Frontline Treatment Options in Mantle Cell Lymphoma
Brian Hill, MD, reviews frontline treatment options for patients with mantle cell lymphoma.
Brian Hill, MD: There are a few different frontline regimens that are used commonly for mantle cell lymphoma. Over the years, it has been realized that simple R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine, prednisone] is probably not the best regimen. Over the past 5 to 10 years, it’s been recognized that incorporation of a high-dose cytarabine regimen into induction therapy improves outcomes based on randomized European trials.
A typical approach is something called the Nordic [Lymphoma Group] regimen, in which cycles of R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine, prednisone] are alternated with a platinum-based regimen like R-DHAP [rituximab, dexamethasone, cytarabine, cisplatin] . There’s also the potential to use R-DHAP [rituximab, dexamethasone, cytarabine, cisplatin] alone without R-CHOP [rituximab, cyclophosphamide, hydroxydaunorubicin hydrochloride, vincristine, prednisone]. In patients who may not be as fit and may not be good candidates for consolidation autologous stem cell transplant, bendamustine-rituximab is effective and generally a well-tolerated induction therapy for mantle cell lymphoma.
Even in higher-risk disease, most people do respond. It was noted that this patient had a partial remission, which is a little suboptimal. Generally, it is preferred to see patients get complete remissions with their induction therapy. Certainly, those who enter complete remission are more likely to have a more durable response after a consolidation autologous stem cell transplant.
In terms of maintenance rituximab, this is an intervention that been shown in randomized trials to improve the survival of patients with mantle cell. In contrast with other more indolent lymphomas, in which maintenance rituximab improves only progression-free survival [PFS]. For mantle cell lymphoma, after autologous stem cell transplant, for instance, the PFS and overall survival of patients are improved by maintenance rituximab. This is considered to be a standard of care at this point.
Transcript edited for clarity.
Case: A 73-Year-Old Male With Mantle Cell Lymphoma
History
- A 73-year-old man was diagnosed with mantle cell lymphoma in 2016
- He was treated with rituximab, dexamethasone, cytarabine + carboplatin followed by autologous stem cell transplant; achieved PR; continued rituximab maintenance therapy
- Ann Arbor stage IV; MIPI score 6.7, high risk
- Late 2019 he experienced clinical relapse and was started on ibrutinib; achieved SD
Currently
- He complains of a 2-month history of loss of appetite and fatigue
- PMH: hyperlipidemia, medically well-controlled
- PE: bilateral clavicular and cervical lymphadenopathy; otherwise unremarkable
- Labs: WBC 11 X 109/L, hemoglobin 9.5 gm/dL, plt 96,000/u, LDH 405 U/I, ANC 3200/mm3
- Lymph node biopsy: IHC; cyclin D1+, CD5 +, CD10+, CD20+, FISH: t (11;14)
- C/A/P CT scan: widespread lymphadenopathy including bilateral clavicular (2.4 cm, 1.5 cm), and inguinal region (4.6 cm)
- PET/CT shows diffuse uptake of 18F-FDG in the clavicular, axillary and inguinal lymph nodes
- Beta-2-microglobulin 4.1 µg/L
- ECOG PS 0
- Treatment was started with fludarabine + cyclophosphamide, followed by a single infusion of CAR T-cell therapy
