Allogeneic Transplantation in Mantle Cell Lymphoma
Panelists: Alexey V. Danilov, MD, PhD, Oregon Health & Science University; Andre Goy, MD, Hackensack University Medical Center; John P. Leonard, MD, New York-Presbyterian/Weill Cornell Medical Center; John M. Pagel, MD, PhD, DSc, Swedish Medical Center Seattle and Issaquah; Stephen J. Schuster, MD, The University of Pennsylvania
John P. Leonard, MD: One of my most memorable patients with mantle cell lymphoma is with a woman who had been through lots of therapies. She was basically on her way to hospice and was doing quite poorly. I vividly remember being in the hospital with her. As a list-ditch thing, we put her on the pivotal trial of ibrutinib, and she had a beautiful response. We did an allogeneic transplant in her, and she’s now 5 years out, doing great. So, the question is, what is the role? And that’s obviously an extreme example. We’re not expecting that these drugs are curing patients. Certainly, there are long-term remissions with ibrutinib, and most likely with acalabrutinib as well. When are you going to do a transplant? If you’ve got a young patient–but they could be an older patient, too–who’s doing well on one of these therapies, you get them into a second or third complete response. Clearly you have to talk to them about allogeneic transplant. No doubt you’re also talking about CAR T cells. But where does allogeneic transplant fit today in this scenario?
Stephen J. Schuster, MD: I think there is a place for it. I think autologous transplant is only useful in first remission to get a nice long progression-free survival. In relapsed patients, as I alluded to before, occasionally the disease is the same as they presented with. But in general, relapsed mantle cell lymphoma is ominous. It tends to be more aggressive when it relapses. It’s not like relapsed follicular lymphoma where you can count on another long remission to second-line therapy. So, I tend to be more aggressive with this disease. Everybody gets rebiopsied, because you need to know what the mutation status is. That tells you how much mileage you get out of chemotherapy and how much you can rely on kinase inhibition or BCL-2 inhibition to get them into a remission. But those remissions or disease control states are only transient. Like in your patient’s case, I think they’re the ones that I would consider doing an allogeneic transplant on if they’re candidates, right now. Hopefully in the future, we will use CAR T cell, or something easier. I’m not the biggest fan of allogeneic transplant.
Andre Goy, MD: Today, the only way we can cure the patient in the relapsed setting is with an allogeneic transplant. Some of these patients have a very, very prolonged survival rate. I have patients who are 15 years out and are doing well.
Stephen J. Schuster, MD: But you wouldn’t do it in first remission, Andre, correct?
Andre Goy, MD: I would not do it in first remission. There are very rare exceptions. For example, if I have some very aggressive case–such as a blastoid diagnosis, or a variant of the disease where there is a lazy response to induction–then I would do that. Otherwise, no.