Hematopoietic stem cell transplantation in mantle cell lymphoma

Bortezomib and Vorinostat Therapy as Maintenance Therapy Post-Autologous Transplant for Non-Hodgkin's Lymphoma Using R-BEAM or BEAM Transplant Conditioning Regimen

INTRODUCTION

The success of autologous stem cell transplantation (ASCT) for treating non-Hodgkin's lymphoma (NHL) is limited by its high relapse rates. To reduce the risk of relapse, additional maintenance therapy can be added post-transplant. In a non-transplant setting at the time of initiation of this study, both bortezomib and vorinostat had been studied alone or in combination for some NHL histology and showed some clinical activity. At our center, this combination therapy post-transplant for multiple myeloma showed acceptable toxicity. Therefore, it seemed reasonable to study this combination therapy post-ASCT for NHL.

METHODS

NHL patients underwent conditioning for ASCT with rituximab, carmustine, etoposide, cytarabine, melphalan/carmustine, etoposide, cytarabine, melphalan. After recovery from the acute transplant-related toxicity, combination therapy with IV bortezomib and oral vorinostat (BV) was started and was given for a total of 12 (28-day) cycles.

RESULTS

Nineteen patients received BV post-ASCT. The most common toxicities were hematologic, gastrointestinal, metabolic, fatigue, and peripheral neuropathy. With a median follow-up of 10.3 years, 11 patients (58%) are alive without disease progression and 12 patients (63%) are alive.

CONCLUSIONS

BV can be given post-ASCT for NHL and produces excellent disease-free and overall survival rates.

Eyelid edema as a first sign of lymphoma

Chronic eyelid edema may be a symptom of different disease. The most common are autoimmune diseases such as orbital pseudotumor, vasculitis, sarcoidosis, or impaired vascular or lymphatic drainage. Rarely has it been reported as the sole manifestation of the lymphoma. Eyelid lymphoma is a special clinical entity in the spectrum of hematological malignancies. Here we present our clinical experience with eyelids lymphomas. First case is a 76-year-old female patient with bilateral edema of upper eyelid non-responding to anti-inflammatory therapy. Histological examination diagnosed mantle cells lymphoma. In the second case, 58-year-old patient was diagnosed with solitary unilateral tumor of the lower eyelid, where primary biopsy was ordered and diagnosis of MALT lymphoma was established after histological examination. In both cases, it was not solitary eyelid tumor, but systemic disease with multiple lymphadenopathy and bone marrow infiltration were found in follow-up examinations. Subsequently, patients care was given to the hemato-oncologist.

Evaluating Acalabrutinib In The Treatment Of Mantle Cell Lymphoma: Design, Development, And Place In Therapy

Mantle cell lymphoma (MCL) is an incurable intermediate-grade lymphoma representing 5-6% of non-Hodgkin's lymphomas diagnosed in the United States. The introduction of inhibitors of Bruton's tyrosine kinase (BTK) into targeted therapy for MCL has significantly improved outcomes in patients with relapsed/refractory (R/R) disease. Since the initial approval of the first-generation inhibitor, ibrutinib, several second-generation inhibitors have been explored. Acalabrutinib, a second-generation BTK inhibitor, has demonstrated impressive efficacy in clinical trials along with a safety profile that thus far appears improved compared to ibrutinib. The results of a Phase II trial in patients with R/R MCL led to the approval of acalabrutinib in this patient population while fueling further exploration of acalabrutinib in several ongoing clinical trials.

Comparation of CART19 and autologous stem-cell transplantation for refractory/relapsed non-Hodgkin's lymphoma

BACKGROUND

Autologous stem-cell transplantation (ASCT) is the standard treatment for R/R B-NHL, while chimeric antigen receptor T (CAR-T) therapy targeting CD19 emerges as an alternative strategy. Here we report a comparative analysis of the two strategies in a single center.

METHODS

We performed a prospective single-arm study of CAR-T therapy in 29 patients with R/R B-NHL and compared the outcomes with contemporaneous 27 patients who received ASCT. NHL was diagnosed by histopathological assessments, and the safety and efficacy were compared.

RESULTS

The CAR-T group exhibited better rates of CR (48.0% vs. 20.8%, P=0.046) and one-year OS (74.4% vs. 44.5%, P=0.044) compared with the ASCT group. Subpopulation analysis showed that patients with IPI scores ≥ 3 achieved significantly higher ORR and CR rates in the CAR-T group than in the ASCT group (ORR: 72.0% vs. 10.0%, P=0.002; CR: 38.9% vs 0% P=0.030, respectively). The most common severe adverse events in the CAR-T group were cytokine release syndrome, neurotoxicity and infection compared with cytopenia, gastrointestinal toxicity and infection in the ASCT group. Additionally, the incidence of non-hematologic severe adverse events (SAEs) was markedly lower in the CAR-T group than in the ASCT group (20.7% vs. 48.1% P=0.030).

CONCLUSION

CAR-T therapy exhibited superior clinical outcomes in safety and efficacy over ASCT in patients with R/R B-NHL, suggesting CAR-T may be a recommended alternative to ASCT.

Reduced-intensity or myeloablative allogeneic hematopoietic cell transplantation for mantle cell lymphoma: a systematic review

Allogeneic hematopoietic cell transplantation (allo-HCT) is the only known treatment that can offer a cure in mantle cell lymphoma, but it is unclear if regimen dose-intensity offers any advantage. We performed a systematic review/meta-analysis to assess efficacy of allo-HCT using myeloablative or reduced-intensity conditioning. We report results according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. On the basis of a relatively lower nonrelapse mortality and a slightly better progression-free survival/event-free survival and overall survival rates, reduced-intensity allo-HCT regimens appear to be the preferred choice when an allo-HCT is being considered for mantle cell lymphoma. The higher rate of relapse when offering reduced-intensity regimens cannot be ignored but certainly highlights opportunities to incorporate post-transplant strategies to mitigate this risk. A prospective comparative study is ultimately needed to generate more conclusive evidence.

Allogeneic Hematopoietic Stem Cell Transplantation in Mantle Cell Lymphoma: A Retrospective Analysis of 7 Patients

Mantle cell lymphoma (MCL) is a B cell non-Hodgkin's lymphoma characterized by a poor prognosis. Many different therapeutic approaches including intensive chemotherapy as well as new targeted therapies are established. However, overall survival remains unsatisfying. As the sole curative option, allogeneic hematopoietic stem cell transplantation (HSCT) has been described, but only a limited number of patients qualify for this procedure. We have retrospectively analyzed 7 patients with stage IV MCL undergoing allogeneic HSCT at our institution. A myeloablative regimen was used in 1 patient, while the other 6 patients received reduced-intensity conditioning. Four patients had an HLA-identical sibling, and the remaining 3 patients had an HLA-identical unrelated donor. One patient developed acute graft-versus-host disease (skin, grade III; intestine, grade II). Two patients died from transplant-related causes, 3 patients died due to progressive disease and the remaining 2 patients are still in complete remission 147 and 8 months after transplantation. Allogeneic HSCT offers a therapeutic treatment option for selected patients in a relapsed/refractory setting. The incorporation of novel agents has improved the outcome of patients with MCL. Thus, the role and optimal time point of allogeneic HSCT should be reevaluated in randomized trials.

Clinicopathologic features and management of blastoid variant of mantle cell lymphoma

The blastoid variant of mantle cell lymphoma (MCL), which accounts for less than one-third of MCL, may arise de novo or as a transformation from the classical form of MCL. Blastoid variant, which predominantly involves men in their sixth decade, has frequent extranodal involvement (40-60%), stage IV disease (up to 85%) and central nervous system (CNS) involvement. Diagnosis relies on morphological features and is challenging. Immunophenotyping may display CD23 and CD10 positivity and CD5 negativity in a subset. Genetic analysis demonstrates an increased number of complex genetic alterations. Blastoid variant responds poorly to conventional chemotherapy and has a short duration of response. Although the optimal therapy remains to be established, CNS prophylaxis and the use of aggressive immunochemotherapy followed by autologous stem cell transplant may prolong the remission rate and survival. Further studies are crucial to expand our understanding of this disease entity and improve the clinical outcome.

Lifting the mantle: Unveiling new treatment approaches in relapsed or refractory mantle cell lymphoma

The management of relapsed/refractory mantle cell lymphoma (MCL) remains a clinical challenge. A standard second-line treatment for relapsed/refractory MCL does not exist. Management of relapsed/refractory MCL requires an individualized treatment approach, incorporating factors such as: functional status, prior treatments, response to prior therapies, and disease biology. Generally, there are two categories of salvage therapy; the first, non-cross-resistant cytotoxic chemotherapeutic agents and, the second, pathway-targeted agents. For transplant eligible patients, the optimal therapy usually consists of salvage, remission re-induction phase followed, whenever possible, by a consolidation phase. Bendamustine and/or high dose cytarabine plus rituximab based chemotherapy represent the most common salvage therapy with an overall response rate of 70-80%. Consolidation with a reduced intensity conditioning allogeneic stem cell transplantation represents the only potentially curative treatment. Overall survival ranges from 30% to 50% at 5 years with this approach. For transplant ineligible patients, ibrutinib is the most effective treatment with an overall response rate of almost 70% and median response duration of 17.5 months. Lacking an effective consolidation, this approach is not considered curative. In this review we characterize the main therapeutic approaches available in this setting and summarize our preferred clinical treatment approach.

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.

Initial therapy of mantle cell lymphoma

Mantle cell lymphoma is a well-recognized distinct clinicopathologic subtype of B-cell non-Hodgkin lymphoma. The current World Health Organization (WHO) classification subdivides this entity into aggressive and other variants. The disease has a predilection for older males, and patients typically present at an advanced stage with frequent splenomegaly and extranodal involvement including bone marrow, peripheral blood, gastrointestinal, and occasional central nervous system involvement. Early studies of therapy outcomes in this disease revealed that while response rates where high, relapse was expected after a limited period of time. Prolonged survival was uncommon, with initial median survival rates typically in the 3-4-year range. Those with a high proliferative rate, blastoid morphology, and selected clinical features were recognized as having a worse prognosis. Therapeutic approaches have diverged into aggressive therapies with high response rates and promising progression free survival rates, which may be applied to younger healthy patients, and less aggressive approaches. Aggressive therapies include intensive chemotherapy alone or chemotherapy followed by autologous stem cell transplant, which has been shown to be most effective when applied in first remission. Whether these more intense therapies result in improved survival as compared with less aggressive therapies is not well established. Allogeneic transplant has also been investigated, although high treatment-related mortality and the risk of chronic graft versus host disease and the relatively advanced age of this patient population have tempered enthusiasm for this approach. A number of less aggressive therapies have been shown to produce promising results. Consolidation and maintenance strategies are an active area of investigation. A number of newer agents have shown promising activity in relapsed disease, and are being investigated in the front-line setting. Overall survival rates are improving in this disease, with current studies suggesting a median survival of 5 or more years.

Autotransplantation for mantle cell lymphoma

Mantle cell lymphoma (MCL) represents about 5% to 9% of all non-Hodgkin lymphomas according to the World Health Organization. The clinical presentation typically consists of diffuse lymphadenopathy and frequent extranodal involvement of the gastrointestinal tract, blood, and bone marrow, as well as frequent splenomegaly. The median survival with standard immunochemotherapy is approximately 3 to 5 years. High-dose chemotherapy and autologous stem cell transplantation (ASCT) have been used either in first partial or complete remission or at the time of relapse in an attempt to prolong the survival for patients with MCL. Autologous SCT has had disappointing results in patients with relapsed MCL with the expected progression-free survival approximately 20% to 40% in most trials. Therefore, most centers now consider ASCT for eligible MCL patients during first remission. If a complete remission can be obtained with the induction chemotherapy, the clinical results following ASCT in complete remission 1 are improved to 60% to 80% progression-free survival greater than 5 years. However, the median age of patients with MCL is older than 60 years, which does not allow ASCT to be used in all patients with MCL. Research is now focused on reducing the relapse rate after transplantation.

ESMO Consensus conferences: guidelines on malignant lymphoma. part 2: marginal zone lymphoma, mantle cell lymphoma, peripheral T-cell lymphoma

To complement the existing treatment guidelines for all tumour types, ESMO organizes consensus conferences to focus on specific issues in each type of tumour. In this setting, a consensus conference on the management of lymphoma was held on 18 June 2011 in Lugano, next to the 11th International Conference on Malignant Lymphoma. The conference convened ∼30 experts from all around Europe, and selected six lymphoma entities to be addressed; for each of them, three to five open questions were to be addressed by the experts. For each question, a recommendation should be given by the panel, referring to the strength of the recommendation based on the level of evidence. This consensus report focuses on the three less common lymphoproliferative malignancies: marginal zone lymphoma, mantle cell lymphoma, and peripheral T-cell lymphomas. A first report had focused on diffuse large B-cell lymphoma, follicular lymphoma, and chronic lymphocytic leukaemia.

Mantle cell lymphoma

MCL is a well-characterized clinically aggressive lymphoma with a poor prognosis. Recent research findings have slightly improved the outcome of this neoplasm. The addition of rituximab to conventional chemotherapy has increased overall response rates, but it does not improve overall survival with respect to chemotherapy alone. The use of intensive frontline therapies including rituximab and consolidated by ASCT ameliorates response rate and prolongs progression-free survival, 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 dissection of pathogenetic pathways in MCL might improve the outcome of conventional chemotherapy in most patients and spare the toxicity of intense therapy in a minority of MCL patients characterized by a relatively indolent disease. Patients not eligible for intensive regimens, such as hyperC-VAD, 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 for relapsed disease, although there are currently no data to recommend this approach as the first-line strategy. As the optimal approach to the management of MCL is still evolving, it is critical that these patients be enrolled in clinical trials to identify better treatment options.

Transplantation for non-Hodgkin lymphoma

High-dose therapy followed by autologous hematopoietic stem cell transplantation (auto-HCT) has become the treatment of choice for patients with relapsed aggressive non-Hodgkin lymphoma (NHL). However, relapse remains the most common cause of treatment failure after auto-HCT. More intensive regimens incorporating radioimmunotherapy into high-dose regimens have been developed to prevent relapse. The role of auto-HCT for follicular lymphoma and mantle cell lymphoma remain inconclusive. Since prognosis of patients with peripheral T-cell lymphoma, not otherwise specified are very poor with conventional chemotherapy, auto-HCT during first remission is being explored in peripheral T-cell lymphoma. Given the lower risk of relapse after allogeneic HCT (allo-HCT) in NHL, allo-HCT has been performed in patients with refractory or relapsed NHL, especially after auto-HCT failure. However, the transplant-related mortality remains high after myeloablative allo-HCT. Reduced-intensity conditioning followed by allo-HCT has been shown to reduce transplant-related mortality but graft-versus-host disease continues to be the major problem, thus the role of allo-HCT in NHL remains an investigational approach for NHL. The outcomes of auto-HCT and allo-HCT for various lymphomas are reviewed.

Should there be a standard therapy for mantle cell lymphoma?

Mantle cell lymphoma (MCL) is an uncommon subtype of B-cell lymphomathat is characterized by monoclonal B cells that express CD5 on their surface, but not CD23, and harbor the t(11:14) chromosomal translocation that leads to dysregulated expression of cyclin D1. MCL is a biologically and clinically heterogeneous disease. It has the unfavorable characteristics of both aggressive and indolent lymphoma in that MCL is not curable with current standard therapy, yet patients have a shorter survival compared with other indolent histology. MCL is incurable, yet more intensive therapy does lead to longer disease-free intervals; therefore, treatment must be designed to optimize survival while maintaining quality of life. Thus, therapy should be individualized based on both the clinical behavior of the lymphoma and the patient’s status. While there is no clear standard therapy that can be recommended for all patients, there may be an optimal choice for each patient. Knowledge of the expected clinical benefits and toxicities of various approaches will allow the physician and patient to appropriately select the therapy.

Patterns and outcome of relapse after autologous stem cell transplantation for mantle cell lymphoma

BACKGROUND

Autologous stem cell transplantation (autoSCT) has improved the outcome of patients with mantle cell lymphoma (MCL) considerably. However, little is known about the patterns and outcome of MCL recurrence after autoSCT.

METHODS

The authors conducted a retrospective study of 118 patients with MCL who underwent autoSCT from August 1992 to August 2008 at 3 different referral centers in Germany.

RESULTS

Fifty-two relapses occurred for a cumulative incidence of 46% after 5 years. Only 3 patients relapsed after 5 years (at 90 months, 91 months, and 171 months) after undergoing autoSCT. A Cox regression analysis of the incidence of relapse identified not receiving rituximab before autoSCT and undergoing salvage autoSCT as predictive factors for relapse, whereas cytosine arabinoside intensification; a total body irradiation-based, high-dose regimen; patient age; and year of transplantation had no influence. The median overall survival (OS) after relapse was 23 months. Twenty patients (39%) underwent allogeneic stem cell transplantation (alloSCT) for relapse, and 11 of those patients remained in ongoing complete remission at the time of the current report. It is noteworthy that there were 4 long-term survivors who lived for >5 years after relapse even without undergoing alloSCT. A Cox regression analysis of OS after relapse revealed that the response duration after autoSCT was an adverse predictor of OS, whereas alloSCT was associated with a significantly longer OS after relapse.

CONCLUSIONS

The current results indicated that autoSCT was capable of inducing long-term remission up to 16 years after treatment, but the outcome of patients with MCL who relapsed after autoSCT was poor, especially if their response duration after autoSCT was short. However, for a subset of patients with relapsed MCL, alloSCT may offer the possibility of durable survival, and individual patients can enjoy long-term survival after relapse even without undergoing alloSCT.

Mantle cell lymphoma: Frontline and salvage therapy

Mantle cell lymphoma (MCL) is a therapeutic challenge because of its lower cure rate when compared with other lymphomas such as diffuse large cell lymphoma. The current emphasis in the treatment of newly diagnosed MCL has been on intensifying chemotherapy, but there is no consensus on the need to consolidate with autologous stem cell transplantation. These approaches, however, have not resulted in a cure. Newer strategies include the use of models to aid in tailoring therapy. Likewise, autologous stem cell consolidation does not cure relapsed disease. Because of its known graft-versus-lymphoma effect, allogeneic stem cell transplantation offers a potentially curative option for relapsed MCL. New insights into resistance pathways and new drugs created to inhibit them offer great promise in the treatment of newly diagnosed and previously treated MCL.

Tackling mantle cell lymphoma (MCL): Potential benefit of allogeneic stem cell transplantation

Mantle cell lymphoma (MCL) is a type of non-Hodgkins lymphoma (NHL) associated with poor progression-free and overall survival. There is a high relapse rate with conventional cytotoxic chemotherapy. Intensive combination chemotherapy including rituximab, dose intense CHOP- (cyclophosphamide-doxorubicin-vincristine-prednisone) like regimens, high dose cytarabine, and/or consolidation with autologous stem cell transplant (autoSCT) have shown promise in significantly prolonging remissions. Data from phase II studies show that even in patients with chemotherapy refractory MCL, allogeneic stem cell transplant (alloSCT) can lead to long term disease control. Most patients with MCL are not candidates for myeloablative alloSCT due to their age, comorbidities, and performance status. The advent of less toxic reduced intensity conditioning (RIC) regimens, which rely more on the graft-versus-lymphoma (GVL) effect, have expanded the population of patients who would be eligible for alloSCT. RIC regimens alter the balance of toxicity and efficacy favoring its use. Treatment decisions are complicated by introduction of novel agents which are attractive options for older, frail patients. Further studies are needed to determine the role and timing of alloSCT in MCL. Currently, for selected fit patients with chemotherapy resistant MCL or those who progress after autoSCT, alloSCT may provide long term survival.

[Mantle cell lymphoma: an overview from diagnosis to future therapies]

Mantle cell lymphoma (MCL) is a rare non-Hodgkin lymphoma (NHL) entity. The translocation between chromosomes 11 and 14 is the cytogenetics hallmark of MCL. This translocation leads to the dysregulation of the CCDN1 gene, and overexpression of cyclin D1 which promotes cell cycling. Despite a classical phenotype (CD19+, CD20+, CD5+, CCND1+, CD10-, CD23-, Bcl-2+, Ig at the membrane, mainly IgM), MCL is not a homogeneous disease and several cytological, phenotypic, cytogenetic and clinical variants have been described. MCL represents 5 % of NHLs with its incidence constantly increasing over the last years. Median age at diagnosis is 68 years. Stage III-IV disease is observed in more than 80 % of patients at presentation, with intestinal and bone marrow being the most frequently involved organs, while the spleen is enlarged in half of cases. Intensive strategies including high-dose chemotherapy, followed by autologous stem cell transplantation have significantly improved the outcome of MCL patients. Median overall survival rate increased from 3 to 5 years during the last decade. At present, induction chemotherapy followed by high-dose chemotherapy and autologous stem cell transplantation is the standard regimen in younger patients. However, most of MCL patients will experience relapse. Thus, close monitoring of minimal residual disease (currently under evaluation) may represent a valuable tool for assessment of disease response during follow-up. Future innovative therapies that are being presently investigated in prospective trials include transduction pathways inhibitors, proteasome inhibitors, pro-apoptotic molecules, immunotherapy and/or radiolabeled immunotherapy, and will likely open a new era for targeted therapies in MCL.

NCI First International Workshop on the Biology, Prevention, and Treatment of Relapse after Allogeneic Hematopoietic Stem Cell Transplantation: report from the Committee on the Epidemiology and Natural History of Relapse following Allogeneic Cell Transplantation

Allogeneic hematopoietic stem cell transplantation (alloHSCT) is increasingly being used for treatment of hematologic malignancies, and the immunologic graft-versus-tumor effect (GVT) provides its therapeutic effectiveness. Disease relapse remains a cause of treatment failure in a significant proportion of patients undergoing alloHSCT without improvements over the last 2-3 decades. We summarize here current data and outline future research regarding the epidemiology, risk factors, and outcomes of relapse after alloHSCT. Although some factors (eg, disease status at alloHSCT or graft-versus-host disease [GVHD] effects) are common, other disease-specific factors may be unique. The impact of reduced-intensity regimens on relapse and survival still need to be assessed using contemporary supportive care and comparable patient populations. The outcome of patients relapsing after an alloHSCT generally remains poor even though interventions including donor leukocyte infusions can benefit some patients. Trials examining targeted therapies along with improved safety of alloHSCT may result in improved outcomes, yet selection bias necessitates prospective assessment to gauge the real contribution of any new therapies. Ongoing chronic GVHD (cGVHD) or other residual post-alloHSCT morbidities may limit the applicability of new therapies. Developing strategies to promptly identify patients as alloHSCT candidates, while malignancy is in a more treatable stage, could decrease relapses rates after alloHSCT. Better understanding and monitoring of minimal residual disease posttransplant could lead to novel preemptive treatments of relapse. Analyses of larger cohorts through multicenter collaborations or registries remain essential to probe questions not amenable to single center or prospective studies. Studies need to provide data with detail on disease status, prior treatments, biologic markers, and posttransplant events. Stringent statistical methods to study relapse remain an important area of research. The opportunities for improvement in prevention and management of post-alloHSCT relapse are apparent, but clinical discipline in their careful study remains important.

Evaluation of the (R)VAD+C regimen for the treatment of newly diagnosed mantle cell lymphoma. Combined results of two prospective phase II trials from the French GOELAMS group

Background There is currently no international consensus for first-line treatment (prior to autologous stem cell transplantation) in mantle cell lymphoma patients. Here, we investigated the efficacy and tolerance of VAD associated with chlorambucil (VAD+C) and rituximab or not before autologous stem cell transplantation.

DESIGN AND METHODS

Between 1996 and 2005, 113 previously untreated mantle cell lymphoma patients were enrolled in two consecutive prospective phase II studies. Responses and response factors to the (R)VAD+C regimen were evaluated. The survival prognostic value of the MIPI score and Ki67 were also analyzed.

RESULTS

The induction phase of 4 courses of (R)VAD+C showed very low hematologic and extra-hematologic toxicity (grade 3-4 thrombopenia and neutropenia, 9% and 2.7%, respectively and grade 3-4 extra-hematologic toxicities, 1.6%). Overall and complete response rates were 73% and 46%, respectively, and rose to 83% and 51% for the 70% of patients with less than two independent response factors (LDH, B symptoms and lymphocytosis). At the end of treatment, 65% of patients were in complete remission. Progression free and overall survival were significantly better in the transplanted population. The MIPI score was confirmed as a predictor of survival. Ki67, serum LDH, Performance Status (PS) and B symptoms were identified as independent prognostic factors of survival. A prognostic scoring system could stratify patients into three risk groups with markedly different median overall survival of 112, 44 and 11 months, respectively. Conclusions The (R)VAD+C is an effective regimen with very low toxicity. In addition to the MIPI score, Ki67 expression provides additional independent prognostic information for the prediction of overall survival (ClinicalTrials.gov Identifier: NCT00285389).

Genomic and gene expression profiling defines indolent forms of mantle cell lymphoma

Mantle cell lymphoma (MCL) is typically a very aggressive disease with poor outcomes, but some cases display an indolent behavior that might not necessitate treatment at diagnosis. To define molecular criteria that might permit recognition of such cases, we compared the clinicopathologic features, gene expression, and genomic profile of patients who had indolent or conventional disease (iMCL or cMCL). Patients with iMCL displayed nonnodal leukemic disease with predominantly hypermutated IGVH and noncomplex karyotypes. iMCL and cMCL shared a common gene expression profile that differed from other leukemic lymphoid neoplasms. However, we identified a signature of 13 genes that was highly expressed in cMCL but underexpressed in iMCL. SOX11 was notable in this signature and we confirmed a restriction of SOX11 protein expression to cMCL. To validate the potential use of SOX11 as a biomarker for cMCL, we evaluated SOX11 protein expression in an independent series of 112 cases of MCL. Fifteen patients with SOX11-negative tumors exhibited more frequent nonnodal presentation and better survival compared with 97 patients with SOX11-positive MCL (5-year overall survival of 78% versus 36%, respectively; P = 0.001). In conclusion, we defined nonnodal presentation, predominantly hypermutated IGVH, lack of genomic complexity, and absence of SOX11 expression as qualities of a specific subtype of iMCL with excellent outcomes that might be managed more conservatively than cMCL.

Controversies in lymphoma: the role of hematopoietic cell transplantation for mantle cell lymphoma and peripheral T cell lymphoma

Mantle cell lymphoma (MCL) and peripheral T cell lymphoma (PTCL) are distinct lymphoma subtypes that each comprise about approximately 10% of the non-Hodgkin lymphomas. Although both subtypes are characterized by high remission rates to frontline chemotherapy, the prognosis is generally poor because of inevitable relapse within 1-2 years or less, depending on the specific histology. Patients with MCL who achieve a complete remission with upfront conventional chemotherapy currently have several options for consolidative therapy including maintenance therapy with rituximab, autologous hematopoietic cell transplantation (HCT), and more recently, allogeneic HCT utilizing a reduced intensity conditioning (RIC) regimen. In the autologous HCT setting, the added efficacy of rituximab is under active investigation as a method of in vivo purging during hematopoietic cell mobilization, as part of the conditioning regimen and as post-HCT maintenance therapy. For patients with PTCL, autologous HCT is commonly offered at relapse but there are a few prospective series utilizing autologous HCT as consolidation of CR1 with encouraging results. There is no conclusive evidence regarding the efficacy of allogeneic HCT, but outcomes with RIC regimens appear promising. This review summarizes the current role of HCT for patients with MCL in first remission and for patients with PTCL as consolidation and for relapsed/refractory disease.

Outcome of deferred initial therapy in mantle-cell lymphoma

PURPOSE

Treatment of mantle-cell lymphoma (MCL) is nonstandardized, though patients are commonly treated immediately at diagnosis. Because data on observation, or "watch and wait," have not been previously reported, we analyzed the outcome of deferred initial therapy.

PATIENTS AND METHODS

Inclusion criteria in this retrospective analysis were a diagnosis of MCL between 1997 and 2007 and known date of first treatment. Hospital and research charts were reviewed for prognostic and treatment-related information. Date of death was derived from hospital records and confirmed using an online Social Security death index.

RESULTS

Of 97 patients with MCL evaluated at Weill Cornell Medical Center, 31 patients (32%) were observed for more than 3 months before initial systemic therapy, with median time to treatment for the observation group of 12 months (range, 4 to 128 months). The observation group (median follow-up, 55 months) had a median age of 58 years (range, 40 to 81 years). Prognostic factors in assessable patients included advanced stage (III/IV) in 75%, elevated lactate dehydrogenase in 25%, and intermediate- or high-risk Mantle Cell International Prognostic Index in 54%. Better performance status and lower-risk standard International Prognostic Index scores were more commonly present in those undergoing observation. Although time to treatment did not predict overall survival in a multivariate analysis, the survival profile of the observation group was statistically superior to that of the early treatment group (not reached v 64 months, P = .004).

CONCLUSION

In selected asymptomatic patients with MCL, deferred initial treatment ("watch and wait") is an acceptable management approach.

Effect of remission status and induction chemotherapy regimen on outcome of autologous stem cell transplantation for mantle cell lymphoma

We analysed the outcomes of autologous stem cell transplantation (ASCT) following high-dose therapy with respect to remission status at the time of transplantation and induction regimen used in 56 consecutive patients with mantle cell lymphoma (MCL). Twenty-one patients received induction chemotherapy with HyperCVAD with or without rituximab (+/-R) followed by ASCT in first complete or partial remission (CR1/PR1), 15 received CHOP (+/-R) followed by ASCT in CR1/PR1 and 20 received ASCT following disease progression. Estimates of overall and progression-free survival (PFS) at 3 years among patients transplanted in CR1/PR1 were 93% and 63% compared with 46% and 36% for patients transplanted with relapsed/refractory disease, respectively. The hazard of mortality among patients transplanted with relapsed/refractory disease was 6.09 times that of patients transplanted in CR1/PR1 (P = 0.006). Patients in the CHOP (+/-R) group had a higher risk of failure for PFS compared with patients in the HyperCVAD (+/-R) group, though the difference did not reach statistical significance (hazard ratio 3.67, P = 0.11). These results suggest that ASCT in CR1/PR1 leads to improved survival outcomes for patients with MCL compared to ASCT with relapsed/refractory disease, and a HyperCVAD (+/-R) induction regimen may be associated with an improved PFS among patients transplanted in CR1/PR1.

Therapeutic options in mantle cell lymphoma

Mantle cell lymphoma (MCL) is an aggressive lymphoma requiring intensive chemotherapy +/- autologous stem cell transplantation (SCT) to achieve optimal rates of progression-free survival. Here we review the treatment options for patients with newly-diagnosed or relapsed MCL and discuss recent advances in management, including the role of autologous and allogeneic SCT.

Bortezomib in mantle cell lymphoma

Mantle cell lymphoma (MCL) represents 6% of non-Hodgkin lymphomas, but is one of the most active fields of clinical investigation. Unfortunately, there is still no standard or curative therapy in MCL. Front-line therapy appears to benefit from intensification either through high-dose therapy with stem cell transplant consolidation or dose-intense chemotherapy with hyperfractionated cyclophosphamide, vincristine, adriamycin/doxorubicin and dexamethasone/rituximab. Most patients still relapse and a multitude of novel agents are currently being tested in this setting, including proteasome inhibitors with bortezomib (the first of its class and the first US FDA-approved drug for MCL), mTOR inhibitors, Bcl-2 inhibitors, antiangiogenesis agents and histone deacetylase inhibitors among others. An obvious effort is needed to enroll patients on clinical trials, the design of which might benefit from pharmacogenomics and a better understanding of MCL biology and its diversity.

Expanding therapeutic options in mantle cell lymphoma

Mantle cell lymphoma (MCL) still carries a poor prognosis. Chemoimmunotherapy (combination with rituximab) is the routine first-line therapy, although data strongly suggest a benefit from intensification through high-dose therapy with stem cell transplantation consolidation or dose-intense chemotherapy with HyperCVAD (fractionated cyclophosphamide/vincristine/doxorubicin/dexamethasone)/rituximab. Unfortunately, most patients still experience relapse, and a multitude of novel agents are currently being tested in this setting, including proteasome inhibitors with bortezomib (the first of its class and first Food and Drug Administration-approved drug in MCL), mammalian target of rapamycin inhibitors, Bcl-2 inhibitors, and antiangiogenesis agents, among others. Because of the relative rarity of the disease-MCL represents 6% of non-Hodgkin lymphoma-an obvious effort is needed to enroll patients on clinical trials. Not surprisingly, as in other non-Hodgkin lymphomas, MCL appears more and more as a heterogeneous disease, which might impact future clinical trial design through pharmacogenomics and hopefully help us develop smaller "molecular" relevant trials.

Mantle cell lymphoma presenting with unusual morphology in an adolescent female: a case report and review of the literature

We report the case of an 18-year-old female initially diagnosed with CD5-negative diffuse large B-cell lymphoma in an inguinal lymph node in 1999 who subsequently relapsed with classic-morphology mantle cell lymphoma with involvement of the bone marrow, gastrointestinal tract, and spleen in 2004. Both the 1999 and 2004 lesions were retrospectively positive for Cyclin D1 by immunohistochemistry and positive for t(11:14)(q13;q32) by fluorescence in situ hybridization, and both lesions had identical B-cell receptor gene rearrangements by polymerase chain reaction. This case of a CD5-negative large cell or pleomorphic blastoid variant of mantle cell lymphoma arising in an 18-year-old represents a very early incidence for this type of lymphoma, which is usually not seen in younger patients.

Blood or marrow transplantation for mantle cell lymphoma

PURPOSE OF REVIEW

Mantle cell lymphoma is a generally incurable disease for which blood or marrow transplantation is frequently considered. This review assesses the more recent literature on high-dose therapeutic approaches for mantle cell lymphoma.

RECENT FINDINGS

The benefit of transplantation is most apparent in first remission. Autologous transplantation can prolong event-free and possibly overall survival, although no plateau has been demonstrated in the survival curve. A randomized controlled trial demonstrated a significant event-free survival advantage to upfront autologous transplantation compared with interferon maintenance. The relative merit of autologous versus allogeneic transplantation remains to be better defined.

SUMMARY

The role of transplantation for mantle cell lymphoma is controversial, as the impact on overall survival is unclear. Transplantation should be considered early in the disease course. Elimination of minimal residual disease through in-vivo purging of stem cells may translate into more durable remissions. Nonmyeloablative allogeneic transplantation and high-dose radioimmunotherapy are topics of ongoing investigation.

Immunotherapy with rituximab/interleukin-2 after autologous stem cell transplantation as treatment for CD20+ non-Hodgkin's lymphoma

BACKGROUND

Relapse of non-Hodgkin's lymphoma (NHL) remains a problem after autologous stem cell transplantation (ASCT). Soon after ASCT, the immune system is not very active, and this immune incompetence could thus result in decreased ability for immune-mediated tumor eradication. The early addition of immunotherapy after ASCT might decrease the incidence of relapse and prolong survival. In an initial phase I/II trial at our center, the immune modulator interleukin-2 (IL-2) increased over baseline natural killer and lymphokine-activated killer activity in vitro. Because rituximab can lyse CD20-bearing cells by antibody-dependent cellular cytotoxicity, adding IL-2 to rituximab might boost its effectiveness. It thus seemed reasonable to study this combination after ASCT. The results of our phase II study are reported herein.

PATIENTS AND METHODS

Twenty patients with CD20+ NHL who had ASCT were treated. The median time to starting therapy was 79 days (range, 49-100 days) after transplantation.

RESULTS

The majority of patients reported grade <or= 2 erythema, induration and pain at IL-2 injection sites, flu-like symptoms, and worsening fatigue. Neutropenia that responded to granulocyte colony-stimulating factor was the most common grade 3/4 toxicity, seen in 45% of patients. There were no treatment-related deaths. Eighteen of 20 patients remain alive in complete remission, with a median follow-up of 55.5 months (range, 17-64 months).

CONCLUSION

Interleukin-2/rituximab can be administered after ASCT with manageable toxicity. A randomized trial is under way to address whether this combination therapy is beneficial to patients with NHL who have had ASCT.

Radioimmunotherapeutic strategies in autologous hematopoietic stem-cell transplantation for malignant lymphoma

High-dose therapy followed by autologous hematopoietic stem-cell transplantation is the preferred therapy for relapsed chemotherapy-sensitive aggressive non-Hodgkin lymphoma, and may play a role in the treatment of high-risk first-remission aggressive lymphomas, mantle-cell lymphomas and relapsed follicular lymphomas. The primary cause of failure of this approach is disease recurrence despite initial responses. Traditional high-dose regimens have relied upon myeloablative combinations of chemotherapy with or without total body irradiation. In the Western world, over 90% of lymphomas are of B-cell origin, and the vast majority of those that come to transplant remain CD20-positive. The development of radioimmunotherapeutic approaches targeting this antigen allows for either dose escalation with stem-cell support, or the addition of targeted therapy to conditioning regimens either as a replacement for total body irradiation or in addition to myeloablative chemotherapy regimens. Results to date with yttrium-90 ibritumomab tiuxetan (Zevalin) and I-131 tositumomab (Bexxar) suggest that the addition of radioimmunoconjugate therapy to conventional conditioning regimens results in a toxicity profile similar to that seen with chemotherapy conditioning alone. Demonstration of improved disease control will ultimately require phase-III studies, though preliminary results are promising.