Treatment Options for Patients With Mantle Cell Lymphoma

At the 2019 Lymphoma & Myeloma Congress, Michael Williams, MD, University of Virginia Health System, Emily Couric Clinical Cancer Center, Charlottesville, discussed treatment approaches for a variety of patients with mantle cell lymphoma.

Transcript

My name is Michael Williams. I'm at the University of Virginia Cancer Center in Charlottesville, Virginia, where I'm Professor of Medicine and Chief of the Hematology/Oncology Division. I've had a longstanding interest in mantle cell lymphoma, which is one of the unique subtypes of non-Hodgkin's lymphoma.

Although it has the reputation of being one of the more difficult lymphomas to treat, in fact, there's a real spectrum of clinical presentations. Some people have a very slowly progressive disease that can be monitored for months or even years without treatment. Others have a very aggressive presentation and need prompt institution of therapy.

It's important to understand that treatment is based both on the type of presentation and of the age of the patient. The traditional standards of care, which are still in place for patients who are eligible for stem cell transplantation.

The usual approach is an induction chemotherapy regimen with rituximab plus a high-dose cytarabine-containing regimen or, in some cases, other chemotherapy agents, such as bendamustine, might be used.

Recommendations are now, for those younger patients, to proceed to an autologous stem cell transplant as a consolidation. Then, that is followed by 3 years of maintenance rituximab with the purpose of improving not just disease control but overall survival, which has been shown in randomized trials.

Now, one of the questions that's out there for younger patients is whether, in fact, stem cell transplant is needed for all patients if they've already achieved a very good deep response to their initial therapy. Maybe they just need treatment with maintenance rituximab. That's the focus of a current national US trial that is exploring whether, in fact, you need the transplant in people who have had a great response.

Now, what if you're not a younger, fit patient who's eligible for transplant? There are a variety of very active treatments for mantle cell lymphoma. Even with transplant, it's typically not felt to be a curative therapy but rather one that controls the disease for as long as possible.

The current approaches are actually looking at incorporating one of the several new targeted agents, such as BTK inhibitors or Bcl-2 inhibitors or immunomodulatory drugs, like lenalidomide, into front-line therapy or, potentially, to use them as front-line therapy without any traditional cytotoxic chemotherapy.

One of the things we often recommend whenever it's available is for patients to pursue a clinical trial where they can be managed at a center that has a lot of mantle cell lymphoma experience and is able to, potentially, offer one of these very promising clinical studies.

That's for newly diagnosed patients who need therapy. What if you've now got recurrence of disease? Again, there are a variety of very effective treatment options in young, otherwise healthy patients. Young, meaning, typically, under the age of 60.

One of the things we consider at that first relapse is whether they're a candidate for allogeneic stem cell transplantation, which, in fact, is a curative therapy for this lymphoma, albeit, one that has risk of significant complications, or even, mortality risk that can run upwards of 10%. That's a question that has to be asked and answered in the younger patient.

Now, if you're not an allogeneic candidate, then there are still a variety, in fact, a series of treatments that can be used. Typically, ibrutinib or acalabrutinib, venetoclax, typically given with an antibody, like rituximab, or lenalidomide and rituximab, which has also shown high response rates in the relapse setting.

As I said earlier, these agents and regimens are actually being moved more toward the front-line and, in fact, for some patients, we may be able to get durable control of mantle cell lymphoma without giving traditional chemotherapy.

Again, in the relapse setting, if you have access to a center with a lot of mantle cell experience or your oncologist can reach out to such a center or, perhaps, has trials available in his or her own office, then those are important to consider.

It's a rapidly evolving field and one that it pays to consider a second opinion and make sure you're getting the most cutting-edge therapeutic recommendations for your particular situation.