ESMO Guideline for Mantle Cell Lymphoma

An Expert Interview With Martin Dreyling, MD, PhD

Martin H. Dreyling, MD, PhD; Linda Brookes, MSc

Disclosures

September 25, 2014

In This Article

Where the Consensus Waivered

Medscape: Is there any mention of central nervous system (CNS) prophylaxis in the new guideline?

Prof Dreyling: With the introduction of cytarabine into the induction regimen, at least in younger patients, we think that CNS relapses will occur less often. We also refer to a recent publication, which summarizes our data,[23] and do not routinely recommend CNS prophylaxis in first-line therapy. We mention that it might only be considered in selected, high-risk cases with blastoid histology, elevated LDH, Eastern Cooperative Group (ECOG) performance status ≥ 2, and a high MIPI score.

Medscape: Were there any other points discussed where it was difficult to reach a consensus?

Prof Dreyling: There were a few points which are not really mentioned formally in the guidelines. For example, the use of positron emission tomography/computed tomography (PET/CT) is not mandatory, but it may be helpful for response evaluation specifically in limited-stage disease. Another point, which is somewhat new in guidelines, is our conclusion that in limited-stage MCL, radiation alone is not enough; we recommend chemotherapy plus radiation. The other recommendation that might help to advise our colleagues is the watch-and-wait approach in indolent cases.

Other aspects in the guideline are really modifications of prior recommendations. For example, in relapsed disease, we essentially recommend either bendamustine or high-dose cytarabine for relapsed patients, but in early relapse or early refractory cases, newer targeted approaches should be strongly considered.

Medscape: Are there any recommendations about new drugs that are in clinical trials?

Prof Dreyling: We only commented on drugs that are registered for use in MCL. However, we also listed data on the most promising investigational drugs, such as idelalisib,[24] ABT-199 (GDC-0199),[25] and obinutuzumab (GA-101),[26] but we purposely did not rank these agents on the strength of recommendations.

Medscape: In other words, the information is available if physicians are considering whether to recommend a patient to go on a clinical trial of a new drug?

Prof Dreyling: Absolutely. For example, we note that on the basis of published data, response rates of idelalisib are high in MCL[24] but response duration seems to be much shorter than with ibrutinib.

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