To SMILE or Not: Supportive Care Matters

Yamaguchi et al 1 evaluated the effectiveness of the corticosteroid (dexamethasone), methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) regimen in a phase II trial. The authors concluded that the regimen is effective in patients with newly diagnosed stage 4 relapsed or refractory extranodal natural killer/T-cell lymphoma, nasal type (ENKL). Given that the prognosis of ENKL remains poor, we need to identify an effective regimen. SMILE appears to be active for ENKL; however, it is apparent that the regimen is extremely toxic, with grade 4 neutropenia occurring in 92% of patients. In essence, supportive care must play an essential role if a clinician decides to treat a patient with ENKL with SMILE.