Management of mantle cell lymphoma in the era of novel targeted drugs

Tadeusz Robak, MD, PhD from the Medical University of Lodz, Lodz, Poland, discusses the progress in the management of mantle cell lymphoma (MCL) in the midst of the development of new targeted drugs. Prof. Robak summarizes the standards presented in the 2014 published guidelines for MCL, established by a number of institutions such as the European Society of Medical Oncology in Europe, creating standards for many oncological diseases. Prof. Robak then proceeds to briefly mention the involvement of new drugs, and the achievements and developments made within the last two years that have influenced the treatment of diseases such as MCL. MCL is described by Prof. Robak as a very heterogeneous disease, much more heterogeneous than they had thought 10-15 years ago.
Prof. Robak outlines the management of the groups of patients, by behavior and on a molecular level. He states that 10-15% of the patients have the most aggressive and progressive form of the disease, showing indolent behavior of the disease, requiring immediate therapy. Such patients are characterized by low tumor burden and smaller lymph nodes. At the molecular level, patients are characterized by SOX11-negativity, non-complex cytogenetics and low International Prognostic Index (IPI), allowing for the identification of the patients where the watch and wait strategy is the best way to manage such patients.
Prof. Robak describes another way to manage patients to be to order them by low clinical stage. Such patients would be treated less aggressively, with few courses of immunochemotherapy then with radiotherapy. About 20% of the patients are not candidates for more aggressive patients; however, 80% of the patients are to be treated more aggressively depending on their age and co-morbidity. He proceeds to state until this congress, despite significant advancements in drug developments, it could not be confirmed that stem cell transplantation could be excluded and replaced with new targeted drugs, highlighting the question of whether or not remission achieved after stem cell transplantation should be maintained. He further elaborates on how believes that patients should be divided by age (under 65 years), and by co-morbidity. Patients who are younger than 65 and patients without severe co-morbidities, should be treated with more aggressive immunochemotherapy based on high dose ara-C and rituximab, followed by consolidation with autologous stem cell transplantation. Prof. Robak further discusses the continuing importance of stem cell transplantation today. Patients older than 65 years of age, who are not fit enough to survive transplant are usually treated with immunochemotherapy. For this group of patients, R-CHOP therapy, i.e. rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone, is recommended, where similar results can be achieved using bendamustine. The combination of bendamustine with rituximab can also produce significant results and can be given instead of R-CHOP. The third therapy option is VR-CAP (R-CHOP regimen but replacing vincristine with bortezomib.
Finally, Prof. Robak discusses the most recently published Phase III trial comparing VR-CAP to R-CHOP (NCT00722137). This trial showed that replacement of vincristine with bortezomib shows a higher overall response rate, higher complete response (CR) rate, and higher progression-free survival (PFS), which suggests that it could be used as a better replacement for R-CHOP. He believes that three regimens seem to show better results for those patients. Recorded at the European Hematology Association (EHA) 2016 Annual Congress in Copenhagen, Denmark.

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