Summary

Mantle Cell Lymphoma due to its clinical heterogeneity requires clear interpretation of prognostic factors to determine treatment options. In this CME, Dr. Vishwanath discusses evidence-based therapeutic strategies for different case presentations of MCL.

Mantle cell lymphoma (MCL) is a relatively unusual non-hodgkin lymphoma with variable prognosis. With the use of rituximab and intensive chemo-immunotherapy followed by autologous stem cell transplant, there has been improvement in progression-free survival (PFS) and overall survival (OS) as well. Even in transplant ineligible patients, less intensive chemotherapy and targeted therapy have improved survival rates.

Discussed here is the management of patients with MCL based on case scenarios:

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Case 1

A 65-year-old asymptomatic gentleman was found to have a WBC count of 65000/microlitre. On physical exam, he had no significant lymphadenopathy. Ultrasound abdomen showed evidence of mild splenomegaly and no enlarged lymph nodes (LN). Peripheral blood flow cytometry was diagnostic of MCL. Bone marrow biopsy showed a Ki 67 of 20%. He had a hypermutated IGHV and TP53 was negative.

What would the appropriate treatment be?

1. Watch and wait
2. R-CHOP
3. Bendamustine with rituximab (BR)
4. Rituximab, Bendamustine with cytarabine
5. R-CVP

The right answer, in this case, would be (a).

A small percentage of patients with MCL have an indolent course. This patient is asymptomatic and has a leukaemic, non-nodal presentation of MCL. This generally has an indolent course similar to CLL. Patients with good PS, absence of B symptoms, with a normal LDH, low Ki 67 (<30%), SOX-11 negativity, TP53 negativity and a non blastoid morphology tend to have a superior overall survival with observation.

A retrospective single center study of 97 patients with MCL reported by Martin et al showed that 32% of patients were observed for over 3 months before initiating systemic therapy and treatment was deferred for more than one year in 14 patients and more than 5 years in three patients. [1]

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Case 2

A 50-year-old male with no comorbidities presented with fever, fatigue, significant weight loss, and abdominal pain. PET/CT showed a large conglomerate retroperitoneal lymph node (LN) with bilateral axillary and cervical lymphadenopathy. His PS was 1. Cervical LN biopsy was diagnostic of MCL (non-blastoid variant), LDH was 400 U/L, Ki 67 40% and biological MIPI score was 6.7 (high risk).

Which of the following treatment options may be considered the most appropriate?

1. BR followed by ASCT
2. R HyperCVAD/MTX-ARAC
3. Nordic regimen
4. RDHAP/R-CHOP followed by ASCT and maintenance rituximab
5. RCHOP followed by ASCT and maintenance rituximab
6. Any of the above

The answer is (f), but the best answer is (d).

Though any of the above options can be used in this case, this patient is young, fit, and with no co-morbidities. He is symptomatic with a high MIPI score and transplant eligible. It would be appropriate to give a high intensive chemo-immunotherapy regimen like R-DHAP alternating with R-CHOP (total 6 cycles) and consolidate with autologous stem cell transplant (ASCT) in CR1.

This was based on a randomised trial of 497 patients with a median age of 55 years comparing R-DHAP alternating with R-CHOP (total 6 cycles) with R-CHOP x 6 cycles followed by high dose cytarabine conditioned ASCT. At a median follow up of 6 years, R-CHOP/R-DHAP resulted in longer time to treatment failure (median 9.1 Vs. 3.9 years). [2]

The addition of ASCT in CR1 improves PFS. [3] Other regimens like R-HyperCVAD alternating with MTX/ARA-C without ASCT can also be used as an induction therapy as shown in a single-center experience which resulted in a failure-free survival of 15 years in one-third of younger patients with MCL. However, there was significant toxicity. [4]

The role of maintenance rituximab (3 years, every 2 months) after ASCT was addressed in the LYMA trial which showed improvement in PFS and OS. [5]

However, there is limited role of rituximab maintenance following BR induction (Rummel, et al. ASH 2016) [6] and the use of BR induction in high-risk MCL is debatable.

The role of minimal residual disease at the end of induction and utility of ASCT in patients with MRD negativity following induction is evolving.

Note: The morphology here was non blastoid. Had it been a blastoid morphology, the treatment option in a young, fit patient would be R-HyperCVAD alternating with MTX/ARA-C and possibly consolidation auto/allo SCT. This patient should also receive intrathecal MTX apart from systemic MTX to prevent CNS relapse which is more common in blastoid variants.

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Case 3

An 80-year-old male presented with B symptoms and lower GI bleed due to colonic involvement by MCL. His PS was 1. PET/CT also showed supra and infradiaphragmatic LN involvement with maximum LN size of 4 x 4cm. Bone marrow showed involvement by MCL with Ki 67 of 30%.

Which of the following treatment options would be appropriate in him?

1. BR
2. R—CHOP
3. R-BAC
4. Rituximab with lenalidomide
5. Ibrutinib
6. a,b,c,b

The right options would be (a), (c) and (d).

Treating elderly patients with MCL is always a challenge. A comprehensive geriatric assessment taking into account the comorbidities is a prerequisite. Using less intensive regimens is the key. BR as shown in the StiL and the BRIGHT study is a reasonable regimen to adopt. [7,8]

R-BAC (bendamustine and cytarabine) with rituximab based on a phase II study which showed CR of 91% with 2 year PFS and OS of 81% may also be considered. However this regimen had significant hematological toxicity and should be used with caution in elderly patients. [9] The combination of Lenalidomide plus rituximab led to ORR of 92% and 5 year PFS of 64% and OS of 77% which is well tolerated in elderly patients may be an option. [10]

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Case 4

A 58-year-old woman was diagnosed with MCL, received 6 cycles of R-CHOP followed by ASCT and maintenance rituximab. Two years later, she develops a relapse.

What would be the most appropriate treatment option?

1. Lenalidomide with rituximab
2. Ibrutinib
3. BR+/- Bortezomib
4. Chemo-immunotherapy followed by Allogeneic SCT
5. Any of the above

Here, it could be (e).

Any of the above options can be considered based on various patient factors like PS, co-morbidities and fitness for allo SCT.

1. Lenalidomide with rituximab is an option for this patient. Wang and colleagues reported results in 52 patients with R/R MCL in a phase I/II trial. The ORR was 57% and the median PFS reported was 11.1 months. It is a well tolerated regimen and effective in R/R MCL. [11]
2. Single-agent Ibrutinib has modest activity in relapsed MCL and can be considered based on a phase 2 study of 111 patients with MCL. The ORR was 68% and median PFS was 13.9 months. [12]
3. In patients like the current one who have not been exposed to BR during induction, the combination of BR with bortezomib is a reasonable option. The ORR was 71% and 2 year PFS was 47% in a phase II study. [13]
4. Chemo-immunotherapy options like BR or R-DHAP followed by allogeneic SCT may be considered. However, this patient is 58 year old and has had an ASCT before. Hence fitness for allo SCT should be assessed prior to transplant.
5. Acalabrutinib, a BTK inhibitor is also an option. However, it is not available in India.

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Click here to see references

1. Martin P, Chadburn A, Christos P, et al. Outcome of deferred initial therapy in mantle-cell lymphoma. J Clin Oncol. 2009 Mar 10;27(8):1209-13.
2. Hermine O, Hoster E, Walewski J, et al. Addition of high-dose cytarabine to immunochemotherapy before autologous stem-cell transplantation in patients aged 65 years or younger with mantle cell lymphoma (MCL Younger): a randomised, open-label, phase 3 trial of the European Mantle Cell Lymphoma Network. Lancet. 2016 Aug 6;388(10044):565-75.
3. Dreyling M, Lenz G, Hoster E, et al. Early consolidation by myeloablative radiochemotherapy followed by autologous stem cell transplantation in first remission significantly prolongs progressionfree survival in mantle-cell lymphoma: results of a prospective randomized trial of the European MCL Network. Blood. 2005 Apr 1;105(7):2677-84.
4. Chihara D, Cheah CY, Westin JR, et al. Rituximab plus hyper-CVAD alternating with MTX/Ara-C in patients with newly diagnosed mantle cell lymphoma: 15-year follow-up of a phase II study from the MD Anderson Cancer Center. Br J Haematol. 2016 Jan;172(1):80-8.
5. Le Gouill S, Thieblemont C, Oberic L, et al. Rituximab after Autologous Stem-Cell Transplantation in Mantle-Cell Lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260.
6. Rummel et al. Results of the MAINTAIN trial. Presented at ASH 2016.
7. Rummel MJ, Maschmeyer G, Ganser A, et al. Bendamustine plus rituximab (B-R) versus CHOP plus rituximab (CHOP-R) as first-line treatment in patients with indolent lymphomas: Nine-year updated results from the StiL NHL1 study. Journal of Clinical Oncology. 2017;35(15_suppl):7501-7501.
8. Flinn IW, van der Jagt R, Kahl BS, et al. Randomized trial of bendamustine-rituximab or R-CHOP/RCVP in first-line treatment of indolent NHL or MCL: the BRIGHT study. Blood. 2014 May 8;123(19):2944-52.
9. Visco C, Chiappella A, Nassi L, et al. Rituximab, bendamustine, and low-dose cytarabine as induction therapy in elderly patients with mantle cell lymphoma: a multicentre, phase 2 trial from Fondazione Italiana Linfomi. Lancet Haematol. 2017 Jan;4(1):e15-e23.
10. Ruan J, Martin P, Christos P, et al. Five-year follow-up of lenalidomide plus rituximab as initial treatment for mantle cell lymphoma. Blood. 2018 Sep 4.
11. Wang M et al. Lenalidomide in combination with rituximab for patients with R/R mantle cell lymphoma: a phase ½ clinical trial. Lancet 2012.
12. Wang M et al. Targeting BTK with Ibrutinib in R/R MCL. NEJM 2013.
13. Friedberg WJ et al. The combination of bendamustine, bortezomib, and rituximab for patients with relapsed/refractory indolent and mantle cell NHL. Blood 2011.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

The writer, Dr. Vishwanath Sathyanarayan is a Medical Oncologist from Apollo Hospitals, Bangalore with a fellowship in Lymphoma & Myeloma from MD Anderson Cancer Center.