practice. The TNS enables an objective assessment of patients’ PN because it encompasses a thorough neurologic assessment.

A TNS we use at my institution encompasses a neurologic examination of sensory and motor symptoms, autonomic function, and reflexes. The TNS is graded according to the NCI Common Terminology Criteria for Adverse Events to determine the patient’s level of PN. However, the application of the TNS to the NCI grading is at the discretion of the clinician and, therefore, is potentially open to bias. That said, a TNS is a good way to establish an objective base that can be correlated. The patient can also be referred to a neurologist for nerve conduction studies and electromyography.

Managing PN
There are different strategies to be considered when a patient presents with PN during PTCL treatment, including adjusting the treatment regimen dosing, physical therapy, or in some, cases palliative pharmacologic or nonpharmacologic treatment. I will discuss some of the most common approaches below.

Dosing
One of the most important factors to consider in treating patients who develop PN is to establish if the intent of PTCL treatment is curative or noncurative. In administering treatment with curative intent with fixed-dose therapy, PN is typically managed with a dose reduction, as the aim is to keep patients on target with their treatment schedule. When treating patients with palliative, noncurative intent, there is greater flexibility both with the schedule for administering medication and by increasing the interval between cycles of therapy to increase the longevity of the treatment plan. This can result in a sustainable approach by leading to a longer-term treatment plan.

Physical Therapy
Physical therapy is often prescribed for patients with PN. The National Institute of Health Sciences states that exercise helps to deliver more blood and oxygen to nerve endings, improves muscle strength, and reduces muscle atrophy. It is important to note that early introduction of physical therapy has the potential to mitigate the dose-limiting effect of PN on chemotherapy.

Medication
Although the role for medications in the treatment for PN remains controversial, some patients have reported relief from PN pain when treated with drugs such as pregabalin and gabapentin. That said, not all patients can tolerate the adverse events of these drugs (eg, dizziness, drowsiness, loss of coordination). Topical medications such as lidocaine or capsaicin patches can help alleviate neuropathic pain, but the application can cause discomfort for patients, who report a burning sensation.

Nonpharmacologic Intervention
In a retrospective study, patients treated with a course of acupuncture reported an improvement in their symptoms. They also reported additional benefits, including a reduction in use of analgesics and improved sleeping patterns.

Conclusion
The role of the oncology registered nurse and oncology advanced practice provider in PTCL management is crucial, as they ensure continuity of care over the trajectory of the patient’s treatment. This enables early identification and management of the patient’s PN symptoms, reducing the dose-limiting effects of PN on PTCL treatment.

Your Thoughts?
What are your most pressing questions about managing PTCL therapy–related adverse events? Join the conversation by leaving a question or comment below.

For more information on the latest data on the management of patients with newly diagnosed PTCL and a brief summary resource, click here.