Dr Kahl on TRIANGLE Data and the Changing Role of ASCT in Frontline MCL Management

“For many years, standard therapy for MCL included semi-intensive induction, ASCT consolidation, and later maintenance rituximab, making the first year [of treatment] difficult for patients… The TRIANGLE study put an end to ASCT in the first-line management of MCL.”

Brad S. Kahl, MD, a professor of medicine in the Division of Oncology and director of the Lymphoma Program at Washington University School of Medicine, discussed how findings from the phase 3 TRIANGLE trial (NCT02858258) have changed the role of autologous stem cell transplantation (ASCT) in the frontline management of mantle cell lymphoma (MCL).

Kahl began by explaining how standard therapy for younger, transplant-eligible patients with MCL commonly consisted of semi-intensive induction therapy followed by ASCT consolidation with rituximab (Rituxana) maintenance later being incorporated into the approach. Although the strategy improved outcomes, Kahl noted that the first year of treatment can be difficult for patients due to its intensity and prolonged duration.

With introduction of novel agents to the MCL treatment paradigm over the past decade, he added that large trials like TRIANGLE, which was conducted by the European Mantle Cell Lymphoma Network, incorporated the BTK inhibitor, ibrutinib (Imbruvica) into frontline treatment strategies. Notably, Kahl underscored how one experimental arm in the trial added ibrutinib to an ASCT-containing strategy, whereas in another arm of the trial, patients received ibrutinib without ASCT.

Results from TRIANGLE were initially presented at an American Society of Hematology Annual Meeting, been published, and now include longer-term follow-up, Kahl said. Moreover, both ibrutinib-containing arms performed better than the arm that did not include the BTK inhibitor, he highlighted. Kahl included how these benefits were observed in failure-free survival and has subsequently extended to overall survival, resulting in the ibrutinib-based regimen without ASCT performing better than the transplant-based strategy.

Based on the improved outcomes observed with the ibrutinib-based arm in TRIANGLE, Kahl believes the study has effectively ended the routine role of ASCT in the first-line management of MCL.