LLM 2021 | Transplant and CAR-T for relapsed MCL

I’ll be talking about transplant and CAR-T for relapsed or refractory mantle cell lymphoma. So, I’m going to talk, a very small part of the presentation will be about autologous stem cell transplant, because there’s much smaller role for autologous stem cell transplant in relapsed disease. Most patients get autologous stem cell transplant in first remission, so at the time of relapse, it’s generally a very limited role for autotransplant generally for patients who have chemosensitive disease and elected not to get a transplant in first remission. That is the main role for autologous stem cell transplant. For allogeneic stem cell transplant, that role has really been changing with the approval of CAR -cells. So allogeneic stem cell transplant, the benefit of that is that it can offer a durable remission for a proportion of patients, but of course it comes at the cost of having a high rate of toxicity, including transplant-related mortality, as well as graft-versus-host disease.

CAR T-cells have more recently entered the field with the approval of brexu-cel, and that’s very exciting for CAR T-cells for relapsed mantle cell lymphoma. They have a really high response rate. The toxicities are similar to other CD19 directed CAR T-cells, specifically axi-cel. But the main concern for CAR T-cells is we don’t know how durable the remissions are. So my general practice in relapsed mantle cell lymphoma, I generally still do a BTK inhibitor in second line, but for many of these patients, I’m already thinking about CAR T-cells and referring for CAR T-cells. If they don’t have a good response to BTK inhibitors, I go ahead and consider them for CAR T-cell. So they have a good response, I generally continue BTK inhibitors until they relapse and then consider CAR T-cells. I’m generally considering CAR T-cells prior to allo stem cell transplant in these patients, and generally, save allo for patients who relapse after CAR T-cells.