Association of pre-transplantation positron emission tomography/computed tomography and outcome in mantle cell lymphoma

Impact of Mantle Cell Lymphoma Contamination of Autologous Stem Cell Grafts on Outcome after High-Dose Chemotherapy

Simple Summary

High-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (Auto-HSCT) is a standard frontline treatment for fit mantle cell lymphoma (MCL) patients. As there is a need for predictive factors to identify patients unlikely to benefit from this therapy, we investigated the prognostic impact of lymphoma cell contamination of autologous stem cell grafts. Analyzing a cohort of 36 MCL patients, we show that lymphoma cell contamination of stem cell grafts is associated with poor outcomes after Auto-HSCT. Its analysis might thus improve risk assessment and enable risk-stratified treatment strategies for MCL patients.

Abstract

Novel predictive factors are needed to identify mantle cell lymphoma (MCL) patients at increased risk for relapse after high-dose chemotherapy and autologous hematopoietic stem cell transplantation (HDCT/Auto-HSCT). Although bone marrow and peripheral blood involvement is commonly observed in MCL and lymphoma cell contamination of autologous stem cell grafts might facilitate relapse after Auto-HSCT, prevalence and prognostic significance of residual MCL cells in autologous grafts are unknown. We therefore performed a multiparameter flow cytometry (MFC)-based measurable residual disease (MRD) assessment in autologous stem cell grafts and analyzed its association with clinical outcome in an unselected retrospective cohort of 36 MCL patients. MRD was detectable in four (11%) autologous grafts, with MRD levels ranging from 0.002% to 0.2%. Positive graft-MRD was associated with a significantly shorter progression-free and overall survival when compared to graft-MRD negative patients (median 9 vs. 56 months and 25 vs. 132 months, respectively) and predicted early relapse after Auto-HSCT (median time to relapse 9 vs. 44 months). As a predictor of outcome after HDCT/Auto-HSCT, MFC-based assessment of graft-MRD might improve risk stratification and support clinical decision making for risk-oriented treatment strategies in MCL.

The value of complete remission according to positron emission tomography prior to autologous stem cell transplantation in lymphoma: a population-based study showing improved outcome

Background

Chimeric antigen-receptor T-cell and bispecific antibody therapies will likely necessitate a reconsideration of the role of autologous stem-cell transplantation (ASCT) in lymphoma. Patients who are likely to profit from ASCT need to be better identified.

Methods

Here, we investigated the value of positron emission tomography/computerized tomography (PET/CT) before ASCT. All 521 patients transplanted for lymphoma 1994–2019 at Karolinska (497 conditioned with BEAM) were included.

Results

Outcome improved over three calendar periods 1994–2004, 2005–2014, 2015–2019 (2-year overall survival [OS]: 66, 73, 83%; P = 0.018). Non-relapse mortality (NRM) at 100 days over the three periods were 9.8, 3.9, 2.9%, respectively. The OS improvement between 1994 and 2004 and 2005–2014 was due to lower NRM (P = 0.027), but the large OS advance from 2015 was not accompanied by a significant reduction in NRM (P = 0.6). The fraction of PET/CT as pre-ASCT assessment also increased over time: 1994–2004, 2%; 2005–2014, 24%; 2015–2019, 60% (P < 0.00005). Complete responses (PET/CT-CR) were observed in 77% and metabolically active partial responses (PET/CT-PR) in 23%. PET/CT-CR was a predictor for survival in the entire population (P = 0.0003), also in the subpopulations of aggressive B-cell (P = 0.004) and peripheral T-cell (P = 0.024) lymphomas. Two-year OS and progression-free survival (OS/PFS) for patients in PET/CT-CR were in relapsed/refractory aggressive B-cell lymphoma 87%/75% and peripheral T-cell lymphoma 91%/78%. The corresponding figures in PET/CT-PR were 43%/44 and 33%/33%. Patients with solitary PET/CT-positive lesions showed acceptable outcome with ASCT followed by local irradiation (2-year OS/PFS 80%/60%). CT was less discriminative: 2-year OS/PFS: CT-CR, 76%/66%; CT-PR, 62%/51%. Outcome was inferior after BEAC compared with BEAM conditioning.

Conclusions

We conclude that the improved outcome reflects better, PET/CT-informed, identification of patients who should proceed to ASCT. The excellent survival of patients in PET/CT-CR indicates that ASCT should remain part of standard therapy for lymphoma.

Application of 18F-fluorodeoxyglucose positron emission tomography/computerized tomography in mantle cell lymphoma

OBJECTIVE

The study is to investigate the application of F-fluorodeoxyglucose (F-FDG) PET/computerized tomography (CT) for the evaluation of mantle cell lymphoma (MCL).

METHODS

We retrospectively analyzed 39 patients who were pathologically diagnosed with MCL and underwent F-FDG PET/CT before treatment between August 2007 and August 2018. We compared the clinical information and PET/CT imaging characteristics in different groups based on bone marrow invasion, spleen invasion or International Prognostic Index (IPI) score. We also assessed the efficacy of PET/CT evaluation basing on the follow-up PET CT findings of 21 MCL patients and their biopsies.

RESULTS

Thirty-five patients were stage IV according to the Revised Ann Arbor Staging System. Lymph node involvement was observed in all 39 cases. The maximum diameter of the affected lymph nodes (4.33 ± 3.09 cm) and maximum standardized uptake value (SUVmax) (8.38 ± 4.99) was positively correlated (r = 0.486, P = 0.002). Extranodal invasion was identified in 38 patients with MCL, and the SUVmax of extranodal invasion was 7.34 ± 3.31. Extranodal invasion was most common in the spleen (25/38) and bone marrow (18/38). The group with bone marrow invasion was more prone to nasopharyngeal, lung and renal invasions (all P < 0.05). The groups with bone marrow invasion or spleen invasion were more likely to have decreased hemoglobin (Hgb) and platelets (all P < 0.01). The IPI high-risk group was more prone to lung involvement, elevated LDH and CRP, and decreased Hgb (all P < 0.05). Among the follow-up of 30 MCL patients, the 2-year progression-free survival and overall survival rates were 73.33 and 87.50%, respectively. PET/CT reexaminations of 21 MCL patients after treatment showed that the sensitivity, specificity, negative predictive value, positive predictive value and accuracy of the efficacy evaluation were 80, 90.91, 88.89, 83.33 and 85.71%, respectively.

CONCLUSION

F-FDG PET/CT imaging has important application value in the diagnosis, staging, treatment efficacy assessment and prognosis monitoring of MCL, especially in the systemic assessment of advanced MCL.

Mantle cell lymphoma

MCL is a well-characterized generally aggressive lymphoma with a poor prognosis. However, patients with a more indolent disease have been reported in whom the initiation of therapy can be delayed without any consequence for the survival. In 2017 the World Health Organization updated the classification of MCL describing two main subtypes with specific molecular characteristics and clinical features, classical and indolent leukaemic nonnodal MCL. Recent research results suggested an improving outcome of this neoplasm. The addition of rituximab to conventional chemotherapy has increased overall response rates, but it did not improve overall survival compared to chemotherapy alone. The use of intensive frontline therapies including rituximab and consolidation with autologous stem cell transplantation ameliorated response rate and prolonged progression-free survival in young fit patients, but any impact on survival remains to be proven. Furthermore, the optimal timing, cytoreductive regimen and conditioning regimen, and the clinical implications of achieving a disease remission even at molecular level remain to be elucidated. The development of targeted therapies as the consequence of better understanding of pathogenetic pathways in MCL might improve the outcome of conventional chemotherapy and spare the toxicity of intense therapy in most patients. Cases not eligible for intensive regimens, may be considered for less demanding therapies, such as the combination of rituximab either with CHOP or with purine analogues, or bendamustine. Allogeneic SCT can be an effective option for relapsed disease in patients who are fit enough and have a compatible donor. Maintenance rituximab may be considered after response to immunochemotherapy as the first-line strategy in a wide range of patients. Finally, since the optimal approach to the management of MCL is still evolving, it is critical that these patients are enrolled in clinical trials to identify the better treatment options.

18F-FDG PET or PET/CT in Mantle Cell Lymphoma

The aim of this systematic review was to examine published data about the potential role of Fluorine-18-fluorodeoxyglucose positron emission tomography or positron emission tomography/computed tomography (¹⁸F-FDG PET or PET/CT) in patients affected by mantle cell lymphoma (MCL). A comprehensive computer literature search of Scopus, PubMed/MEDLINE, and Embase databases was conducted, including articles indexed up to November, 2019; 25 studies or subsets in studies analyzing the value of ¹⁸F-FDG PET or PET/CT in patients with MCL were eligible for inclusion. From the analyses of the selected studies, the following main findings are described: (1) MCL are ¹⁸F-FDG-avid in most of cases, especially nodal lesions, but bone marrow and gastrointestinal disease localizations have low ¹⁸F-FDG avidity; (2) ¹⁸F-FDG PET/CT seems to be helpful in staging setting, showing a better diagnostic performance than conventional imaging and a positive impact on clinical stage; (3) ¹⁸F-FDG PET/CT is useful in evaluating treatment response, especially after chemotherapy and transplantation; and (4) metabolic response after therapy seems to have a prognostic role. Despite several limitations affecting this analysis, especially related to the heterogeneity of the studies included, MCL is an ¹⁸F-FDG-avid lymphoma in most of the cases, with the exception of bone marrow and gastrointestinal disease. Moreover, ¹⁸F-FDG PET/CT seems to be useful in evaluating treatment response and prognosis.

The Role of 18F-FDG PET/CT in Staging and Prognostication of Mantle Cell Lymphoma: An Italian Multicentric Study

Mantle cell lymphoma (MCL) is an aggressive lymphoma subtype with poor prognosis in which 18F-FDG-PET/CT role in treatment response evaluation and prediction of outcome is still unclear. The aim of this multicentric study was to investigate the role of 18F-FDG-PET/CT in staging MCL and the prognostic role of Deauville criteria (DC) in terms of progression-free survival (PFS) and overall survival (OS). We retrospectively enrolled 229 patients who underwent baseline and end-of-treatment (eot) 18F-FDG-PET/CT after first-line therapy. EotPET/CT scans were visually interpreted according to DC. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT for evaluation of bone marrow (BM) were 27%, 100%, 100%, 48% and 57%, respectively. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of PET/CT for evaluation of the gastrointestinal (GI) tract were 60%, 99%, 93%, 90% and 91%, respectively. At a median follow-up of 40 months, relapse occurred in 104 cases and death in 49. EotPET/CT results using DC significantly correlated with PFS, not with OS. Instead, considering OS, only MIPI score was significantly correlated. In conclusion, we demonstrated that MCL is an FDG-avid lymphoma and 18F-FDG-PET/CT is a useful tool for staging purpose, showing good specificity for BM and GI evaluation, but suboptimal sensitivity. EotPET/CT result was the only independent significant prognostic factor that correlated with PFS.

Diagnostic and Clinical Impact of Staging 18F-FDG PET/CT in Mantle-Cell Lymphoma: A Two-Center Experience

INTRODUCTION

The diagnostic accuracy of fluorine-18-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) in staging mantle-cell lymphoma has not yet investigated. The aim of this 2-center retrospective study was to investigate the utility of ¹⁸F-FDG PET/CT in assessing nodal, splenic, bone marrow (BM), and gastrointestinal (GI) disease compared to CT, BM, and GI endoscopy; and to assess its clinical impact.

PATIENTS AND METHODS

One hundred twenty-two patients with histologically proven mantle-cell lymphoma were included. PET/CT BM findings were considered positive if isolated/multiple focal uptake in the BM not explained by benign findings and/or diffuse BM uptake higher than liver with/without focal uptakes were present. PET/CT findings were considered positive for GI involvement in the presence of isolated/multiple focal uptake in the GI organ.

RESULTS

All patients had positive PET/CT showing the presence of at least one hypermetabolic lesion, with the exception of one case. PET/CT results, compared to CT, detected more nodal and/or splenic lesions in 26 patients. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of PET/CT for BM were 52%, 98%, 97%, 65%, and 74%; for GI 64%, 91%, 69%, 90%, and 85%; and for GI excluding diabetic patients, 78%, 92%, 72%, 94%, and 89%. PET/CT permitted upstaging of 21 cases and downstaging of 2.

CONCLUSION

¹⁸F-FDG PET/CT showed excellent detection rate in nodal and splenic disease-a rate better than CT. For BM and GI evaluation, in order to reach good accuracy, the selection of patients and the use of specific criteria for evaluation of these organs seems to be crucial. Moreover, PET/CT altered the management and therapeutic approach in about 20% of patients.

Toward a Risk-Tailored Therapeutic Policy in Mantle Cell Lymphoma

PURPOSE OF REVIEW

Mantle cell lymphoma (MCL) prognosis is strictly related to the characteristics of the disease, which can range from very indolent cases to highly aggressive and refractory ones. Here we will review the current knowledge on MCL biomarkers.

RECENT FINDINGS

Biomarker-informed diagnosis is essential for differentiating MCL from other mature B cell tumors. Diagnosis of MCL relies on the identification of the t(11;14) translocation by FISH or the consequently aberrant expression of cyclin D1 by immunohistochemistry. For the few cases staining negative for cyclin D1, SOX11 may help to define the diagnosis. Prognostic biomarkers have been proposed to stratify MCL patients, including baseline clinical aspects (leukemic non-nodal presentation, in situ presentation, Mantle cell International Prognostic Index-MIPI), pathological aspects (blastoid morphology, Ki-67 proliferation index, SOX11 expression), genetic aspects (immunoglobulin gene mutation status, TP53 deletion or mutation, CDKN2A deletion), and depth of response after treatment (PET imaging, molecular minimal residual disease). Such tools are increasingly used as a guide for therapeutic decisions. Watchful waiting approach is recommended for patients harboring favorable clinico-biological features, such as leukemic non-nodal presentation, low MIPI score, non-blastoid disease, low Ki-67 proliferation rate, mutated immunoglobulin genes, and the lack of SOX11 expression. For patients in need of frontline therapy, the decision of whether to undertake intensive regimens is based upon patient's age and comorbidities. Central nervous system prophylaxis is recommended for cases showing blastoid morphology. The duration of remission is tightly correlated to the depth of response. With the aim of achieving a longer duration of remission and survival, younger patients may pursue more intensive regimens incorporating high-dose cytarabine, followed by myeloablative consolidation chemotherapy, autologous stem cell transplantation, and rituximab maintenance. Older patients could, on the other hand, benefit from lower intensity immunochemotherapy followed or not by a maintenance therapy depending on which frontline regimen is used. Despite the identification of several potential useful biomarkers that may inform the treatment decisions and the design of clinical trials, the treatment choice remains nowadays determined by the patient age and fitness rather than by the individual patient characteristics. Tailoring therapy toward a risk-adapted strategy to accommodate the wide spectrum of disease is an urgent challenge, and clinical trials may explore the feasibility of a biomarker-defined therapeutic policy.

18F-FDG PET/CT in the clinical management of patients with lymphoma

The aim of this work was to review the current recommendations for staging and response assessment of patients with Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) in routine clinical practice after chemotherapy and/or stem cell transplantation. A five-point scale (5-PS) from the First International Workshop on PET in Lymphoma in Deauville, France, in 2009, was recommended as the standard tool to score imaging to assess treatment response in patients with lymphoma using ¹⁸F-Fluorodeoxyglucose (FDG) PET/CT. Following the recommendations of the 11th and 12th International Conferences on Malignant Lymphoma held in Lugano (Switzerland), in 2011 and 2013, respectively, a consensus (the so-called Lugano Classification) was reached regarding the use of PET/CT for staging and response assessment in FDG-avid lymphomas. As a result, ¹⁸F-FDG PET/CT was formally incorporated into standard staging for FDG-avid lymphomas. A bone marrow biopsy is no longer indicated for the routine staging of HL and most diffuse large B-cell lymphomas. PET/CT will be used to assess response in FDG-avid histologies using the 5-point scale. The recent introduction of biological agents with immune mechanisms requires flexibility in interpretations of the Lugano criteria due to tumour flare or a pseudo-progression effect produced by these agents. Provisional criteria have been proposed (Lymphoma Response to Immunomodulatory Therapy Criteria) with the introduction of the term 'Indeterminate Response' in order to identify this phenomenon until confirmed as flare/pseudoprogression or true progression. All these recommendations will improve evaluations of patients with lymphoma, and allow comparison of results from clinical practice and trials.

Recommendations for Clinical Trial Development in Mantle Cell Lymphoma

Mantle cell lymphoma (MCL) comprises around 6% of all non-Hodgkin's lymphoma (NHL) diagnoses. In younger patients, age less than 60 to 65 years, aggressive induction often followed by consolidation with autologous stem cell transplant has suggested improved outcomes in this population. Less intensive therapies in older patients often followed by maintenance have been studied or are under active investigation. However, despite recent advances, MCL remains incurable, with a median overall survival of around five years. Patients with high-risk disease have particularly poor outcomes. Treatment varies widely across institutions, and to date no randomized trials comparing intensive vs less intensive approaches have been reported. Although recent data have highlighted the heterogeneity of MCL outcomes, patient assessment for treatment selection has largely been driven by patient age with little regard to fitness, disease biology, or disease risk. One critical advance is the finding that minimal residual disease status (MRD) after induction correlates with long-term outcomes. As such, its use as a potential end point could inform clinical trial design. In order to more rapidly improve the outcomes of MCL patients, clinical trials are needed that prospectively stratify patients on the basis of MCL biology and disease risk, incorporate novel agents, and use MRD to guide the need for additional therapy.

Pretransplantation Minimal Residual Disease Predicts Survival in Patients with Mantle Cell Lymphoma Undergoing Autologous Stem Cell Transplantation in Complete Remission

Autologous stem cell transplantation (ASCT) is standard therapy for mantle cell lymphoma (MCL) in remission after induction chemotherapy, with the best results for patients in complete remission (CR). We hypothesized that evaluation of minimal residual disease (MRD) before ASCT could further stratify outcomes for these patients. Patients with MCL who underwent ASCT in clinical CR between 1996 and 2011 with pretransplantation MRD testing were eligible. Presence of a clonal IgH rearrangement, t(11; 14) by PCR or positive flow cytometry from blood or bone marrow, was considered positive. An adjusted proportional hazards model for associations with progression-free (PFS) and overall survival (OS) was performed. Of 75 MCL patients in CR, 8 (11%) were MRD positive. MRD positivity was associated with shorter OS and PFS. The median OS for MRD-negative patients was not reached, with 82% survival at 5 years, whereas for the MRD-positive patients, median OS was 3.01 years (hazard ratio [HR], 4.04; P = .009), with a median follow-up of 5.1 years. The median PFS for MRD-negative patients was not reached with 75% PFS at 5 years, whereas for MRD-positive patients, it was 2.38 years (HR, 3.69; P = .002). MRD positivity is independently associated with poor outcomes after ASCT for MCL patients in CR.

Role of allogeneic stem cell transplantation in mantle cell lymphoma

Despite a wide spectrum of treatment options, mantle cell lymphoma (MCL) remains a challenging hematologic malignancy to manage. Advances in front-line therapy, including the monoclonal antibody rituximab and increasing use of cytarabine, have improved remission rates. Autologous hematopoietic cell transplantation (HCT) can effectively consolidate remission of MCL, leading to encouraging survival beyond 5 yr. However, nearly all patients with MCL will relapse and require salvage therapy. Novel agents such as ibrutinib, bortezomib, and lenalidomide have dramatically expanded the options for treating relapsed MCL. In this review, we summarize the clinical evidence supporting the use of allogeneic donor HCT in MCL and make recommendations on indications for its use. Data suggest that allogeneic donor HCT is the only curative therapy for patients with poor prognosis or aggressive MCL. Patient selection, timing, and optimal use remain a matter of scientific debate and given the rapidly changing therapeutic landscape of MCL, the outcomes of allogeneic HCT should be interpreted in the context of novel therapeutics.

Next-generation surveillance strategies for patients with lymphoma

While remission and cure rates for Hodgkin and non-Hodgkin lymphoma continue to improve, surveillance approaches remain controversial, especially in light of recent reports suggesting limited benefit for routine radiologic assessment. Routine cross-sectional imaging results in considerable patient expense and anxiety, and this approach does not clearly improve patient outcomes. Next-generation approaches including minimal residual disease detection may provide an opportunity to identify relapse early and intervene prior to progression of clinical disease. This review discusses the role of surveillance imaging in Hodgkin and non-Hodgkin lymphoma and provides an introduction to serologic assessment of minimal residual disease. Future studies will need to focus on the clinical application of minimal residual disease surveillance and its ability to predict relapse, treatment response and survival.

Nordic MCL3 study: 90Y-ibritumomab-tiuxetan added to BEAM/C in non-CR patients before transplant in mantle cell lymphoma

The main objective of the MCL3 study was to improve outcome for patients not in complete remission (CR) before transplant by adding (90)Y-ibritumomab-tiuxetan (Zevalin) to the high-dose regimen. One hundred sixty untreated, stage II-IV mantle cell lymphoma patients <66 years received rituximab (R)-maxi-CHOP (cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone) alternating with R-high-dose cytarabine (6 cycles total), followed by high-dose BEAM/C (bis-chloroethylnitrosourea, etoposide, cytarabine, and melphalan or cyclophosphamide) and autologous stem cell transplantation from 2005 to 2009. Zevalin (0.4 mCi/kg) was given to responders not in CR before transplant. Overall response rate pretransplant was 97%. The outcome did not differ from that of the historic control: the MCL2 trial with similar treatment except for Zevalin. Overall survival (OS), event-free survival (EFS), and progression-free survival (PFS) at 4 years were 78%, 62%, and 71%, respectively. For responding non-CR patients who received Zevalin, duration of response was shorter than for the CR group. Inferior PFS, EFS, and OS were predicted by positron emission tomography (PET) positivity pretransplant and detectable minimal residual disease (MRD) after transplant. In conclusion, positive PET and MRD were strong predictors of outcome. Intensification with Zevalin may be too late to improve the outcome of patients not in CR before transplant. This trial was registered at www.clinicaltrials.gov as #NCT00514475.

Is there a role for therapy response assessment with 2-[fluorine-18] fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography in mantle cell lymphoma?

2-[Fluorine-18] fluoro-2-deoxy-D-glucose-positron emission tomography/computed tomography (FDG-PET/CT) scanning is used for response assessment in mantle cell lymphoma (MCL). However, its ability to predict outcome is debatable. We retrospectively evaluated the prognostic impact of interim and post therapy FDG-PET/CT scan on outcome of 58 consecutive MCL patients. Scans performed at diagnosis, mid-therapy, post-chemotherapy and post-transplant were reviewed and outcome analyzed. Median age was 59; MCL International Prognostic Index (MIPI) was low in 45%, intermediate in 41% and high in 14%. Thirty-four patients (58%) received R-CHOP (rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, prednisone) or R-CHOP-like chemotherapy, 24 (42%) underwent upfront autologous stem-cell transplant (ASCT). Three-year overall (OS) and progression-free-survival (PFS) were 81% and 45%, respectively. No differences in OS or PFS between PET-positive and PET-negative groups both for interim and post-therapy scans were observed. We conclude that in patients treated with R-CHOP, using the International-Harmonization-Project criteria for FDG-PET/CT interpretation, there is no role for interim or post-therapy PET.

Pretransplantation fluorine-18-deoxyglucose--positron emission tomography scan lacks prognostic value in chemosensitive B cell non-hodgkin lymphoma patients undergoing nonmyeloablative allogeneic stem cell transplantation

Whether chemosensitivity, as determined by positron emission tomography using fluorine-18-deoxyglucose (FDG-PET), is a requirement for successful allogeneic hematopoietic stem cell transplantation (allo-SCT) has yet to be established. We analyzed 88 patients with B cell non-Hodgkin lymphoma (B-NHL) for event-free (EFS) and overall survival (OS) according to computed tomography (CT) and FDG-PET criteria before uniform nonmyeloablative (NMA) allo-SCT. Patients who were chemosensitive, according to CT criteria, experienced significantly greater EFS (P < .001) and OS (P < .03) compared with those who were chemorefractory at the time of allo-SCT. Of 58 patients within this cohort who were chemosensitive by CT criteria, there was no difference in EFS (P = .85) or OS (P = .96) between FDG-PET-positive (Deauville 4 to 5, n = 24) and FDG-PET-negative (Deauville 1 to 3, n = 34) patients. There was no difference in survival according to age < or ≥ 60 years, prior autologous-stem cell transplantation, allograft characteristics, or histology. FDG-PET adds no prognostic value in chemosensitive B-NHL before NMA-allo-SCT.

Management perspective for mantle cell lymphoma

SUMMARY Mantle cell lymphoma (MCL) is genetically characterized by the t(11;14) (q13;q32) translocation resulting in the overexpression of cyclin D1. It generally has an aggressive clinical course with a poor prognosis. However, there is now a recognized subgroup with clinically indolent MCL. Management of MCL can be challenging. Early recognition of young and fit patients for potential intensive therapy and autologous stem cell transplant is important. Combination of rituximab with high-dose cytarabine should be used in upfront therapy for appropriate patients. In elderly and/or less fit patients, chemoimmunotherapy may be considered. Novel agents offer promising potential in the management of MCL and are likely to change the way it is treated.

Hematopoietic cell transplantation for mantle cell lymphoma: predictive value of pretransplant positron emission tomography/computed tomography and bone marrow evaluations for outcomes

BACKGROUND

The prognostic roles of 18F-fludeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) imaging and marrow involvement evaluation on outcomes following autologous and allogeneic hematopoietic cell transplantation (HCT) for mantle cell lymphoma (MCL) are uncertain and require more data.

PATIENTS AND METHODS

We categorized 66 patients with MCL who received HCT (38 autologous and 28 allogeneic) on the basis of pre-HCT residual disease (RD) status as assessed by marrow MCL morphology and flow/molecular analysis and PET/CT imaging to RD positive (RD(+)) (either or both measures positive) and RD(-) (both negative). We analyzed the predictive value of these RD detection methods on transplant outcomes.

RESULTS

The 2-year relapse rate after autograft was significantly higher in pre-HCT RD(+) patients (46% [95% CI 16-77%]) than in patients who were RD(-) (19% [95% CI 0-42%]; P = .02), leading to worse 5-year disease-free survival (DFS) in RD(+) patients (46% [95% CI 14%-73%] vs. 68% [95% CI 33-87%], P = .04). In multivariate analysis, RD(+) status was associated with a reduction in DFS (hazard ratio, 5.6; P = .02). Most allogeneic HCT recipients had advanced disease and most were RD(+) (12 PET/CT(+); 5 marrow-positive). The 5-year DFS and relapse rates after allogeneic HCT were 34% and 25% for all patients and 40% and 33% for RD(+) recipients, suggesting that active disease at the time of allograft does not preclude long-term remissions in advanced MCL.

CONCLUSION

Both autologous and allogeneic HCT lead to promising long-term survival. RD detected prior to autograft was associated with increased relapse and worse 5 year DFS. Allograft recipients had favorable long-term outcomes even in presence of pre-HCT detectable disease.