Mantle cell lymphoma

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 Tarsheen Sethi, MD, MSCI
Yale University
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76 regimens on this page
101 variants on this page

Contents


Guidelines

ESMO

Older

NCCN

First-line therapy, pre-phase

CVP (Prednisolone)

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CVP: Cyclophosphamide, Oncovin (Vincristine), Prednisolone

Regimen

Study Evidence
Le Gouill et al. 2017 (LyMa) Non-randomized portion of RCT

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Chemotherapy

21-day course

Subsequent treatment

References

  1. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article link to protocol contains verified protocol in supplement PubMed NCT00921414

First-line therapy, randomized data

BR

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BR: Bendamustine, Rituximab
RB: Rituximab, Bendamustine

Regimen variant #1, 3 cycles

Study Evidence
Armand et al. 2016 (DFCI 12-168) Phase II

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Chemotherapy

Targeted therapy

28-day cycle for 3 cycles

Subsequent treatment

Regimen variant #2, 6 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Rummel et al. 2013 (StiL NHL1) 2003-2008 Phase III (E-switch-ic) R-CHOP Superior PFS
Chen et al. 2016 (SWOG S1106) 2012-2013 Randomized Phase II (E-de-esc) R-Hyper-CVAD/R-MA Did not meet primary endpoint of PFS24

Chemotherapy

Targeted therapy

Supportive medications

  • Antiemetics, antipyretics, and antibiotics according to local standard of care
  • Prophylactic use of G-CSF allowed according ASCO guidelines (2006)

28-day cycle for up to 6 cycles

Subsequent treatment

Regimen variant #3, 8 cycles

Study Years of enrollment Evidence Comparator Comparative Efficacy
Flinn et al. 2014 (BRIGHT) 2009-2012 Phase III (E-switch-ic) 1. R-CHOP
2. R-CVP 		Superior PFS (*)

Note: Reported efficacy is based on the 2019 update.

Chemotherapy

Targeted therapy

Supportive medications

  • Antiemetics, antipyretics, and antibiotics according to local standard of care
  • Prophylactic use of G-CSF allowed according ASCO guidelines (2006)

28-day cycle for up to 8 cycles

References

  1. StiL NHL1: Rummel MJ, Niederle N, Maschmeyer G, Banat GA, von Grünhagen U, Losem C, Kofahl-Krause D, Heil G, Welslau M, Balser C, Kaiser U, Weidmann E, Dürk H, Ballo H, Stauch M, Roller F, Barth J, Hoelzer D, Hinke A, Brugger W; StiL. Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. Lancet. 2013 Apr 6;381(9873):1203-10. Epub 2013 Feb 20. Erratum in: Lancet. 2013 Apr 6;381(9873):1184. link to original article contains verified protocol PubMed NCT00991211
    1. Update: Abstract: Mathias J. Rummel, MD, Georg Maschmeyer, MD, Arnold Ganser, Andrea Heider, PhD, Ulrich von Grünhagen, MD, PhD5, Christoph Losem, Gerhard Heil, MD, Manfred Welslau, Christina Balser, MD, Ulrich Kaiser, MD, Eckhart Weidmann, Heinz Dürk, MD, Hans Peter Böck, Martina Beate Stauch, MD, Jürgen Barth, Wolfgang Blau, MD, Alexander Burchardt, MD, Frank Kauff, PhD, Axel Hinke, PhD and Wolfram Brugger, MD. Bendamustine Plus Rituximab (B-R) Versus CHOP Plus Rituximab (CHOP-R) As First-Line Treatment in Patients with Indolent and Mantle Cell Lymphomas (MCL) – 7 Year Updated Results from the StiL NHL1 Study. Blood 2014 124:4407. link to abstract
  2. BRIGHT: Flinn IW, van der Jagt R, Kahl BS, Wood P, Hawkins TE, Macdonald D, Hertzberg M, Kwan YL, Simpson D, Craig M, Kolibaba K, Issa S, Clementi R, Hallman DM, Munteanu M, Chen L, Burke JM. Randomized trial of bendamustine-rituximab or R-CHOP/R-CVP in first-line treatment of indolent NHL or MCL: the BRIGHT study. Blood. 2014 May 8;123(19):2944-52. Epub 2014 Mar 3. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Flinn IW, van der Jagt R, Kahl B, Wood P, Hawkins T, MacDonald D, Simpson D, Kolibaba K, Issa S, Chang J, Trotman J, Hallman D, Chen L, Burke JM. First-line treatment of patients with indolent non-Hodgkin lymphoma or mantle-cell lymphoma with bendamustine plus rituximab versus R-CHOP or R-CVP: results of the BRIGHT 5-year follow-up study. J Clin Oncol. 2019 Apr 20;37(12):984-991. Epub 2019 Feb 27. link to original article link to PMC article PubMed
  3. DFCI 12-168: Armand P, Redd R, Bsat J, Mayuram S, Giardino A, Fisher DC, LaCasce AS, Jacobson C, Davids MS, Brown JR, Weng L, Wilkins J, Faham M, Freedman AS, Joyce R, Jacobsen ED. A phase 2 study of rituximab-bendamustine and rituximab-cytarabine for transplant-eligible patients with mantle cell lymphoma. Br J Haematol. 2016 Apr;173(1):89-95. Epub 2016 Jan 5. link to original article contains verified protocol PubMed
  4. SWOG S1106: Chen RW, Li H, Bernstein SH, Kahwash S, Rimsza LM, Forman SJ, Constine L, Shea TC, Cashen AF, Blum KA, Fenske TS, Barr PM, Phillips T, Leblanc M, Fisher RI, Cheson BD, Smith SM, Faham M, Wilkins J, Leonard JP, Kahl BS, Friedberg JW. RB but not R-HCVAD is a feasible induction regimen prior to auto-HCT in frontline MCL: results of SWOG Study S1106. Br J Haematol. 2017 Mar;176(5):759-769. Epub 2016 Dec 19. link to original article link to PMC article does not contain protocol PubMed NCT01412879
    1. Update: Kamdar M, Li H, Chen RW, Rimsza LM, Leblanc ML, Fenske TS, Shea TC, Barr PM, Phillips TJ, Leonard JP, Kahl BS, Friedberg JW, Smith SM. Five-year outcomes of the S1106 study of R-hyper-CVAD vs R-bendamustine in transplant-eligible patients with mantle cell lymphoma. Blood Adv. 2019 Oct 22;3(20):3132-3135. link to original article link to PMC article PubMed

CHOP

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CHOP: Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Nickenig et al. 2006 (GLSG '96) 1996-1998 Phase III (C) MCP Might have superior ORR
Lenz et al. 2005 2000-2002 Phase III (C) R-CHOP Inferior ORR

Chemotherapy

21-day cycle for 6 to 8 cycles

References

  1. Lenz G, Dreyling M, Hoster E, Wörmann B, Dührsen U, Metzner B, Eimermacher H, Neubauer A, Wandt H, Steinhauer H, Martin S, Heidemann E, Aldaoud A, Parwaresch R, Hasford J, Unterhalt M, Hiddemann W; German Low Grade Lymphoma Study Group. Immunochemotherapy with rituximab and cyclophosphamide, doxorubicin, vincristine, and prednisone significantly improves response and time to treatment failure, but not long-term outcome in patients with previously untreated mantle cell lymphoma: results of a prospective randomized trial of the German Low Grade Lymphoma Study Group (GLSG). J Clin Oncol. 2005 Mar 20;23(9):1984-92. Epub 2005 Jan 24. link to original article PubMed
  2. GLSG '96: Nickenig C, Dreyling M, Hoster E, Pfreundschuh M, Trumper L, Reiser M, Wandt H, Lengfelder E, Unterhalt M, Hiddemann W; German Low-Grade Lymphoma Study Group. Combined cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) improves response rates but not survival and has lower hematologic toxicity compared with combined mitoxantrone, chlorambucil, and prednisone (MCP) in follicular and mantle cell lymphomas: results of a prospective randomized trial of the German Low-Grade Lymphoma Study Group. Cancer. 2006 Sep 1;107(5):1014-22. link to original article contains verified protocol PubMed

FC

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FC: Fludarabine, Cyclophosphamide

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Rule et al. 2015 (CRUK-UCL-MCLIII) 2002-2010 Phase III (C) FCR Inferior OS

Chemotherapy

  • Fludarabine (Fludara) 40 mg/m2 PO once per day on days 1 to 3
    • Patients intolerant of the oral route received 25 mg/m2 IV once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) 250 mg/m2 PO once per day on days 1 to 3
    • Patients intolerant of the oral route received 250 mg/m2 IV once per day on days 1 to 3

Supportive medications

  • PJP prophylaxis was mandatory

28-day cycle for up to 8 cycles

References

  1. CRUK-UCL-MCLIII: Rule S, Smith P, Johnson PW, Bolam S, Follows G, Gambell J, Hillmen P, Jack A, Johnson S, Kirkwood AA, Kruger A, Pocock C, Seymour JF, Toncheva M, Walewski J, Linch D. The addition of rituximab to fludarabine and cyclophosphamide chemotherapy results in a significant improvement in overall survival in patients with newly diagnosed mantle cell lymphoma: results of a randomized UK National Cancer Research Institute trial. Haematologica. 2016 Feb;101(2):235-40. Epub 2015 Nov 26. link to original article contains verified protocol link to PMC article PubMed NCT00641095

FCR

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FCR: Fludarabine, Cyclophosphamide, Rituximab
R-FC: Rituximab, Fludarabine, Cyclophosphamide

Regimen variant #1, 30/250/375

Study Years of enrollment Evidence Comparator Comparative Efficacy
Kluin-Nelemans et al. 2012 (MCLelderly) 2004-2010 Phase III (E-switch-ic) R-CHOP Inferior OS

Chemotherapy

Targeted therapy

28-day cycle for 6 cycles

Subsequent treatment

Regimen variant #2, 40/25/375

Study Years of enrollment Evidence Comparator Comparative Efficacy
Rule et al. 2015 (CRUK-UCL-MCLIII) 2002-2010 Phase III (E-esc) FC Superior OS

Chemotherapy

  • Fludarabine (Fludara) 40 mg/m2 PO once per day on days 1 to 3
    • Patients intolerant of the oral route received 25 mg/m2 IV once per day on days 1 to 3
  • Cyclophosphamide (Cytoxan) 250 mg/m2 PO once per day on days 1 to 3
    • Patients intolerant of the oral route received 250 mg/m2 IV once per day on days 1 to 3

Targeted therapy

Supportive medications

  • PJP prophylaxis was mandatory

28-day cycle for up to 8 cycles

References

  1. MCLelderly: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Trneny M, Geisler CH, Stilgenbauer S, Thieblemont C, Vehling-Kaiser U, Doorduijn JK, Coiffier B, Forstpointner R, Tilly H, Kanz L, Feugier P, Szymczyk M, Hallek M, Kremers S, Lepeu G, Sanhes L, Zijlstra JM, Bouabdallah R, Lugtenburg PJ, Macro M, Pfreundschuh M, Procházka V, Di Raimondo F, Ribrag V, Uppenkamp M, André M, Klapper W, Hiddemann W, Unterhalt M, Dreyling MH. Treatment of older patients with mantle-cell lymphoma. N Engl J Med. 2012 Aug 9;367(6):520-31. link to original article contains verified protocol PubMed NCT00209209
    1. Update: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Geisler CH, Trneny M, Stilgenbauer S, Kaiser F, Doorduijn JK, Salles G, Szymczyk M, Tilly H, Kanz L, Schmidt C, Feugier P, Thieblemont C, Zijlstra JM, Ribrag V, Klapper W, Pott C, Unterhalt M, Dreyling MH. Treatment of Older Patients With Mantle Cell Lymphoma (MCL): Long-Term Follow-Up of the Randomized European MCL Elderly Trial. J Clin Oncol. 2020 Jan 20;38(3):248-256. Epub 2019 Dec 5. link to original article PubMed
  2. CRUK-UCL-MCLIII: Rule S, Smith P, Johnson PW, Bolam S, Follows G, Gambell J, Hillmen P, Jack A, Johnson S, Kirkwood AA, Kruger A, Pocock C, Seymour JF, Toncheva M, Walewski J, Linch D. The addition of rituximab to fludarabine and cyclophosphamide chemotherapy results in a significant improvement in overall survival in patients with newly diagnosed mantle cell lymphoma: results of a randomized UK National Cancer Research Institute trial. Haematologica. 2016 Feb;101(2):235-40. Epub 2015 Nov 26. link to original article contains verified protocol link to PMC article PubMed NCT00641095

MCP

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MCP: Mitoxantrone, Chlorambucil, Prednisone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Nickenig et al. 2006 (GLSG '96) 1996-1998 Phase III (E-switch-ic) CHOP Might have inferior ORR

Note: the chlorambucil dose is written in the reference as "3 x 3 mg/m2"; total dose per day is 9 mg/m2.

Chemotherapy

28-day cycle for 6 to 8 cycles

References

  1. GLSG '96: Nickenig C, Dreyling M, Hoster E, Pfreundschuh M, Trumper L, Reiser M, Wandt H, Lengfelder E, Unterhalt M, Hiddemann W; German Low-Grade Lymphoma Study Group. Combined cyclophosphamide, vincristine, doxorubicin, and prednisone (CHOP) improves response rates but not survival and has lower hematologic toxicity compared with combined mitoxantrone, chlorambucil, and prednisone (MCP) in follicular and mantle cell lymphomas: results of a prospective randomized trial of the German Low-Grade Lymphoma Study Group. Cancer. 2006 Sep 1;107(5):1014-22. link to original article contains verified protocol PubMed

R-CHOP

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R-CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisone

Example orders

Regimen variant #1, prednisone 100 mg

Study Years of enrollment Evidence Comparator Comparative Efficacy
Kluin-Nelemans et al. 2012 (MCLelderly) 2004-2010 Phase III (C) R-FC Superior OS
Hermine et al. 2016 (MCL Younger) 2004-2010 Phase III (C) See link See link
Flinn et al. 2014 (BRIGHT) 2009-2012 Phase III (C) BR Seems to have non-inferior CR rate

Targeted therapy

Chemotherapy

Supportive medications

21-day cycle for up to 8 cycles

Subsequent treatment

Regimen variant #2, prednisone 100 mg/m2

Study Years of enrollment Evidence Comparator Comparative Efficacy
Lenz et al. 2005 2000-2002 Phase III (E-esc) CHOP Superior ORR
Robak et al. 2015 (LYM-3002) 2008-2011 Phase III (C) VR-CAP Inferior OS (*)

Note the slight difference between the two protocols in terms of rituximab timing. Reported efficacy for LYM-3002 is based on the 2018 update.

Targeted therapy

Chemotherapy

21-day cycle for 6 cycles (Lenz et al. 2005) or up to 8 cycles (LYM-3002)

Regimen variant #3, uncapped vincristine

Study Years of enrollment Evidence Comparator Comparative Efficacy
Rummel et al. 2013 (StiL NHL1) 2003-2008 Phase III (C) BR Inferior PFS

Targeted therapy

Chemotherapy

21-day cycle up to maximum of 6 cycles

Regimen variant #4, 3 cycles, rituximab in cycle 3 only

Study Evidence
Delarue et al. 2012 Phase II

Targeted therapy

Chemotherapy

CNS prophylaxis

Intrathecal prophylaxis with the following was given per physician discretion; no timeframe or total number of doses is described:

21-day cycle for up to 3 cycles

Subsequent treatment

  • R-DHAP; patients who progress after first 2 cycles go directly to R-DHAP

Regimen variant #5, 4 cycles

Study Evidence
Smith et al. 2012 (ECOG E1499) Phase II

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Targeted therapy

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

References

  1. Lenz G, Dreyling M, Hoster E, Wörmann B, Dührsen U, Metzner B, Eimermacher H, Neubauer A, Wandt H, Steinhauer H, Martin S, Heidemann E, Aldaoud A, Parwaresch R, Hasford J, Unterhalt M, Hiddemann W; German Low Grade Lymphoma Study Group. Immunochemotherapy with rituximab and cyclophosphamide, doxorubicin, vincristine, and prednisone significantly improves response and time to treatment failure, but not long-term outcome in patients with previously untreated mantle cell lymphoma: results of a prospective randomized trial of the German Low Grade Lymphoma Study Group (GLSG). J Clin Oncol. 2005 Mar 20;23(9):1984-92. Epub 2005 Jan 24. link to original article PubMed
  2. Delarue R, Haioun C, Ribrag V, Brice P, Delmer A, Tilly H, Salles G, Van Hoof A, Casasnovas O, Brousse N, Lefrere F, Hermine O; Groupe d'Etude des Lymphomes de l'Adulte. CHOP and DHAP plus rituximab followed by autologous stem cell transplantation in mantle cell lymphoma: a phase 2 study from the Groupe d'Etude des Lymphomes de l'Adulte. Blood. 2013 Jan 3;121(1):48-53. Epub 2012 Jun 20. link to original article contains verified protocol PubMed
  3. MCLelderly: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Trneny M, Geisler CH, Stilgenbauer S, Thieblemont C, Vehling-Kaiser U, Doorduijn JK, Coiffier B, Forstpointner R, Tilly H, Kanz L, Feugier P, Szymczyk M, Hallek M, Kremers S, Lepeu G, Sanhes L, Zijlstra JM, Bouabdallah R, Lugtenburg PJ, Macro M, Pfreundschuh M, Procházka V, Di Raimondo F, Ribrag V, Uppenkamp M, André M, Klapper W, Hiddemann W, Unterhalt M, Dreyling MH. Treatment of older patients with mantle-cell lymphoma. N Engl J Med. 2012 Aug 9;367(6):520-31. link to original article contains verified protocol PubMed NCT00209209
    1. Update: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Geisler CH, Trneny M, Stilgenbauer S, Kaiser F, Doorduijn JK, Salles G, Szymczyk M, Tilly H, Kanz L, Schmidt C, Feugier P, Thieblemont C, Zijlstra JM, Ribrag V, Klapper W, Pott C, Unterhalt M, Dreyling MH. Treatment of Older Patients With Mantle Cell Lymphoma (MCL): Long-Term Follow-Up of the Randomized European MCL Elderly Trial. J Clin Oncol. 2020 Jan 20;38(3):248-256. Epub 2019 Dec 5. link to original article PubMed
  4. ECOG E1499: Smith MR, Li H, Gordon L, Gascoyne RD, Paietta E, Forero-Torres A, Kahl BS, Advani R, Hong F, Horning SJ. Phase II study of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone immunochemotherapy followed by yttrium-90-ibritumomab tiuxetan in untreated mantle-cell lymphoma: Eastern Cooperative Oncology Group Study E1499. J Clin Oncol. 2012 Sep 1;30(25):3119-26. Epub 2012 Jul 30. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Smith MR, Hong F, Li H, Gordon LI, Gascoyne RD, Paietta EM, Advani RH, Forero-Torres A, Horning SJ, Kahl BS. Mantle cell lymphoma initial therapy with abbreviated R-CHOP followed by (90)Y-ibritumomab tiuxetan: 10-year follow-up of the phase 2 ECOG-ACRIN study E1499. Leukemia. 2017 Feb;31(2):517-519. Epub 2016 Oct 26. link to PMC article PubMed
  5. StiL NHL1: Rummel MJ, Niederle N, Maschmeyer G, Banat GA, von Grünhagen U, Losem C, Kofahl-Krause D, Heil G, Welslau M, Balser C, Kaiser U, Weidmann E, Dürk H, Ballo H, Stauch M, Roller F, Barth J, Hoelzer D, Hinke A, Brugger W; StiL. Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. Lancet. 2013 Apr 6;381(9873):1203-10. Epub 2013 Feb 20. Erratum in: Lancet. 2013 Apr 6;381(9873):1184. link to original article contains verified protocol PubMed NCT00991211
    1. Update: Abstract: Mathias J. Rummel, MD, Georg Maschmeyer, MD, Arnold Ganser, Andrea Heider, PhD, Ulrich von Grünhagen, MD, PhD5, Christoph Losem, Gerhard Heil, MD, Manfred Welslau, Christina Balser, MD, Ulrich Kaiser, MD, Eckhart Weidmann, Heinz Dürk, MD, Hans Peter Böck, Martina Beate Stauch, MD, Jürgen Barth, Wolfgang Blau, MD, Alexander Burchardt, MD, Frank Kauff, PhD, Axel Hinke, PhD and Wolfram Brugger, MD. Bendamustine Plus Rituximab (B-R) Versus CHOP Plus Rituximab (CHOP-R) As First-Line Treatment in Patients with Indolent and Mantle Cell Lymphomas (MCL) – 7 Year Updated Results from the StiL NHL1 Study. Blood 2014 124:4407. link to abstract
  6. BRIGHT: Flinn IW, van der Jagt R, Kahl BS, Wood P, Hawkins TE, Macdonald D, Hertzberg M, Kwan YL, Simpson D, Craig M, Kolibaba K, Issa S, Clementi R, Hallman DM, Munteanu M, Chen L, Burke JM. Randomized trial of bendamustine-rituximab or R-CHOP/R-CVP in first-line treatment of indolent NHL or MCL: the BRIGHT study. Blood. 2014 May 8;123(19):2944-52. Epub 2014 Mar 3. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Flinn IW, van der Jagt R, Kahl B, Wood P, Hawkins T, MacDonald D, Simpson D, Kolibaba K, Issa S, Chang J, Trotman J, Hallman D, Chen L, Burke JM. First-line treatment of patients with indolent non-Hodgkin lymphoma or mantle-cell lymphoma with bendamustine plus rituximab versus R-CHOP or R-CVP: results of the BRIGHT 5-year follow-up study. J Clin Oncol. 2019 Apr 20;37(12):984-991. Epub 2019 Feb 27. link to original article link to PMC article PubMed
  7. LYM-3002: Robak T, Huang H, Jin J, Zhu J, Liu T, Samoilova O, Pylypenko H, Verhoef G, Siritanaratkul N, Osmanov E, Alexeeva J, Pereira J, Drach J, Mayer J, Hong X, Okamoto R, Pei L, Rooney B, van de Velde H, Cavalli F; the LYM-3002 Investigators. Bortezomib-based therapy for newly diagnosed mantle-cell lymphoma. N Engl J Med. 2015 Mar 5;372(10):944-953. link to original article contains verified protocol PubMed
    1. Update: Robak T, Jin J, Pylypenko H, Verhoef G, Siritanaratkul N, Drach J, Raderer M, Mayer J, Pereira J, Tumyan G, Okamoto R, Nakahara S, Hu P, Appiani C, Nemat S, Cavalli F; LYM-3002 investigators. Frontline bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone (VR-CAP) versus rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in transplantation-ineligible patients with newly diagnosed mantle cell lymphoma: final overall survival results of a randomised, open-label, phase 3 study. Lancet Oncol. 2018 Nov;19(11):1449-58. Epub 2018 Oct 18. link to original article PubMed
  8. MCL Younger: Hermine O, Hoster E, Walewski J, Bosly A, Stilgenbauer S, Thieblemont C, Szymczyk M, Bouabdallah R, Kneba M, Hallek M, Salles G, Feugier P, Ribrag V, Birkmann J, Forstpointner R, Haioun C, Hänel M, Casasnovas RO, Finke J, Peter N, Bouabdallah K, Sebban C, Fischer T, Dührsen U, Metzner B, Maschmeyer G, Kanz L, Schmidt C, Delarue R, Brousse N, Klapper W, Macintyre E, Delfau-Larue MH, Pott C, Hiddemann W, Unterhalt M, Dreyling M; European Mantle Cell Lymphoma Network. Addition of high-dose cytarabine to immunochemotherapy before autologous stem-cell transplantation in patients aged 65 years or younger with mantle cell lymphoma (MCL Younger): a randomised, open-label, phase 3 trial of the European Mantle Cell Lymphoma Network. Lancet. 2016 Aug 6;388(10044):565-75. Epub 2016 Jun 14. link to original article PubMed

R-CHOP (Prednisolone)

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R-CHOP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisolone

Example orders

Regimen

Study Evidence
Van 't Veer et al. 2008 (HOVON 45) Phase II

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Targeted therapy

Chemotherapy

21-day cycle for 3 cycles

Subsequent treatment

References

  1. HOVON 45: Van 't Veer MB, de Jong D, MacKenzie M, Kluin-Nelemans HC, van Oers MH, Zijlstra J, Hagenbeek A, van Putten WL. High-dose Ara-C and BEAM with autograft rescue in R-CHOP responsive mantle cell lymphoma patients. Br J Haematol. 2009 Feb;144(4):524-30. Epub 2008 Nov 26. link to original article contains verified protocol PubMed

R-CHOP-14 (Prednisolone)

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R-CHOP-14: Rituximab, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisolone every 14 days

Regimen

Study Evidence
Le Gouill et al. 2017 (LyMa) Non-randomized portion of RCT

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Preceding treatment

Targeted therapy

Chemotherapy

Supportive medications

  • Not specified

14-day cycle for 4 cycles

Subsequent treatment

References

  1. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article link to protocol contains verified protocol in supplement PubMed NCT00921414

R-CHOP/R-DHAP

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R-CHOP/R-DHAP: Rituximab, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Predniso(lo)ne alternating with Rituximab, Dexamethasone, High-dose Ara-C (Cytarabine), Platinol (Cisplatin)

Protocol

Study Years of enrollment Evidence Comparator Comparative Efficacy
Hermine et al. 2016 (MCL Younger) 2004-2010 Phase III (E-esc) See link See link

R-CHOP portion

Targeted therapy

Chemotherapy

21-day cycle for up to 3 cycles, alternating with R-DHAP

R-DHAP portion

Targeted therapy

Chemotherapy

21-day cycle for 3 cycles, alternating with R-CHOP

Subsequent treatment

  • Cytarabine, Melphalan, TBI with autologous hematopoietic stem cell transplant

References

  1. MCL Younger: Hermine O, Hoster E, Walewski J, Bosly A, Stilgenbauer S, Thieblemont C, Szymczyk M, Bouabdallah R, Kneba M, Hallek M, Salles G, Feugier P, Ribrag V, Birkmann J, Forstpointner R, Haioun C, Hänel M, Casasnovas RO, Finke J, Peter N, Bouabdallah K, Sebban C, Fischer T, Dührsen U, Metzner B, Maschmeyer G, Kanz L, Schmidt C, Delarue R, Brousse N, Klapper W, Macintyre E, Delfau-Larue MH, Pott C, Hiddemann W, Unterhalt M, Dreyling M; European Mantle Cell Lymphoma Network. Addition of high-dose cytarabine to immunochemotherapy before autologous stem-cell transplantation in patients aged 65 years or younger with mantle cell lymphoma (MCL Younger): a randomised, open-label, phase 3 trial of the European Mantle Cell Lymphoma Network. Lancet. 2016 Aug 6;388(10044):565-75. Epub 2016 Jun 14. link to original article contains verified protocol PubMed

R-CVP

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R-CVP: Rituximab, Cyclophosphamide, Vincristine, Prednisone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Flinn et al. 2014 (BRIGHT) 2009-2012 Phase III (C) BR Seems to have non-inferior CR rate

Targeted therapy

Chemotherapy

Supportive medications

21-day cycle for up to 8 cycles

References

  1. BRIGHT: Flinn IW, van der Jagt R, Kahl BS, Wood P, Hawkins TE, Macdonald D, Hertzberg M, Kwan YL, Simpson D, Craig M, Kolibaba K, Issa S, Clementi R, Hallman DM, Munteanu M, Chen L, Burke JM. Randomized trial of bendamustine-rituximab or R-CHOP/R-CVP in first-line treatment of indolent NHL or MCL: the BRIGHT study. Blood. 2014 May 8;123(19):2944-52. Epub 2014 Mar 3. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Flinn IW, van der Jagt R, Kahl B, Wood P, Hawkins T, MacDonald D, Simpson D, Kolibaba K, Issa S, Chang J, Trotman J, Hallman D, Chen L, Burke JM. First-line treatment of patients with indolent non-Hodgkin lymphoma or mantle-cell lymphoma with bendamustine plus rituximab versus R-CHOP or R-CVP: results of the BRIGHT 5-year follow-up study. J Clin Oncol. 2019 Apr 20;37(12):984-991. Epub 2019 Feb 27. link to original article link to PMC article PubMed

R-Hyper-CVAD/R-MA

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R-Hyper-CVAD/R-MA: Rituximab, Hyperfractionated Cyclophosphamide, Vincristine, Adriamycin (Doxorubicin), Dexamethasone alternating with Rituximab, Methotrexate, Ara-C (Cytarabine)

Protocol

Study Years of enrollment Evidence Comparator Comparative Efficacy
Romaguera et al. 2005 1999-2002 Phase II
Wang et al. 2008 NR Phase II
Bernstein et al. 2013 (SWOG S0213) 2002-2006 Phase II
Merli et al. 2012 2005-2010 Phase II
Chen et al. 2016 (SWOG S1106) 2012-2013 Randomized Phase II (E-esc) BR Did not meet primary endpoint of PFS24

Note: Romaguera et al. 2005 had slightly different doxorubicin dosages in the text vs. table 1. SWOG S0213 used the original protocol as specified in Romaguera et al. 2005.

Part A (cycles 1, 3, 5, 7)

Targeted therapy

  • Rituximab (Rituxan) 375 mg/m2 IV once on day 1, given first
    • Patients with peripheral blood involvement could have the cycle 1 dose of rituximab delayed or omitted by clinician discretion

Chemotherapy

Supportive medications

  • Mesna (Mesnex) 600 mg/m2/day IV continuous infusion over 76 hours, started on day 2, 1 hour before Cyclophosphamide (Cytoxan) and completed 12 hours after the last dose of Cyclophosphamide (Cytoxan)
    • "Over 76 hours" is not exactly specified in Romaguera et al. 2005; Wang et al. 2008. It is based on the assumption that "completed 12 hours after the last dose of cyclophosphamide" means that it would finish 12 hours after the last dose of cyclophosphamide completes.

All growth factors and antibiotics given for 10 days, starting 24 to 36 hours after doxorubicin infusion is complete

21-day cycles, alternating every 21 days with Part B, for a total of 4 cycles of Part A and 4 cycles of Part B

Part B (cycles 2, 4, 6, 8)

Targeted therapy

Chemotherapy

  • Methotrexate (MTX) 200 mg/m2 IV over 2 hours once on day 2, then 800 mg/m2 IV over 22 hours (total dose per cycle: 1000 mg/m2)
    • Urine alkalinized to pH of 6.8 or more prior to the start of methotrexate and kept within that range until methotrexate is cleared
    • Patients with a Cr greater than 1.5 mg/dL received a 50% reduced dose of methotrexate
  • Cytarabine (Ara-C) as follows:
    • Standard patients: 3000 mg/m2 IV over 2 hours every 12 hours on days 3 & 4 (total dose per cycle: 12,000 mg/m2)
    • Patients older than 60 or with creatinine greater than 1.5 mg/dL: 1000 mg/m2 IV over 2 hours every 12 hours on days 3 & 4 (total dose per cycle: 4000 mg/m2)

Supportive medications

  • Folinic acid (Leucovorin) 50 mg PO once on day 3, 12 hours after Methotrexate (MTX) is complete, then 15 mg PO every 6 hours for 8 doses. If serum methotrexate level at 24 hours is greater than 1000 nmol/L or at 48 hours is greater than 100 nmol/L, dose is increased to 100 mg IV Q3H.
  • Prednisolone 1% ophthalmic solution 2 drops in each eye four times per day on days 3 to 9 was started on the day of the start of Cytarabine (Ara-C) infusion and was continued for 7 days to prevent chemical conjunctivitis.

The starting day of the following medications was not specified. All medications are given for 10 days.

21-day cycles, alternating every 21 days with Part A, for a total of 4 cycles of Part A and 4 cycles of Part B

Subsequent treatment

  • Merli et al. 2012, responders: autologous HSCT (regimen not specified)

References

  1. Romaguera JE, Fayad L, Rodriguez MA, Broglio KR, Hagemeister FB, Pro B, McLaughlin P, Younes A, Samaniego F, Goy A, Sarris AH, Dang NH, Wang M, Beasley V, Medeiros LJ, Katz RL, Gagneja H, Samuels BI, Smith TL, Cabanillas FF. High rate of durable remissions after treatment of newly diagnosed aggressive mantle-cell lymphoma with rituximab plus hyper-CVAD alternating with rituximab plus high-dose methotrexate and cytarabine. J Clin Oncol. 2005 Oct 1;23(28):7013-23. Epub 2005 Sep 6. link to original article contains verified protocol PubMed
    1. Update: Romaguera JE, Fayad LE, Feng L, Hartig K, Weaver P, Rodriguez MA, Hagemeister FB, Pro B, McLaughlin P, Younes A, Samaniego F, Goy A, Cabanillas F, Kantarjian H, Kwak L, Wang M. Ten-year follow-up after intense chemoimmunotherapy with Rituximab-HyperCVAD alternating with Rituximab-high dose methotrexate/cytarabine (R-MA) and without stem cell transplantation in patients with untreated aggressive mantle cell lymphoma. Br J Haematol. 2010 Jul;150(2):200-8. Epub 2010 May 26. Review. Erratum in: Br J Haematol.n 2010 Oct;151(1):111. link to original article PubMed
    2. Update: Chihara D, Cheah CY, Westin JR, Fayad LE, Rodriguez MA, Hagemeister FB, Pro B, McLaughlin P, Younes A, Samaniego F, Goy A, Cabanillas F, Kantarjian H, Kwak LW, Wang ML, Romaguera JE. Rituximab plus hyper-CVAD alternating with MTX/Ara-C in patients with newly diagnosed mantle cell lymphoma: 15-year follow-up of a phase II study from the MD Anderson Cancer Center. Br J Haematol. 2016 Jan;172(1):80-8. Epub 2015 Dec 9. link to original article link to PMC article PubMed
  2. Wang M, Fayad L, Cabanillas F, Hagemeister F, McLaughlin P, Rodriguez MA, Kwak LW, Zhou Y, Kantarjian H, Romaguera J. Phase 2 trial of rituximab plus hyper-CVAD alternating with rituximab plus methotrexate-cytarabine for relapsed or refractory aggressive mantle cell lymphoma. Cancer. 2008 Nov 15;113(10):2734-41.link to original article contains verified protocol PubMed
  3. Merli F, Luminari S, Ilariucci F, Petrini M, Visco C, Ambrosetti A, Stelitano C, Caracciolo F, Di Renzo N, Angrilli F, Carella AM, Capodanno I, Barbolini E, Galimberti S, Federico M. Rituximab plus HyperCVAD alternating with high dose cytarabine and methotrexate for the initial treatment of patients with mantle cell lymphoma, a multicentre trial from Gruppo Italiano Studio Linfomi. Br J Haematol. 2012 Feb;156(3):346-53. Epub 2011 Dec 7. link to original article PubMed
  4. SWOG S0213: Bernstein SH, Epner E, Unger JM, Leblanc M, Cebula E, Burack R, Rimsza L, Miller TP, Fisher RI. A phase II multicenter trial of hyperCVAD MTX/Ara-C and rituximab in patients with previously untreated mantle cell lymphoma; SWOG 0213. Ann Oncol. 2013 Jun;24(6):1587-93. Epub 2013 Mar 15. link to original article link to PMC article PubMed
  5. SWOG S1106: Chen RW, Li H, Bernstein SH, Kahwash S, Rimsza LM, Forman SJ, Constine L, Shea TC, Cashen AF, Blum KA, Fenske TS, Barr PM, Phillips T, Leblanc M, Fisher RI, Cheson BD, Smith SM, Faham M, Wilkins J, Leonard JP, Kahl BS, Friedberg JW. RB but not R-HCVAD is a feasible induction regimen prior to auto-HCT in frontline MCL: results of SWOG Study S1106. Br J Haematol. 2017 Mar;176(5):759-769. Epub 2016 Dec 19. link to PMC article PubMed NCT01412879
    1. Update: Kamdar M, Li H, Chen RW, Rimsza LM, Leblanc ML, Fenske TS, Shea TC, Barr PM, Phillips TJ, Leonard JP, Kahl BS, Friedberg JW, Smith SM. Five-year outcomes of the S1106 study of R-hyper-CVAD vs R-bendamustine in transplant-eligible patients with mantle cell lymphoma. Blood Adv. 2019 Oct 22;3(20):3132-3135. link to original article link to PMC article PubMed

VR-CAP

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VR-CAP: Velcade (Bortezomib), Rituximab, Cyclophosphamide, Adriamycin (Doxorubicin), Prednisone
VcR-CAP: Velcade (Bortezomib), Rituximab, Cyclophosphamide, Adriamycin (Doxorubicin), Prednisone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Robak et al. 2015 (LYM-3002) 2008-2011 Phase III (E-RT-esc) R-CHOP Superior OS (*)

Note: reported efficacy is based on the 2018 update.

Targeted therapy

Chemotherapy

21-day cycle for up to 8 cycles

References

  1. LYM-3002: Robak T, Huang H, Jin J, Zhu J, Liu T, Samoilova O, Pylypenko H, Verhoef G, Siritanaratkul N, Osmanov E, Alexeeva J, Pereira J, Drach J, Mayer J, Hong X, Okamoto R, Pei L, Rooney B, van de Velde H, Cavalli F; the LYM-3002 Investigators. Bortezomib-based therapy for newly diagnosed mantle-cell lymphoma. N Engl J Med. 2015 Mar 5;372(10):944-953. link to original article contains verified protocol PubMed
    1. Update: Robak T, Jin J, Pylypenko H, Verhoef G, Siritanaratkul N, Drach J, Raderer M, Mayer J, Pereira J, Tumyan G, Okamoto R, Nakahara S, Hu P, Appiani C, Nemat S, Cavalli F; LYM-3002 investigators. Frontline bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone (VR-CAP) versus rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in transplantation-ineligible patients with newly diagnosed mantle cell lymphoma: final overall survival results of a randomised, open-label, phase 3 study. Lancet Oncol. 2018 Nov;19(11):1449-58. Epub 2018 Oct 18. link to original article PubMed

First-line therapy, non-randomized or retrospective data

Chlorambucil & Rituximab

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Regimen

Study Evidence
Sachanas et al. 2011 Phase II

Chemotherapy

  • Chlorambucil (Leukeran) as follows:
    • Cycles 1 to 8: 10 mg PO once per day on days 2 to 11
    • Cycles 9 to 12: 10 mg PO once per day on days 1 to 10

Targeted therapy

28-day cycle for 12 cycles

Subsequent treatment

References

  1. Sachanas S, Pangalis GA, Vassilakopoulos TP, Korkolopoulou P, Kontopidou FN, Athanasoulia M, Yiakoumis X, Kalpadakis C, Georgiou G, Masouridis S, Moschogiannis M, Tsirkinidis P, Pappis V, Kokoris SI, Siakantaris MP, Panayiotidis P, Angelopoulou MK. Combination of rituximab with chlorambucil as first line treatment in patients with mantle cell lymphoma: a highly effective regimen. Leuk Lymphoma. 2011 Mar;52(3):387-93. Epub 2010 Dec 6. link to original article contains verified protocol PubMed

Cladribine monotherapy

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Regimen

Study Evidence
Inwards et al. 2008 (NCCTG 95-80-53) Phase II

Chemotherapy

28-day cycle for up to 6 cycles

References

  1. NCCTG 95-80-53: Inwards DJ, Fishkin PA, Hillman DW, Brown DW, Ansell SM, Kurtin PJ, Fonseca R, Morton RF, Veeder MH, Witzig TE. Long-term results of the treatment of patients with mantle cell lymphoma with cladribine (2-CDA) alone (95-80-53) or 2-CDA and rituximab (N0189) in the North Central Cancer Treatment Group. Cancer. 2008 Jul 1;113(1):108-16. link to original article contains verified protocol link to PMC article PubMed

Cladribine & Rituximab

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Regimen

Study Evidence
Inwards et al. 2008 (NCCTG N0189) Phase II

Chemotherapy

Targeted therapy

Supportive medications

OR

28-day cycle for up to 6 cycles

References

  1. NCCTG N0189: Inwards DJ, Fishkin PA, Hillman DW, Brown DW, Ansell SM, Kurtin PJ, Fonseca R, Morton RF, Veeder MH, Witzig TE. Long-term results of the treatment of patients with mantle cell lymphoma with cladribine (2-CDA) alone (95-80-53) or 2-CDA and rituximab (N0189) in the North Central Cancer Treatment Group. Cancer. 2008 Jul 1;113(1):108-16. link to original article contains verified protocol link to PMC article PubMed

Lenalidomide & Rituximab

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LR: Lenalidomide & Rituximab

Regimen

Study Evidence
Ruan et al. 2015 (Cornell 1103011566) Phase II

Targeted therapy

  • Lenalidomide (Revlimid) as follows:
    • Cycle 1: 20 mg PO once per day on days 1 to 21
    • Cycle 2 onwards (if no dose-limiting adverse events in cycle 1): 25 mg PO once per day on days 1 to 21
  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 1, 8, 15, 22
    • Cycles 4, 6, 8, 10, 12: 375 mg/m2 IV once on day 1

Supportive medications

28-day cycle for 12 cycles

Subsequent treatment

References

  1. Cornell 1103011566: Ruan J, Martin P, Shah B, Schuster SJ, Smith SM, Furman RR, Christos P, Rodriguez A, Svoboda J, Lewis J, Katz O, Coleman M, Leonard JP. Lenalidomide plus rituximab as initial treatment for mantle-cell lymphoma. N Engl J Med. 2015 Nov 5;373(19):1835-44. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Ruan J, Martin P, Christos P, Cerchietti L, Tam W, Shah B, Schuster SJ, Rodriguez A, Hyman D, Calvo-Vidal MN, Smith SM, Svoboda J, Furman RR, Coleman M, Leonard JP. Five-year follow-up of lenalidomide plus rituximab as initial treatment of mantle cell lymphoma. Blood. 2018 Nov 8;132(19):2016-2025. Epub 2018 Sep 4. link to original article PubMed

Observation

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Regimen

Study Evidence
Martin et al. 2009 Retrospective

Also known as "watchful waiting".

References

  1. Retrospective: Martin P, Chadburn A, Christos P, Weil K, Furman RR, Ruan J, Elstrom R, Niesvizky R, Ely S, Diliberto M, Melnick A, Knowles DM, Chen-Kiang S, Coleman M, Leonard JP. Outcome of deferred initial therapy in mantle-cell lymphoma. J Clin Oncol. 2009 Mar 10;27(8):1209-13. link to original article PubMed
  2. Retrospective: Cohen JB, Han X, Jemal A, Ward EM, Flowers CR. Deferred therapy is associated with improved overall survival in patients with newly diagnosed mantle cell lymphoma. Cancer. 2016 Aug 1;122(15):2356-63. Epub 2016 May 6. link to original article PubMed

R-BAC

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R-BAC: Rituximab, Bendamustine, Ara-C (Cytarabine)

Regimen variant #1, 375/70/500 ("RBAC500")

Study Evidence
Visco et al. 2016 (FIL-RBAC500) Phase II

Targeted therapy

Chemotherapy

28-day cycle for up to 6 cycles

Regimen variant #2, 375/70/800

Study Evidence
Visco et al. 2013 (VI-1903) Phase II

Note: up to 6 cycles were given for newly diagnosed patients under the age of 80, who tolerated treatment, or had regression of disease between cycles 2 and 4.

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once on day 1
    • Cycle 2 onwards: 375 mg/m2 IV once on day 2

Chemotherapy

  • Bendamustine 70 mg/m2 IV once per day on days 2 & 3
  • Cytarabine (Ara-C) 800 mg/m2 IV over 2 hours once per day on days 2 to 4, starting 2 hours after bendamustine on days 2 & 3

28-day cycle for 4 to 6 cycles (see note)

References

  1. VI-1903: Visco C, Finotto S, Zambello R, Paolini R, Menin A, Zanotti R, Zaja F, Semenzato G, Pizzolo G, D'Amore ES, Rodeghiero F. Combination of rituximab, bendamustine, and cytarabine for patients with mantle-cell non-Hodgkin lymphoma ineligible for intensive regimens or autologous transplantation. J Clin Oncol. 2013 Apr 10;31(11):1442-9. Epub 2013 Feb 11. link to original article contains verified protocol PubMed
  2. FIL-RBAC500: Visco C, Chiappella A, Nassi L, Patti C, Ferrero S, Barbero D, Evangelista A, Spina M, Molinari A, Rigacci L, Tani M, Di Rocco A, Pinotti G, Fabbri A, Zambello R, Finotto S, Gotti M, Carella AM, Salvi F, Pileri SA, Ladetto M, Ciccone G, Gaidano G, Ruggeri M, Martelli M, Vitolo U. Rituximab, bendamustine, and low-dose cytarabine as induction therapy in elderly patients with mantle cell lymphoma: a multicentre, phase 2 trial from Fondazione Italiana Linfomi. Lancet Haematol. 2017 Jan;4(1):e15-e23. Epub 2016 Dec 2. link to original article contains protocol PubMed

maxi-R-CHOP/R-HiDAC

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maxi-R-CHOP/R-HiDAC: maximum-strength Rituximab, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Predniso(lo)ne alternating with Rituximab, High-Dose Ara-C (Cytarabine)

Protocol

Study Evidence
Geisler et al. 2008 (Nordic MCL2) Phase II

Note: This is also known as the "Nordic regimen". Protocol originally started rituximab during cycle 4, but the protocol was amended to start it on cycle 2.

maxi-R-CHOP portion

Targeted therapy

Chemotherapy

21-day cycles, alternating with R-HiDAC

R-HiDAC portion

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycles 2 & 4: 375 mg/m2 IV once on day 1
    • Cycle 6: 375 mg/m2 IV once per day on days 1 & 9

Chemotherapy

  • Cytarabine (Ara-C) as follows:
    • 60 and younger: 3000 mg/m2 IV over 3 hours every 12 hours on days 1 & 2 (total dose per cycle: 12,000 mg/m2)
    • Older than 60: 2000 mg/m2 IV over 3 hours every 12 hours on days 1 & 2 (total dose per cycle: 8000 mg/m2)

Supportive medications

  • Filgrastim (Neupogen) given during cycle 6 as part of stem cell mobilization, with at least 2 million CD34+ cells/kg harvested

21-day cycles, alternating with maxi-R-CHOP

Subsequent treatment

  • After 6 cycles (3 cycles of maxi-R-CHOP and 3 cycles of R-HiDAC), treatment is followed in 1 to 2 weeks with BEAC with autologous HSCT or BEAM with autologous HSCT. If transplant was delayed, an additional 1 to 2 cycles of chemotherapy with maxi-R-CHOP or R-HiDAC could be given.

References

  1. Nordic MCL2: Geisler CH, Kolstad A, Laurell A, Andersen NS, Pedersen LB, Jerkeman M, Eriksson M, Nordström M, Kimby E, Boesen AM, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Akerman M, Ehinger M, Sundström C, Langholm R, Delabie J, Karjalainen-Lindsberg ML, Brown P, Elonen E; Nordic Lymphoma Group. Long-term progression-free survival of mantle cell lymphoma after intensive front-line immunochemotherapy with in vivo-purged stem cell rescue: a nonrandomized phase 2 multicenter study by the Nordic Lymphoma Group. Blood. 2008 Oct 1;112(7):2687-93. Epub 2008 Jul 14. link to original article link to PMC article PubMed
    1. Update: Geisler CH, Kolstad A, Laurell A, Jerkeman M, Räty R, Andersen NS, Pedersen LB, Eriksson M, Nordström M, Kimby E, Bentzen H, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Ehinger M, Sundström C, Delabie J, Karjalainen-Lindsberg ML, Brown P, Elonen E; Nordic Lymphoma Group. Nordic MCL2 trial update: six-year follow-up after intensive immunochemotherapy for untreated mantle cell lymphoma followed by BEAM or BEAC + autologous stem-cell support: still very long survival but late relapses do occur. Br J Haematol. 2012 Aug;158(3):355-62. Epub 2012 May 29. Erratum in: Br J Haematol. 2012 Sep;158(6):815-6. link to original article PubMed
    2. Update: Eskelund CW, Kolstad A, Jerkeman M, Räty R, Laurell A, Eloranta S, Smedby KE, Husby S, Pedersen LB, Andersen NS, Eriksson M, Kimby E, Bentzen H, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Ehinger M, Sundström C, Delabie J, Karjalainen-Lindsberg ML, Workman CT, Garde C, Elonen E, Brown P, Grønbaek K, Geisler CH. 15-year follow-up of the Second Nordic Mantle Cell Lymphoma trial (MCL2): prolonged remissions without survival plateau. Br J Haematol. 2016 Nov;175(3):410-418. Epub 2016 Jul 5. link to original article PubMed

R-DHAC

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R-DHAC: Rituximab, Dexamethasone, High-dose Ara-C (Cytarabine), Carboplatin

Regimen

Study Evidence
Le Gouill et al. 2017 (LyMa) Non-randomized portion of RCT

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Preceding treatment

Targeted therapy

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

References

  1. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article link to protocol contains verified protocol in supplement PubMed NCT00921414

R-DHAOx

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R-DHAOx: Rituximab, Dexamethasone, High-dose Ara-C (Cytarabine), Oxaliplatin

Regimen

Study Evidence
Le Gouill et al. 2017 (LyMa) Non-randomized portion of RCT

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Preceding treatment

Targeted therapy

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

References

  1. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article link to protocol contains verified protocol in supplement PubMed NCT00921414

R-DHAP

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R-DHAP: Rituximab, Dexamethasone, High-dose Ara-C (Cytarabine), Platinol (Cisplatin)

Regimen variant #1, 3 cycles

Study Evidence
Delarue et al. 2012 Phase II

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment. The authors did not clearly specify the total dose/schedule of cytarabine; below is the dosing used in the NCIC-CTG LY.12 trial

Preceding treatment

Targeted therapy

Chemotherapy

CNS prophylaxis

Intrathecal prophylaxis with the following was given per physician discretion; no timeframe or total number of doses is described:

21-day cycle for 3 cycles

Subsequent treatment

Regimen variant #2, 4 cycles

Study Evidence
Le Gouill et al. 2017 (LyMa) Non-randomized portion of RCT

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment.

Preceding treatment

Targeted therapy

Chemotherapy

21-day cycle for 4 cycles

Subsequent treatment

References

  1. Case series: de Guibert S, Jaccard A, Bernard M, Turlure P, Bordessoule D, Lamy T. Rituximab and DHAP followed by intensive therapy with autologous stem-cell transplantation as first-line therapy for mantle cell lymphoma. Haematologica. 2006 Mar;91(3):425-6. link to original article does not contain protocol PubMed
  2. Delarue R, Haioun C, Ribrag V, Brice P, Delmer A, Tilly H, Salles G, Van Hoof A, Casasnovas O, Brousse N, Lefrere F, Hermine O; Groupe d'Etude des Lymphomes de l'Adulte. CHOP and DHAP plus rituximab followed by autologous stem cell transplantation in mantle cell lymphoma: a phase 2 study from the Groupe d'Etude des Lymphomes de l'Adulte. Blood. 2013 Jan 3;121(1):48-53. Epub 2012 Jun 20. link to original article contains verified protocol PubMed
  3. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article link to protocol contains verified protocol in supplement PubMed NCT00921414

R-HiDAC

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R-HiDAC: Rituximab & High Dose Ara-C (Cytarabine)

Regimen variant #1, Ara-C 2000 mg/m2

Study Evidence
Van 't Veer et al. 2008 (HOVON 45) Phase II

Preceding treatment

Targeted therapy

Chemotherapy

11-day course

Subsequent treatment

  • Stem cells were collected after this cycle with G-CSF given to "enhance" collection. Patients then proceeded to BEAM with autologous HSCT

Regimen variant #2, Ara-C 3000 mg/m2

Study Evidence
Armand et al. 2016 (DFCI 12-168) Phase II

Note: this is a component of a sequential treatment protocol; to our knowledge there are no references to support using it as a stand-alone treatment. See paper for advice on cytarabine dose reduction.

Preceding treatment

Targeted therapy

Chemotherapy

  • Cytarabine (Ara-C) 3000 mg/m2 IV every 12 hours on days 1 & 2 (total dose per cycle: 12,000 mg/m2)

3 cycles (duration not specified)

Subsequent treatment

  • High-dose therapy with autologous HSCT

References

  1. HOVON 45: Van 't Veer MB, de Jong D, MacKenzie M, Kluin-Nelemans HC, van Oers MH, Zijlstra J, Hagenbeek A, van Putten WL. High-dose Ara-C and BEAM with autograft rescue in R-CHOP responsive mantle cell lymphoma patients. Br J Haematol. 2009 Feb;144(4):524-30. Epub 2008 Nov 26. link to original article contains verified protocol PubMed
  2. DFCI 12-168: Armand P, Redd R, Bsat J, Mayuram S, Giardino A, Fisher DC, LaCasce AS, Jacobson C, Davids MS, Brown JR, Weng L, Wilkins J, Faham M, Freedman AS, Joyce R, Jacobsen ED. A phase 2 study of rituximab-bendamustine and rituximab-cytarabine for transplant-eligible patients with mantle cell lymphoma. Br J Haematol. 2016 Apr;173(1):89-95. Epub 2016 Jan 5. link to original article contains verified protocol PubMed

R-M-CHOP

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R-M-CHOP: Rituximab, MTX (Methotrexate), Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin, Prednisone

Regimen

Study Evidence
Damon et al. 2009 (CALGB 59909) Phase II

Note: this is the induction portion ("Treatments 1 & 2") of CALGB 59909. Median days between treatment 1 & 2 was 23 days, with a range of 16 to 41 days observed.

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Circulating mantle cells up to 10,000 cells/uL: 375 mg/m2 IV once on day 1

Chemotherapy

Supportive medications

  • Folinic acid (Leucovorin) 50 mg/m2 IV every 6 hours for 3 doses, starting 24 hours after completion of Methotrexate (MTX), then 10 mg/m2 IV or PO every 6 hours until serum methotrexate level less than 50 nmol/L
  • Filgrastim (Neupogen) 5 mcg/kg SC once per day, starting on day 4, to continue until ANC greater than 10,000/uL once or greater than 5000/uL twice
  • Levofloxacin (Levaquin) 500 mg PO once per day, starting on day 6, to continue until ANC is greater than or equal to 1500/uL
  • Fluconazole (Diflucan) 200 mg PO once per day, starting on day 6, to continue until ANC is greater than or equal to 1500/uL

2 cycles, with interval between cycle 1 & 2 based on count recovery

Subsequent treatment

  • Patients with less than or equal to 15% involvement by disease in bone marrow biopsy after cycle 2: EAR with stem cell mobilization, 4 weeks after treatment 2, if ANC greater than or equal to 1000/uL, platelets greater than or equal to 100 x 109/L, Cr less than 2 mg/dL, total bilirubin less than 2x upper limit of normal, and AST less than 3x upper limit of normal.
  • Patients with bone marrow biopsy after treatment 2 has greater than 15% involvement by disease, repeat treatment 2 (identified as "treatment 2.5")
  • Patients with greater than 15% bone marrow involvement by disease after treatment 2.5 were removed from protocol

CNS therapy

If cerebrospinal fluid (CSF) contained disease with CSF WBC count greater than or equal to 5 cells/uL:

  • Methotrexate (MTX) 12 mg IT x 10 total doses during treatments 1 to 3; not given concurrently with intrathecal methotrexate or cytarabine

If CSF contained greater than 5 cells/uL:

  • In addition to intrathecal chemotherapy above, patient also received 2 Gy x 12 fractions (total dose 24 Gy) cranial radiation

References

  1. CALGB 59909: Damon LE, Johnson JL, Niedzwiecki D, Cheson BD, Hurd DD, Bartlett NL, Lacasce AS, Blum KA, Byrd JC, Kelly M, Stock W, Linker CA, Canellos GP. Immunochemotherapy and autologous stem-cell transplantation for untreated patients with mantle-cell lymphoma: CALGB 59909. J Clin Oncol. 2009 Dec 20;27(36):6101-8. Epub 2009 Nov 16. link to original article contains protocol link to PMC article PubMed

R-MACLO/R-IVAM

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R-MACLO/R-IVAM: Rituximab, MTX (Methotrexate), Adriamycin (Doxorubicin), Cyclophosphamide, Leucovorin (Folinic acid), Oncovin (Vincristine) alternating with Rituximab, VP-16 (Etoposide), Ara-C (Cytarabine), Mesna

Protocol variant #1

Study Evidence
Lossos et al. 2010 (UM-MCL1) Phase II

R-MACLO portion (Cycles 1 & 3)

Targeted therapy

Chemotherapy

Supportive medications

  • Folinic acid (Leucovorin) 180 mg/m2 IV once 12 hours after Methotrexate (MTX) is complete, then 12 mg/m2 IV every 6 hours for at least 10 doses or until serum methotrexate level is less than 50 nmol/L
  • G-CSF given starting on day 13, continued until ANC greater than 1500/uL for two consecutive days

Next cycle to start after count recovery

R-IVAM portion (Cycles 2 & 4)

Targeted therapy

Chemotherapy

Supportive medications

  • Mesna (Mesnex) 360 mg/m2 IV every 3 hours on days 1 to 5, starting prior to Ifosfamide (Ifex) (total dose per cycle: 14,400 mg/m2)
  • G-CSF starting on day 7, continued until ANC greater than 1500/uL for two consecutive days

Next cycle to start after count recovery + 2 weeks

Total of 4 cycles

Subsequent treatment

  • Patients achieving a CR: thalidomide maintenance

Protocol variant #2

Study Evidence
Lossos et al. 2010 (UM-MCL2) Phase II

The only difference between this protocol and protocol #1 above is the dose of the MTX and the maintenance portion. It is unclear from the text whether the total dose of MTX is reduced to 3000 mg/m2 or if the 23 hour infusional portion is reduced to 3000 mg/m2.

R-MACLO portion (Cycles 1 & 3)

Targeted therapy

Chemotherapy

Supportive medications

  • Folinic acid (Leucovorin) 180 mg/m2 IV once 12 hours after Methotrexate (MTX) is complete, then 12 mg/m2 IV every 6 hours for at least 10 doses or until serum methotrexate level is less than 50 nmol/L
  • G-CSF given starting on day 13, continued until ANC greater than 1500/uL for two consecutive days

Next cycle to start after count recovery

R-IVAM portion (Cycles 2 & 4)

Targeted therapy

Chemotherapy

Supportive medications

  • Mesna (Mesnex) 360 mg/m2 IV every 3 hours on days 1 to 5, starting prior to Ifosfamide (Ifex) (total dose per cycle: 14,400 mg/m2)
  • G-CSF starting on day 7, continued until ANC greater than 1500/uL for two consecutive days

Next cycle to start after count recovery + 2 weeks

Total of 4 cycles

Subsequent treatment

References

  1. UM-MCL1/UM-MCL2: Lossos IS, Hosein PJ, Morgensztern D, Coleman F, Escalón MP, Byrne GE Jr, Rosenblatt JD, Walker GR. High rate and prolonged duration of complete remissions induced by rituximab, methotrexate, doxorubicin, cyclophosphamide, vincristine, ifosfamide, etoposide, cytarabine, and thalidomide (R-MACLO-IVAM-T), a modification of the National Cancer Institute 89-C-41 regimen, in patients with newly diagnosed mantle cell lymphoma. Leuk Lymphoma. 2010 Mar;51(3):406-14. link to original article contains verified protocol PubMed
    1. Update: Hosein PJ, Sandoval-Sus JD, Goodman D, Arteaga AG, Reis I, Hoffman J, Stefanovic A, Rosenblatt JD, Lossos IS. Updated survival analysis of two sequential prospective trials of R-MACLO-IVAM followed by maintenance for newly diagnosed mantle cell lymphoma. Am J Hematol. 2015 Jun;90(6):E111-6. Epub 2015 Apr 2. link to original article link to PMC article PubMed

RiPAD+C

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RiPAD+C: Rituximab, PS-341 (Bortezomib), Adriamycin (Doxorubicin), Dexamethasone, Chlorambucil

Regimen

Study Years of enrollment Evidence
Houot et al. 2011 (ManteauRiBVD) 2007-2008 Phase II

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 1 & 8
    • Cycle 2 onwards: 375 mg/m2 IV once on day 1
  • Bortezomib (Velcade) 1.3 mg/m2 (route not specified) once per day on days 1, 4, 8, 11

Chemotherapy

35-day cycle for up to 6 cycles

References

  1. ManteauRiBVD: Houot R, Le Gouill S, Ojeda Uribe M, Mounier C, Courby S, Dartigeas C, Bouabdallah K, Alexis Vigier M, Moles MP, Tournilhac O, Arakelyan N, Rodon P, El Yamani A, Sutton L, Fornecker L, Assouline D, Harousseau JL, Maisonneuve H, Caulet-Maugendre S, Gressin R; GOELAMS. Combination of rituximab, bortezomib, doxorubicin, dexamethasone and chlorambucil (RiPAD+C) as first-line therapy for elderly mantle cell lymphoma patients: results of a phase II trial from the GOELAMS. Ann Oncol. 2012 Jun;23(6):1555-61. Epub 2011 Oct 19. link to original article contains verified protocol PubMed NCT00740415

R-VAD+C

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R-VAD+C: Rituximab, Vincristine, Adriamycin (Doxorubicin), Dexamethasone, Chlorambucil

Regimen

Study Evidence
Gressin et al. 2010 (GOELAMS LM2001) Phase II

Targeted therapy

Chemotherapy

35-day cycle for 4 to 8 cycles

Subsequent treatment

References

  1. GOELAMS LM2001: Gressin R, Caulet-Maugendre S, Deconinck E, Tournilhac O, Gyan E, Moles MP, El Yamani A, Cornillon J, Rossi JF, Le Gouill S, Lepeu G, Damaj G, Celigny PS, Maisonneuve H, Corront B, Vilque JP, Casassus P, Lamy T, Colonna M, Colombat P; GOELAMS. Evaluation of the (R)VAD+C regimen for the treatment of newly diagnosed mantle cell lymphoma: combined results of two prospective phase II trials from the French GOELAMS Group. Haematologica. 2010 Aug;95(8):1350-7. Epub 2010 Mar 10. link to original article contains verified protocol link to PMC article PubMed

VAD+C

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VAD+C: Vincristine, Adriamycin (Doxorubicin), Dexamethasone, Chlorambucil

Regimen

Study Evidence
Gressin et al. 2010 (GOELAMS LM1996) Phase II

Chemotherapy

35-day cycle for 4 to 8 cycles

Subsequent treatment

References

  1. GOELAMS LM1996: Gressin R, Caulet-Maugendre S, Deconinck E, Tournilhac O, Gyan E, Moles MP, El Yamani A, Cornillon J, Rossi JF, Le Gouill S, Lepeu G, Damaj G, Celigny PS, Maisonneuve H, Corront B, Vilque JP, Casassus P, Lamy T, Colonna M, Colombat P; GOELAMS. Evaluation of the (R)VAD+C regimen for the treatment of newly diagnosed mantle cell lymphoma: combined results of two prospective phase II trials from the French GOELAMS Group. Haematologica. 2010 Aug;95(8):1350-7. Epub 2010 Mar 10. link to original article contains verified protocol link to PMC article PubMed

VcR-CVAD

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VcR-CVAD: Velcade (Bortezomib), Rituximab, Cyclophosphamide, Vincristine, Adriamycin (Doxorubicin), Dexamethasone

Regimen

Study Evidence
Chang et al. 2011 Phase II
Chang et al. 2014 (ECOG E1405) Phase II

Targeted therapy

Chemotherapy

Supportive medications

  • Mesna (Mesnex) dose not specified Chang et al. 2011; not mentioned in Chang et al. 2014
  • Growth factor support with one of the following:

21-day cycle for 6 cycles

Subsequent treatment

  • ECOG E1405, at least PR: Maintenance rituximab or high-dose therapy with autologous HSCT (regimen not specified), patient choice

References

  1. Chang JE, Peterson C, Choi S, Eickhoff JC, Kim K, Yang DT, Gilbert LA, Rogers ES, Werndli JE, Huie MS, McFarland TA, Volk M, Blank J, Callander NS, Longo WL, Kahl BS. VcR-CVAD induction chemotherapy followed by maintenance rituximab in mantle cell lymphoma: a Wisconsin Oncology Network study. Br J Haematol. 2011 Oct;155(2):190-7. Epub 2011 Aug 16. link to original article contains verified protocol link to PMC article PubMed
  2. ECOG E1405: Chang JE, Li H, Smith MR, Gascoyne RD, Paietta EM, Yang DT, Advani RH, Horning SJ, Kahl BS. Phase 2 study of VcR-CVAD with maintenance rituximab for untreated mantle cell lymphoma: an Eastern Cooperative Oncology Group study (E1405). Blood. 2014 Mar 13;123(11):1665-73. Epub 2014 Jan 23. link to original article contains verified protocol link to PMC article PubMed

VR-CHOP

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VR-CHOP: Velcade (Bortezomib), Rituximab, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Predniso(lo)ne

Regimen

Study Evidence
Ruan et al. 2010 Phase II
Till et al. 2015 (SWOG S0601) Phase II

Doses here are the phase II dose of bortezomib and the R-CHOP protocol as specified in the phase I report by Furman et al. 2010

Targeted therapy

Chemotherapy

Supportive medications

21-day cycle for 6 cycles

Subsequent treatment

References

  1. Ruan J, Martin P, Furman RR, Lee SM, Cheung K, Vose JM, Lacasce A, Morrison J, Elstrom R, Ely S, Chadburn A, Cesarman E, Coleman M, Leonard JP. Bortezomib plus CHOP-rituximab for previously untreated diffuse large B-cell lymphoma and mantle cell lymphoma. J Clin Oncol. 2011 Feb 20;29(6):690-7. Epub 2010 Dec 28. link to original article contains verified protocol PubMed
  2. SWOG S0601: Till BG, Li H, Bernstein SH, Fisher RI, Burack WR, Rimsza LM, Floyd JD, DaSilva MA, Moore DF Jr, Pozdnyakova O, Smith SM, LeBlanc M, Friedberg JW. Phase II trial of R-CHOP plus bortezomib induction therapy followed by bortezomib maintenance for newly diagnosed mantle cell lymphoma: SWOG S0601. Br J Haematol. 2016 Jan;172(2):208-18. Epub 2015 Oct 22. link to original article contains verified protocol link to PMC article PubMed

Consolidation after first-line therapy

BEAC, then auto HSCT

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BEAC: Rituximab, BiCNU (Carmustine), Etoposide, Ara-C (Cytarabine), Cyclophosphamide

Regimen

Study Evidence
Geisler et al. 2008 (Nordic MCL2) Phase II

Preceding treatment

Chemotherapy

Stem cells reinfused after chemotherapy, unclear exactly which day

References

  1. Nordic MCL2: Geisler CH, Kolstad A, Laurell A, Andersen NS, Pedersen LB, Jerkeman M, Eriksson M, Nordström M, Kimby E, Boesen AM, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Akerman M, Ehinger M, Sundström C, Langholm R, Delabie J, Karjalainen-Lindsberg ML, Brown P, Elonen E; Nordic Lymphoma Group. Long-term progression-free survival of mantle cell lymphoma after intensive front-line immunochemotherapy with in vivo-purged stem cell rescue: a nonrandomized phase 2 multicenter study by the Nordic Lymphoma Group. Blood. 2008 Oct 1;112(7):2687-93. Epub 2008 Jul 14. link to original article link to PMC article contains verified protocol PubMed
    1. Update: Geisler CH, Kolstad A, Laurell A, Jerkeman M, Räty R, Andersen NS, Pedersen LB, Eriksson M, Nordström M, Kimby E, Bentzen H, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Ehinger M, Sundström C, Delabie J, Karjalainen-Lindsberg ML, Brown P, Elonen E; Nordic Lymphoma Group. Nordic MCL2 trial update: six-year follow-up after intensive immunochemotherapy for untreated mantle cell lymphoma followed by BEAM or BEAC + autologous stem-cell support: still very long survival but late relapses do occur. Br J Haematol. 2012 Aug;158(3):355-62. Epub 2012 May 29. Erratum in: Br J Haematol. 2012 Sep;158(6):815-6. link to original article PubMed
    2. Update: Eskelund CW, Kolstad A, Jerkeman M, Räty R, Laurell A, Eloranta S, Smedby KE, Husby S, Pedersen LB, Andersen NS, Eriksson M, Kimby E, Bentzen H, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Ehinger M, Sundström C, Delabie J, Karjalainen-Lindsberg ML, Workman CT, Garde C, Elonen E, Brown P, Grønbaek K, Geisler CH. 15-year follow-up of the Second Nordic Mantle Cell Lymphoma trial (MCL2): prolonged remissions without survival plateau. Br J Haematol. 2016 Nov;175(3):410-418. Epub 2016 Jul 5. link to original article PubMed

BEAM, then auto HSCT

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BEAM: Rituximab, BiCNU (Carmustine), Etoposide, Ara-C (Cytarabine), Melphalan

Regimen variant #1

Study Evidence
Geisler et al. 2008 (Nordic MCL2) Phase II

Preceding treatment

Chemotherapy

Stem cells re-infused after chemotherapy, unclear exactly which day

Regimen variant #2

Study Evidence
Van 't Veer et al. 2008 (HOVON 45) Phase II

Preceding treatment

Chemotherapy

Stem cells re-infused on day 0

References

  1. Nordic MCL2: Geisler CH, Kolstad A, Laurell A, Andersen NS, Pedersen LB, Jerkeman M, Eriksson M, Nordström M, Kimby E, Boesen AM, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Akerman M, Ehinger M, Sundström C, Langholm R, Delabie J, Karjalainen-Lindsberg ML, Brown P, Elonen E; Nordic Lymphoma Group. Long-term progression-free survival of mantle cell lymphoma after intensive front-line immunochemotherapy with in vivo-purged stem cell rescue: a nonrandomized phase 2 multicenter study by the Nordic Lymphoma Group. Blood. 2008 Oct 1;112(7):2687-93. Epub 2008 Jul 14. link to original article link to PMC article contains verified protocol PubMed
    1. Update: Geisler CH, Kolstad A, Laurell A, Jerkeman M, Räty R, Andersen NS, Pedersen LB, Eriksson M, Nordström M, Kimby E, Bentzen H, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Ehinger M, Sundström C, Delabie J, Karjalainen-Lindsberg ML, Brown P, Elonen E; Nordic Lymphoma Group. Nordic MCL2 trial update: six-year follow-up after intensive immunochemotherapy for untreated mantle cell lymphoma followed by BEAM or BEAC + autologous stem-cell support: still very long survival but late relapses do occur. Br J Haematol. 2012 Aug;158(3):355-62. Epub 2012 May 29. Erratum in: Br J Haematol. 2012 Sep;158(6):815-6. link to original article PubMed
    2. Update: Eskelund CW, Kolstad A, Jerkeman M, Räty R, Laurell A, Eloranta S, Smedby KE, Husby S, Pedersen LB, Andersen NS, Eriksson M, Kimby E, Bentzen H, Kuittinen O, Lauritzsen GF, Nilsson-Ehle H, Ralfkiaer E, Ehinger M, Sundström C, Delabie J, Karjalainen-Lindsberg ML, Workman CT, Garde C, Elonen E, Brown P, Grønbaek K, Geisler CH. 15-year follow-up of the Second Nordic Mantle Cell Lymphoma trial (MCL2): prolonged remissions without survival plateau. Br J Haematol. 2016 Nov;175(3):410-418. Epub 2016 Jul 5. link to original article PubMed
  2. HOVON 45: Van 't Veer MB, de Jong D, MacKenzie M, Kluin-Nelemans HC, van Oers MH, Zijlstra J, Hagenbeek A, van Putten WL. High-dose Ara-C and BEAM with autograft rescue in R-CHOP responsive mantle cell lymphoma patients. Br J Haematol. 2009 Feb;144(4):524-30. Epub 2008 Nov 26. link to original article contains verified protocol PubMed
  3. SWOG S1106: Chen RW, Li H, Bernstein SH, Kahwash S, Rimsza LM, Forman SJ, Constine L, Shea TC, Cashen AF, Blum KA, Fenske TS, Barr PM, Phillips T, Leblanc M, Fisher RI, Cheson BD, Smith SM, Faham M, Wilkins J, Leonard JP, Kahl BS, Friedberg JW. RB but not R-HCVAD is a feasible induction regimen prior to auto-HCT in frontline MCL: results of SWOG Study S1106. Br J Haematol. 2017 Mar;176(5):759-769. Epub 2016 Dec 19. link to original article link to PMC article does not contain protocol PubMed NCT01412879
    1. Update: Kamdar M, Li H, Chen RW, Rimsza LM, Leblanc ML, Fenske TS, Shea TC, Barr PM, Phillips TJ, Leonard JP, Kahl BS, Friedberg JW, Smith SM. Five-year outcomes of the S1106 study of R-hyper-CVAD vs R-bendamustine in transplant-eligible patients with mantle cell lymphoma. Blood Adv. 2019 Oct 22;3(20):3132-3135. link to original article link to PMC article PubMed

CBV, then auto HSCT

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CBV: Cyclophosphamide, BiCNU (Carmustine), VP-16 (Etoposide)

Regimen

Study Evidence
Damon et al. 2009 (CALGB 59909) Phase II

Note: this is the transplant portion ("Treatment 4") of CALGB 59909.

Preceding treatment

Note: Stiff et al. 1998 based BCNU dosing on ideal body weight, whereas CALGB 59909 capped based on BSA, as described below.

Chemotherapy

Supportive medications

Stem cells re-infused on day 0

Targeted therapy

Additional considerations

If any patient appeared to be experiencing carmustine-induced pneumonitis:

References

  1. CALGB 59909: Damon LE, Johnson JL, Niedzwiecki D, Cheson BD, Hurd DD, Bartlett NL, Lacasce AS, Blum KA, Byrd JC, Kelly M, Stock W, Linker CA, Canellos GP. Immunochemotherapy and autologous stem-cell transplantation for untreated patients with mantle-cell lymphoma: CALGB 59909. J Clin Oncol. 2009 Dec 20;27(36):6101-8. Epub 2009 Nov 16. link to original article contains protocol link to PMC article PubMed
  2. SWOG S1106: Chen RW, Li H, Bernstein SH, Kahwash S, Rimsza LM, Forman SJ, Constine L, Shea TC, Cashen AF, Blum KA, Fenske TS, Barr PM, Phillips T, Leblanc M, Fisher RI, Cheson BD, Smith SM, Faham M, Wilkins J, Leonard JP, Kahl BS, Friedberg JW. RB but not R-HCVAD is a feasible induction regimen prior to auto-HCT in frontline MCL: results of SWOG Study S1106. Br J Haematol. 2017 Mar;176(5):759-769. Epub 2016 Dec 19. link to original article link to PMC article does not contain protocol PubMed NCT01412879
    1. Update: Kamdar M, Li H, Chen RW, Rimsza LM, Leblanc ML, Fenske TS, Shea TC, Barr PM, Phillips TJ, Leonard JP, Kahl BS, Friedberg JW, Smith SM. Five-year outcomes of the S1106 study of R-hyper-CVAD vs R-bendamustine in transplant-eligible patients with mantle cell lymphoma. Blood Adv. 2019 Oct 22;3(20):3132-3135. link to original article link to PMC article PubMed

Cyclophosphamide & TBI, then auto HSCT

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CY/TBI: CYclophosphamide & Total Body Irradiation

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Dreyling et al. 2004 1996-2004 Phase III (E-esc) Interferon alfa Seems to have superior PFS

Preceding treatment

Chemotherapy

Radiotherapy

Stem cells re-infused on day 0

References

  1. Dreyling M, Lenz G, Hoster E, Van Hoof A, Gisselbrecht C, Schmits R, Metzner B, Truemper L, Reiser M, Steinhauer H, Boiron JM, Boogaerts MA, Aldaoud A, Silingardi V, Kluin-Nelemans HC, Hasford J, Parwaresch R, Unterhalt M, Hiddemann W. Early consolidation by myeloablative radiochemotherapy followed by autologous stem cell transplantation in first remission significantly prolongs progression-free survival in mantle-cell lymphoma: results of a prospective randomized trial of the European MCL Network. Blood. 2005 Apr 1;105(7):2677-84. Epub 2004 Dec 9. link to original article contains verified protocol PubMed

Ibritumomab tiuxetan protocol

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Regimen

Study Evidence
Smith et al. 2012 (ECOG E1499) Phase II

Preceding treatment

Radioimmunotherapy

  • Rituximab (Rituxan) 250 mg/m2 IV once per day on days 1 & 8, given first on day 8
  • Ibritumomab tiuxetan & Yttrium-90 (Zevalin) as follows:
    • Platelets at least 150 x 109/L: 0.4 mCi/kg (maximum dose of 32 mCi) IV once on day 8, given second
    • Platelets between 100 and 149 x 109/L: 0.3 mCi/kg (maximum dose of 32 mCi) IV once on day 8, given second

8-day course

References

  1. ECOG E1499: Smith MR, Li H, Gordon L, Gascoyne RD, Paietta E, Forero-Torres A, Kahl BS, Advani R, Hong F, Horning SJ. Phase II study of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone immunochemotherapy followed by yttrium-90-ibritumomab tiuxetan in untreated mantle-cell lymphoma: Eastern Cooperative Oncology Group Study E1499. J Clin Oncol. 2012 Sep 1;30(25):3119-26. Epub 2012 Jul 30. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Smith MR, Hong F, Li H, Gordon LI, Gascoyne RD, Paietta EM, Advani RH, Forero-Torres A, Horning SJ, Kahl BS. Mantle cell lymphoma initial therapy with abbreviated R-CHOP followed by (90)Y-ibritumomab tiuxetan: 10-year follow-up of the phase 2 ECOG-ACRIN study E1499. Leukemia. 2017 Feb;31(2):517-519. Epub 2016 Oct 26. link to PMC article PubMed

Melphalan & TBI, then auto HSCT

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TBI: Total Body Irradiation

Regimen

Study Evidence
Gressin et al. 2010 (GOELAMS LM1996) Phase II
Gressin et al. 2010 (GOELAMS LM2001) Phase II

Preceding treatment

Chemotherapy

Radiotherapy

Stem cells reinfused after chemoradiotherapy, unclear exactly which day

References

  1. GOELAMS LM1996/LM2001: Gressin R, Caulet-Maugendre S, Deconinck E, Tournilhac O, Gyan E, Moles MP, El Yamani A, Cornillon J, Rossi JF, Le Gouill S, Lepeu G, Damaj G, Celigny PS, Maisonneuve H, Corront B, Vilque JP, Casassus P, Lamy T, Colonna M, Colombat P; GOELAMS. Evaluation of the (R)VAD+C regimen for the treatment of newly diagnosed mantle cell lymphoma: combined results of two prospective phase II trials from the French GOELAMS Group. Haematologica. 2010 Aug;95(8):1350-7. Epub 2010 Mar 10. link to original article link to PMC article contains partial protocol PubMed

R-BEAM, then auto HSCT

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R-BEAM: Rituximab, BiCNU (Carmustine), Etoposide, Ara-C (Cytarabine), Melphalan

Regimen

Study Evidence
Le Gouill et al. 2017 (LyMa) Non-randomized portion of RCT

Preceding treatment

Targeted therapy

Chemotherapy

Stem cells re-infused on day 0

Stem cells re-infused on day 0

Subsequent treatment

References

  1. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article contains verified protocol PubMed NCT00921414

TAM6, then auto HSCT

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TAM: Total-body irradiation, Ara-C (Cytarabine), Melphalan

Regimen

Study Evidence
Delarue et al. 2012 Phase II

Preceding treatment

Radiotherapy

Chemotherapy

Supportive medications

"Antimicrobial prophylaxis and use of G-CSF or erythropoietin were permitted according to physician decision."

References

  1. Delarue R, Haioun C, Ribrag V, Brice P, Delmer A, Tilly H, Salles G, Van Hoof A, Casasnovas O, Brousse N, Lefrere F, Hermine O; Groupe d'Etude des Lymphomes de l'Adulte. CHOP and DHAP plus rituximab followed by autologous stem cell transplantation in mantle cell lymphoma: a phase 2 study from the Groupe d'Etude des Lymphomes de l'Adulte. Blood. 2013 Jan 3;121(1):48-53. Epub 2012 Jun 20. link to original article contains verified protocol PubMed

Maintenance after first-line therapy

Bortezomib monotherapy

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Regimen

Study Evidence
Till et al. 2015 (SWOG S0601) Phase II

Preceding treatment

Targeted therapy

3-month cycle for 8 cycles (2 years)

References

  1. SWOG S0601: Till BG, Li H, Bernstein SH, Fisher RI, Burack WR, Rimsza LM, Floyd JD, DaSilva MA, Moore DF Jr, Pozdnyakova O, Smith SM, LeBlanc M, Friedberg JW. Phase II trial of R-CHOP plus bortezomib induction therapy followed by bortezomib maintenance for newly diagnosed mantle cell lymphoma: SWOG S0601. Br J Haematol. 2016 Jan;172(2):208-18. Epub 2015 Oct 22. link to original article contains verified protocol link to PMC article PubMed

Interferon alfa monotherapy

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Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Dreyling et al. 2004 1996-2004 Phase III (C) Cy/TBI, then auto HSCT Seems to have inferior PFS
Kluin-Nelemans et al. 2012 (MCLelderly) 2004-2010 Phase III (C) Rituximab Inferior combined OS (*)

Note: in MCLelderly, inferiority was only demonstrated in the group of patients who got R-CHOP first; overall, there was no statistically significant survival difference between the two maintenance groups. Neither of these trials specified the type of interferon alfa used.

Preceding treatment

Immunotherapy

Continued indefinitely

References

  1. Dreyling M, Lenz G, Hoster E, Van Hoof A, Gisselbrecht C, Schmits R, Metzner B, Truemper L, Reiser M, Steinhauer H, Boiron JM, Boogaerts MA, Aldaoud A, Silingardi V, Kluin-Nelemans HC, Hasford J, Parwaresch R, Unterhalt M, Hiddemann W. Early consolidation by myeloablative radiochemotherapy followed by autologous stem cell transplantation in first remission significantly prolongs progression-free survival in mantle-cell lymphoma: results of a prospective randomized trial of the European MCL Network. Blood. 2005 Apr 1;105(7):2677-84. Epub 2004 Dec 9. link to original article PubMed
  2. MCLelderly: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Trneny M, Geisler CH, Stilgenbauer S, Thieblemont C, Vehling-Kaiser U, Doorduijn JK, Coiffier B, Forstpointner R, Tilly H, Kanz L, Feugier P, Szymczyk M, Hallek M, Kremers S, Lepeu G, Sanhes L, Zijlstra JM, Bouabdallah R, Lugtenburg PJ, Macro M, Pfreundschuh M, Procházka V, Di Raimondo F, Ribrag V, Uppenkamp M, André M, Klapper W, Hiddemann W, Unterhalt M, Dreyling MH. Treatment of older patients with mantle-cell lymphoma. N Engl J Med. 2012 Aug 9;367(6):520-31. link to original article PubMed NCT00209209
    1. Update: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Geisler CH, Trneny M, Stilgenbauer S, Kaiser F, Doorduijn JK, Salles G, Szymczyk M, Tilly H, Kanz L, Schmidt C, Feugier P, Thieblemont C, Zijlstra JM, Ribrag V, Klapper W, Pott C, Unterhalt M, Dreyling MH. Treatment of Older Patients With Mantle Cell Lymphoma (MCL): Long-Term Follow-Up of the Randomized European MCL Elderly Trial. J Clin Oncol. 2020 Jan 20;38(3):248-256. Epub 2019 Dec 5. link to original article PubMed

Lenalidomide monotherapy

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Regimen variant #1, 10 mg/day

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ladetto et al. 2020 (MCL0208) 2010-2015 Phase III (E-esc) Observation Seems to have superior PFS

Note: this dosing was intended for patients with platelet count between 60 and 100 x 109/L.

Preceding treatment

Targeted therapy

28-day cycle for 24 cycles

Regimen variant #2, 15 mg/day

Study Years of enrollment Evidence Comparator Comparative Efficacy
Ladetto et al. 2020 (MCL0208) 2010-2015 Phase III (E-esc) Observation Seems to have superior PFS

Note: this dosing was intended for patients with platelet count greater than 100 x 109/L.

Preceding treatment

Targeted therapy

28-day cycle for 24 cycles

References

  1. MCL0208: Ladetto M, Cortelazzo S, Ferrero S, Evangelista A, Mian M, Tavarozzi R, Zanni M, Cavallo F, Di Rocco A, Stefoni V, Pagani C, Re A, Chiappella A, Balzarotti M, Zilioli VR, Gomes da Silva M, Arcaini L, Molinari AL, Ballerini F, Ferreri AJM, Puccini B, Benedetti F, Stefani PM, Narni F, Casaroli I, Stelitano C, Ciccone G, Vitolo U, Martelli M; Fondazione Italiana Linfomi. Lenalidomide maintenance after autologous haematopoietic stem-cell transplantation in mantle cell lymphoma: results of a Fondazione Italiana Linfomi (FIL) multicentre, randomised, phase 3 trial. Lancet Haematol. 2021 Jan;8(1):e34-e44. Epub 2020 Dec 22. link to original article contains protocol PubMed NCT02354313

Lenalidomide & Rituximab

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Regimen

Study Evidence
Ruan et al. 2015 (Cornell 1103011566) Phase II

Preceding treatment

Targeted therapy

28-day cycles

References

  1. Cornell 1103011566: Ruan J, Martin P, Shah B, Schuster SJ, Smith SM, Furman RR, Christos P, Rodriguez A, Svoboda J, Lewis J, Katz O, Coleman M, Leonard JP. Lenalidomide plus rituximab as initial treatment for mantle-cell lymphoma. N Engl J Med. 2015 Nov 5;373(19):1835-44. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Ruan J, Martin P, Christos P, Cerchietti L, Tam W, Shah B, Schuster SJ, Rodriguez A, Hyman D, Calvo-Vidal MN, Smith SM, Svoboda J, Furman RR, Coleman M, Leonard JP. Five-year follow-up of lenalidomide plus rituximab as initial treatment of mantle cell lymphoma. Blood. 2018 Nov 8;132(19):2016-2025. Epub 2018 Sep 4. link to original article PubMed

Rituximab monotherapy

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Regimen variant #1, 6 doses

Study Evidence
Sachanas et al. 2011 Phase II

Preceding treatment

Targeted therapy

2-month cycle for 6 cycles (1 year)

Regimen variant #2, 12 doses

Study Evidence
Räty et al. 2012 Phase II

Preceding treatment

  • Induction chemotherapy x 10, with CR/PR

Targeted therapy

2-month cycle for 12 cycles (2 years)

Regimen variant #3, 16 doses

Study Evidence
Chang et al. 2014 (ECOG E1405) Phase II

Preceding treatment

Targeted therapy

6-month cycle for 4 cycles (2 years)

Regimen variant #4, 18 doses

Study Years of enrollment Evidence Comparator Comparative Efficacy
Le Gouill et al. 2017 (LyMa) 2008-2012 Phase III (E-esc) Observation Seems to have superior OS

Preceding treatment

Targeted therapy

2-month cycle for 18 cycles (3 years)

Regimen variant #5, 24 doses

Study Evidence
Lossos et al. 2010 (UM-MCL2) Phase II

Preceding treatment

Targeted therapy

6-month cycle for 6 cycles (3 years)

Regimen variant #6, indefinite

Study Years of enrollment Evidence Comparator Comparative Efficacy
Kluin-Nelemans et al. 2012 (MCLelderly) 2004-2010 Phase III (E-switch-ooc) Interferon alfa Superior combined OS (*)

Note: superiority was only demonstrated in the group of patients who got R-CHOP first; overall, there was no statistically significant survival difference between the two maintenance groups.

Preceding treatment

Targeted therapy

2-month cycles

References

  1. UM-MCL1/UM-MCL2: Lossos IS, Hosein PJ, Morgensztern D, Coleman F, Escalón MP, Byrne GE Jr, Rosenblatt JD, Walker GR. High rate and prolonged duration of complete remissions induced by rituximab, methotrexate, doxorubicin, cyclophosphamide, vincristine, ifosfamide, etoposide, cytarabine, and thalidomide (R-MACLO-IVAM-T), a modification of the National Cancer Institute 89-C-41 regimen, in patients with newly diagnosed mantle cell lymphoma. Leuk Lymphoma. 2010 Mar;51(3):406-14. link to original article contains verified protocol PubMed
    1. Update: Hosein PJ, Sandoval-Sus JD, Goodman D, Arteaga AG, Reis I, Hoffman J, Stefanovic A, Rosenblatt JD, Lossos IS. Updated survival analysis of two sequential prospective trials of R-MACLO-IVAM followed by maintenance for newly diagnosed mantle cell lymphoma. Am J Hematol. 2015 Jun;90(6):E111-6. Epub 2015 Apr 2. link to original article link to PMC article PubMed
  2. Sachanas S, Pangalis GA, Vassilakopoulos TP, Korkolopoulou P, Kontopidou FN, Athanasoulia M, Yiakoumis X, Kalpadakis C, Georgiou G, Masouridis S, Moschogiannis M, Tsirkinidis P, Pappis V, Kokoris SI, Siakantaris MP, Panayiotidis P, Angelopoulou MK. Combination of rituximab with chlorambucil as first line treatment in patients with mantle cell lymphoma: a highly effective regimen. Leuk Lymphoma. 2011 Mar;52(3):387-93. Epub 2010 Dec 6. link to original article contains verified protocol PubMed
  3. MCLelderly: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Trneny M, Geisler CH, Stilgenbauer S, Thieblemont C, Vehling-Kaiser U, Doorduijn JK, Coiffier B, Forstpointner R, Tilly H, Kanz L, Feugier P, Szymczyk M, Hallek M, Kremers S, Lepeu G, Sanhes L, Zijlstra JM, Bouabdallah R, Lugtenburg PJ, Macro M, Pfreundschuh M, Procházka V, Di Raimondo F, Ribrag V, Uppenkamp M, André M, Klapper W, Hiddemann W, Unterhalt M, Dreyling MH. Treatment of older patients with mantle-cell lymphoma. N Engl J Med. 2012 Aug 9;367(6):520-31. link to original article contains verified protocol PubMed NCT00209209
    1. Update: Kluin-Nelemans HC, Hoster E, Hermine O, Walewski J, Geisler CH, Trneny M, Stilgenbauer S, Kaiser F, Doorduijn JK, Salles G, Szymczyk M, Tilly H, Kanz L, Schmidt C, Feugier P, Thieblemont C, Zijlstra JM, Ribrag V, Klapper W, Pott C, Unterhalt M, Dreyling MH. Treatment of Older Patients With Mantle Cell Lymphoma (MCL): Long-Term Follow-Up of the Randomized European MCL Elderly Trial. J Clin Oncol. 2020 Jan 20;38(3):248-256. Epub 2019 Dec 5. link to original article PubMed
  4. Räty R, Honkanen T, Jantunen E, Jyrkkiö S, Karjalainen-Lindsberg ML, Kuittinen O, Lehto M, Mikkola M, Poikonen E, Rauhala A, Rimpiläinen J, Räsänen A, Siitonen S, Suominen M, Vapaatalo M, Elonen E; Finnish Lymphoma Group. Prolonged immunochemotherapy with rituximab, cytarabine and fludarabine added to cyclophosphamide, doxorubicin, vincristine and prednisolone and followed by rituximab maintenance in untreated elderly patients with mantle cell lymphoma: a prospective study by the Finnish Lymphoma Group. Leuk Lymphoma. 2012 Oct;53(10):1920-8. Epub 2012 Apr 23. link to original article contains verified protocol PubMed
    1. Update: Abstract: Riikka Räty, Tuomo Honkanen, Esa Jantunen, MD, PhD, Sirkku Jyrkkiö, Marja-Liisa Karjalainen-Lindsberg, MD, PhD, Outi Kuittinen, Minna Lehto, Maija Mikkola, Eira Poikonen, Auvo Rauhala, Johanna Rimpiläinen, Anu Räsänen, MD, Sanna Siitonen, Merja Suominen, MD, Mirja Vapaatalo and Erkki Elonen. Rituximab Maintenance Bimonthly for Two Years after Prolonged Immunochemotherapy in Elderly Patients with Mantle Cell Lymphoma (MCL) Results in Long Remissions: Update with Six-Year Follow-up of a Prospective Study By the Finnish Lymphoma Group. Blood 2014 124:1749. link to abstract
  5. ECOG E1405: Chang JE, Li H, Smith MR, Gascoyne RD, Paietta EM, Yang DT, Advani RH, Horning SJ, Kahl BS. Phase 2 study of VcR-CVAD with maintenance rituximab for untreated mantle cell lymphoma: an Eastern Cooperative Oncology Group study (E1405). Blood. 2014 Mar 13;123(11):1665-73. Epub 2014 Jan 23. link to original article contains verified protocol link to PMC article PubMed
  6. LyMa: Le Gouill S, Thieblemont C, Oberic L, Moreau A, Bouabdallah K, Dartigeas C, Damaj G, Gastinne T, Ribrag V, Feugier P, Casasnovas O, Zerazhi H, Haioun C, Maisonneuve H, Houot R, Jardin F, Van Den Neste E, Tournilhac O, Le Dû K, Morschhauser F, Cartron G, Fornecker LM, Canioni D, Callanan M, Béné MC, Salles G, Tilly H, Lamy T, Gressin R, Hermine O; LYSA. Rituximab after autologous stem-cell transplantation in mantle-cell lymphoma. N Engl J Med. 2017 Sep 28;377(13):1250-1260. link to original article contains verified protocol PubMed NCT00921414

Relapsed or refractory, randomized data

BCHOP

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BCHOP: Bortezomib, Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisolone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Furtado et al. 2014 (NCRN-Ply-26s) 2007-2011 Randomized Phase II (E-esc) CHOP Seems to have superior OS

Targeted therapy

Chemotherapy

Supportive medications

21-day cycle for up to 8 cycles

References

  1. NCRN-Ply-26s: Furtado M, Johnson R, Kruger A, Turner D, Rule S. Addition of bortezomib to standard dose chop chemotherapy improves response and survival in relapsed mantle cell lymphoma. Br J Haematol. 2015 Jan;168(1):55-62. Epub 2014 Aug 22. link to original article contains verified protocol PubMed NCT00513955

BR

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BR: Bendamustine, Rituximab

Regimen variant #1

Study Years of enrollment Evidence Comparator Comparative Efficacy
Czuczman et al. 2015 NR Phase II
Rummel et al. 2015 (StiL NHL 2-2003) 2003-2010 Phase III (E-switch-ic) FR Seems to have superior OS

Chemotherapy

Targeted therapy

Supportive medications

28-day cycle for 6 to 8 cycles

Regimen variant #2

Study Evidence
Rummel et al. 2005 Phase II, <20 pts in subgroup
Robinson et al. 2008 Phase II, <20 pts in subgroup

Note: Robinson et al. 2008 said that patients "could receive up to six cycles if disease regression was evident between the second and fourth cycles".

Chemotherapy

Targeted therapy

  • Rituximab (Rituxan) as follows:
    • One week prior to start of cycle 1: 375 mg/m2 IV once
    • Cycles 1 to 4: 375 mg/m2 IV once on day 1
    • 4 weeks after cycle 4: 375 mg/m2 IV once

28-day cycle for 4 cycles (Rummel et al. 2005) or up to 6 cycles (Robinson et al. 2008; see note)

References

  1. Rummel MJ, Al-Batran SE, Kim SZ, Welslau M, Hecker R, Kofahl-Krause D, Josten KM, Dürk H, Rost A, Neise M, von Grünhagen U, Chow KU, Hansmann ML, Hoelzer D, Mitrou PS. Bendamustine plus rituximab is effective and has a favorable toxicity profile in the treatment of mantle cell and low-grade non-Hodgkin's lymphoma. J Clin Oncol. 2005 May 20;23(15):3383-9. link to original article contains verified protocol PubMed
  2. Robinson KS, Williams ME, van der Jagt RH, Cohen P, Herst JA, Tulpule A, Schwartzberg LS, Lemieux B, Cheson BD. Phase II multicenter study of bendamustine plus rituximab in patients with relapsed indolent B-cell and mantle cell non-Hodgkin's lymphoma. J Clin Oncol. 2008 Sep 20;26(27):4473-9. Epub 2008 Jul 14. link to original article contains verified protocol PubMed
  3. Czuczman MS, Goy A, Lamonica D, Graf DA, Munteanu MC, van der Jagt RH. Phase II study of bendamustine combined with rituximab in relapsed/refractory mantle cell lymphoma: efficacy, tolerability, and safety findings. Ann Hematol. 2015 Dec;94(12):2025-32. Epub 2015 Sep 28. link to original article contains verified protocol PubMed
  4. StiL NHL 2-2003: Rummel M, Kaiser U, Balser C, Stauch M, Brugger W, Welslau M, Niederle N, Losem C, Boeck HP, Weidmann E, von Gruenhagen U, Mueller L, Sandherr M, Hahn L, Vereshchagina J, Kauff F, Blau W, Hinke A, Barth J; StiL. Bendamustine plus rituximab versus fludarabine plus rituximab for patients with relapsed indolent and mantle-cell lymphomas: a multicentre, randomised, open-label, non-inferiority phase 3 trial. Lancet Oncol. 2016 Jan;17(1):57-66. Epub 2015 Dec 5. link to original article contains protocol PubMed NCT01456351

CHOP (Prednisolone)

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CHOP: Cyclophosphamide, Hydroxydaunorubicin (Doxorubicin), Oncovin (Vincristine), Prednisolone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Furtado et al. 2014 (NCRN-Ply-26s) 2007-2011 Randomized Phase II (C) BCHOP Seems to have inferior OS

Note: this regimen uses prednisolone, unlike most CHOP regimens which use prednisone.

Chemotherapy

21-day cycle for 6 to 8 cycles

References

  1. NCRN-Ply-26s: Furtado M, Johnson R, Kruger A, Turner D, Rule S. Addition of bortezomib to standard dose chop chemotherapy improves response and survival in relapsed mantle cell lymphoma. Br J Haematol. 2015 Jan;168(1):55-62. Epub 2014 Aug 22. link to original article contains verified protocol PubMed NCT00513955

FCM

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FCM: Fludarabine, Cyclophosphamide, Mitoxantrone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Forstpointner et al. 2004 1998-2001 Phase III (C) R-FCM Inferior OS

Chemotherapy

28-day cycle for 4 cycles

Subsequent treatment

References

  1. Forstpointner R, Dreyling M, Repp R, Hermann S, Hänel A, Metzner B, Pott C, Hartmann F, Rothmann F, Rohrberg R, Böck HP, Wandt H, Unterhalt M, Hiddemann W; German Low-Grade Lymphoma Study Group. The addition of rituximab to a combination of fludarabine, cyclophosphamide, mitoxantrone (FCM) significantly increases the response rate and prolongs survival as compared with FCM alone in patients with relapsed and refractory follicular and mantle cell lymphomas: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood. 2004 Nov 15;104(10):3064-71. Epub 2004 Jul 29. link to original article contains verified protocol PubMed content property of HemOnc.org
    1. Update: Forstpointner R, Unterhalt M, Dreyling M, Böck HP, Repp R, Wandt H, Pott C, Seymour JF, Metzner B, Hänel A, Lehmann T, Hartmann F, Einsele H, Hiddemann W; German Low Grade Lymphoma Study Group. Maintenance therapy with rituximab leads to a significant prolongation of response duration after salvage therapy with a combination of rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM) in patients with recurring and refractory follicular and mantle cell lymphomas: Results of a prospective randomized study of the German Low Grade Lymphoma Study Group (GLSG). Blood. 2006 Dec 15;108(13):4003-8. Epub 2006 Aug 31. link to original article contains verified protocol PubMed

FR

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FR: Fludarabine, Rituximab

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Rummel et al. 2015 (StiL NHL 2-2003) 2003-2010 Phase III (C) BR Seems to have inferior OS

Chemotherapy

Targeted therapy

28-day cycle for up to 6 cycles

References

  1. StiL NHL 2-2003: Rummel M, Kaiser U, Balser C, Stauch M, Brugger W, Welslau M, Niederle N, Losem C, Boeck HP, Weidmann E, von Gruenhagen U, Mueller L, Sandherr M, Hahn L, Vereshchagina J, Kauff F, Blau W, Hinke A, Barth J; StiL. Bendamustine plus rituximab versus fludarabine plus rituximab for patients with relapsed indolent and mantle-cell lymphomas: a multicentre, randomised, open-label, non-inferiority phase 3 trial. Lancet Oncol. 2016 Jan;17(1):57-66. Epub 2015 Dec 5. link to original article contains protocol PubMed NCT01456351

Ibrutinib monotherapy

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Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy Comparative Toxicity
Wang et al. 2013 (PCYC-1104-CA) 2011-2012 Phase II (RT)
Dreyling et al. 2015 (RAY) 2012-2013 Phase III (E-switch-ic) Temsirolimus Superior PFS Improved HRQoL

Targeted therapy

Continued indefinitely

References

  1. PCYC-1104-CA: Wang ML, Rule S, Martin P, Goy A, Auer R, Kahl BS, Jurczak W, Advani RH, Romaguera JE, Williams ME, Barrientos JC, Chmielowska E, Radford J, Stilgenbauer S, Dreyling M, Jedrzejczak WW, Johnson P, Spurgeon SE, Li L, Zhang L, Newberry K, Ou Z, Cheng N, Fang B, McGreivy J, Clow F, Buggy JJ, Chang BY, Beaupre DM, Kunkel LA, Blum KA. Targeting BTK with ibrutinib in relapsed or refractory mantle-cell lymphoma. N Engl J Med. 2013 Aug 8;369(6):507-16. Epub 2013 Jun 19. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Wang ML, Blum KA, Martin P, Goy A, Auer R, Kahl BS, Jurczak W, Advani RH, Romaguera JE, Williams ME, Barrientos JC, Chmielowska E, Radford J, Stilgenbauer S, Dreyling M, Jedrzejczak WW, Johnson P, Spurgeon SE, Zhang L, Baher L, Cheng M, Lee D, Beaupre DM, Rule S. Long-term follow-up of MCL patients treated with single-agent ibrutinib: updated safety and efficacy results. Blood. 2015 Aug 6;126(6):739-45. Epub 2015 Jun 9. link to original article link to PMC article PubMed
  2. RAY: Dreyling M, Jurczak W, Jerkeman M, Silva RS, Rusconi C, Trneny M, Offner F, Caballero D, Joao C, Witzens-Harig M, Hess G, Bence-Bruckler I, Cho SG, Bothos J, Goldberg JD, Enny C, Traina S, Balasubramanian S, Bandyopadhyay N, Sun S, Vermeulen J, Rizo A, Rule S. Ibrutinib versus temsirolimus in patients with relapsed or refractory mantle-cell lymphoma: an international, randomised, open-label, phase 3 study. Lancet. 2016 Feb 20;387(10020):770-8. Epub 2015 Dec 4. Erratum in: Lancet. 2016 Feb 20;387(10020):750.link to original article contains verified protocol PubMed
    1. HRQoL analysis: Hess G, Rule S, Jurczak W, Jerkeman M, Santucci Silva R, Rusconi C, Caballero D, Joao C, Witzens-Harig M, Bence-Bruckler I, Cho SG, Zhou W, Goldberg JD, Trambitas C, Enny C, Vermeulen J, Traina S, Chiou CF, Diels J, Dreyling M. Health-related quality of life data from a phase 3, international, randomized, open-label, multicenter study in patients with previously treated mantle cell lymphoma treated with ibrutinib versus temsirolimus. Leuk Lymphoma. 2017 Dec;58(12):2824-2832. Epub 2017 May 30. link to original article PubMed
    2. Update: Rule S, Jurczak W, Jerkeman M, Rusconi C, Trneny M, Offner F, Caballero D, Joao C, Witzens-Harig M, Hess G, Bence-Bruckler I, Cho SG, Thieblemont C, Zhou W, Henninger T, Goldberg J, Vermeulen J, Dreyling M. Ibrutinib versus temsirolimus: 3-year follow-up of patients with previously treated mantle cell lymphoma from the phase 3, international, randomized, open-label RAY study. Leukemia. 2018 Aug;32(8):1799-1803. Epub 2018 Feb 2. link to original article link to PMC article PubMed

Lenalidomide monotherapy

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Regimen

FDA-recommended dose
Study Years of enrollment Evidence Comparator Comparative Efficacy
Wiernik et al. 2008 (CC-5013-NHL-002) 2005-2006 Phase II, <20 pts in subgroup
Witzig et al. 2011 (NHL-003) 2006-2008 Phase II
Eve et al. 2012 2008-2010 Phase II
Goy et al. 2013 (EMERGE) 2009-2012 Phase II (RT)
Trněný et al. 2016 (SPRINT) 2009-2013 Randomized Phase II (E-switch-ooc) Investigator's choice of:
1. Chlorambucil
2. Cytarabine
3. Fludarabine
4. Gemcitabine
5. Rituximab 		Superior PFS

Participants in EMERGE "were required to have had prior treatment with rituximab, cyclophosphamide and anthracycline (or mitoxantrone), and to have relapsed or progressed (<12 months) after or were refractory to bortezomib." Investigator's choice in the SPRINT trial was restricted to single-agent therapy with cytarabine, rituximab, gemcitabine, fludarabine, or chlorambucil.

Targeted therapy

28-day cycles

Subsequent treatment

References

  1. CC-5013-NHL-002: Wiernik PH, Lossos IS, Tuscano JM, Justice G, Vose JM, Cole CE, Lam W, McBride K, Wride K, Pietronigro D, Takeshita K, Ervin-Haynes A, Zeldis JB, Habermann TM. Lenalidomide monotherapy in relapsed or refractory aggressive non-Hodgkin's lymphoma. J Clin Oncol. 2008 Oct 20;26(30):4952-7. Epub 2008 Jul 7. link to original article contains verified protocol PubMed NCT00179660
    1. Update: Habermann TM, Lossos IS, Justice G, Vose JM, Wiernik PH, McBride K, Wride K, Ervin-Haynes A, Takeshita K, Pietronigro D, Zeldis JB, Tuscano JM. Lenalidomide oral monotherapy produces a high response rate in patients with relapsed or refractory mantle cell lymphoma. Br J Haematol. 2009 May;145(3):344-9. Epub 2009 Feb 24. link to original article contains verified protocol PubMed
    2. Pooled Update: Witzig TE, Zinzani PL, Habermann TM, Tuscano JM, Drach J, Ramchandren R, Kalayoglu Besisik S, Takeshita K, Casadebaig Bravo ML, Zhang L, Fu T, Goy A. Long-term analysis of phase II studies of single-agent lenalidomide in relapsed/refractory mantle cell lymphoma. Am J Hematol. 2017 Oct;92(10):E575-E583. Epub 2017 Aug 28. link to original article PubMed
  2. NHL-003: Witzig TE, Vose JM, Zinzani PL, Reeder CB, Buckstein R, Polikoff JA, Bouabdallah R, Haioun C, Tilly H, Guo P, Pietronigro D, Ervin-Haynes AL, Czuczman MS. An international phase II trial of single-agent lenalidomide for relapsed or refractory aggressive B-cell non-Hodgkin's lymphoma. Ann Oncol. 2011 Jul;22(7):1622-7. Epub 2011 Jan 12. link to original article contains verified protocol PubMed NCT00413036
    1. Update: Zinzani PL, Vose JM, Czuczman MS, Reeder CB, Haioun C, Polikoff J, Tilly H, Zhang L, Prandi K, Li J, Witzig TE. Long-term follow-up of lenalidomide in relapsed/refractory mantle cell lymphoma: subset analysis of the NHL-003 study. Ann Oncol. 2013 Nov;24(11):2892-7. Epub 2013 Sep 12. link to original article link to PMC article PubMed
    2. Pooled Update: Witzig TE, Zinzani PL, Habermann TM, Tuscano JM, Drach J, Ramchandren R, Kalayoglu Besisik S, Takeshita K, Casadebaig Bravo ML, Zhang L, Fu T, Goy A. Long-term analysis of phase II studies of single-agent lenalidomide in relapsed/refractory mantle cell lymphoma. Am J Hematol. 2017 Oct;92(10):E575-E583. Epub 2017 Aug 28. link to original article PubMed
  3. Eve HE, Carey S, Richardson SJ, Heise CC, Mamidipudi V, Shi T, Radford JA, Auer RL, Bullard SH, Rule SA. Single-agent lenalidomide in relapsed/refractory mantle cell lymphoma: results from a UK phase II study suggest activity and possible gender differences. Br J Haematol. 2012 Oct;159(2):154-63. Epub 2012 Aug 9. link to original article contains verified protocol PubMed
  4. EMERGE: Goy A, Sinha R, Williams ME, Kalayoglu Besisik S, Drach J, Ramchandren R, Zhang L, Cicero S, Fu T, Witzig TE. Single-agent lenalidomide in patients with mantle-cell lymphoma who relapsed or progressed after or were refractory to bortezomib: Phase II MCL-001 (EMERGE) study. J Clin Oncol. 2013 Oct 10;31(29):3688-95. Epub 2013 Sep 3. link to original article contains verified protocol link to PMC article PubMed
    1. Update: Goy A, Kalayoglu Besisik S, Drach J, Ramchandren R, Robertson MJ, Avivi I, Rowe JM, Herbrecht R, Van Hoof A, Zhang L, Cicero S, Fu T, Witzig T. Longer-term follow-up and outcome by tumour cell proliferation rate (Ki-67) in patients with relapsed/refractory mantle cell lymphoma treated with lenalidomide on MCL-001(EMERGE) pivotal trial. Br J Haematol. 2015 Aug;170(4):496-503. Epub 2015 Apr 28. link to original article link to PMC article PubMed
    2. Pooled Update: Witzig TE, Zinzani PL, Habermann TM, Tuscano JM, Drach J, Ramchandren R, Kalayoglu Besisik S, Takeshita K, Casadebaig Bravo ML, Zhang L, Fu T, Goy A. Long-term analysis of phase II studies of single-agent lenalidomide in relapsed/refractory mantle cell lymphoma. Am J Hematol. 2017 Oct;92(10):E575-E583. Epub 2017 Aug 28. link to original article PubMed
  5. SPRINT: Trněný M, Lamy T, Walewski J, Belada D, Mayer J, Radford J, Jurczak W, Morschhauser F, Alexeeva J, Rule S, Afanasyev B, Kaplanov K, Thyss A, Kuzmin A, Voloshin S, Kuliczkowski K, Giza A, Milpied N, Stelitano C, Marks R, Trümper L, Biyukov T, Patturajan M, Bravo MC, Arcaini L; SPRINT trial investigators and in collaboration with the European Mantle Cell Lymphoma Network. Lenalidomide versus investigator's choice in relapsed or refractory mantle cell lymphoma (MCL-002; SPRINT): a phase 2, randomised, multicentre trial. Lancet Oncol. 2016 Mar;17(3):319-31. Epub 2016 Feb 15. link to original article PubMed

R-FCM

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R-FCM: Rituximab, Fludarabine, Cyclophosphamide, Mitoxantrone

Regimen

Study Years of enrollment Evidence Comparator Comparative Efficacy
Forstpointner et al. 2004 1998-2001 Phase III (E-esc) FCM Superior OS

Targeted therapy

Chemotherapy

28-day cycle for 4 cycles

Subsequent treatment

References

  1. Forstpointner R, Dreyling M, Repp R, Hermann S, Hänel A, Metzner B, Pott C, Hartmann F, Rothmann F, Rohrberg R, Böck HP, Wandt H, Unterhalt M, Hiddemann W; German Low-Grade Lymphoma Study Group. The addition of rituximab to a combination of fludarabine, cyclophosphamide, mitoxantrone (FCM) significantly increases the response rate and prolongs survival as compared with FCM alone in patients with relapsed and refractory follicular and mantle cell lymphomas: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood. 2004 Nov 15;104(10):3064-71. Epub 2004 Jul 29. link to original article contains verified protocol PubMed
    1. Update: Forstpointner R, Unterhalt M, Dreyling M, Böck HP, Repp R, Wandt H, Pott C, Seymour JF, Metzner B, Hänel A, Lehmann T, Hartmann F, Einsele H, Hiddemann W; German Low Grade Lymphoma Study Group. Maintenance therapy with rituximab leads to a significant prolongation of response duration after salvage therapy with a combination of rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM) in patients with recurring and refractory follicular and mantle cell lymphomas: Results of a prospective randomized study of the German Low Grade Lymphoma Study Group (GLSG). Blood. 2006 Dec 15;108(13):4003-8. Epub 2006 Aug 31. link to original article contains verified protocol PubMed

Temsirolimus monotherapy

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Regimen variant #2, 25 mg

Study Evidence
Ansell et al. 2008 Phase II

Targeted therapy

Supportive medications

28-day cycle for up to 13 cycles, stopped at various timepoints (see paper for details)

Regimen variant #2, 175 -> 75

Study Years of enrollment Evidence Comparator Comparative Efficacy Comparative Toxicity
Hess et al. 2009 2005-2007 Phase III (E-switch-ooc) Investigator's choice:
1. Alemtuzumab
2. Chlorambucil
3. Cladribine
4. Etoposide
5. Fludarabine
6. Gemcitabine
7. Temsirolimus 175/25
8. Thalidomide
9. Vinblastine 		Superior PFS
Dreyling et al. 2015 (RAY) 2012-2013 Phase III (C) Ibrutinib Inferior PFS Worse HRQoL

The most commonly compared regimens in Hess et al. 2009 were single agent gemcitabine and single agent fludarabine.

Targeted therapy

  • Temsirolimus (Torisel) as follows:
    • Cycle 1: 175 mg IV over 30 to 60 minutes once per day on days 1, 8, 15
    • Cycle 2 onwards: 75 mg IV over 30 to 60 minutes once per day on days 1, 8, 15

Supportive medications

21-day cycles

Regimen variant #3, 250 mg

Study Evidence
Witzig et al. 2005 Phase II

Targeted therapy

Supportive medications

  • Use of white blood cell growth factors at physician discretion if neutropenia occurred.
  • Use of erythropoietin for anemia was allowed.

28-day cycle for up to 13 cycles or 2 cycles past CR

References

  1. Witzig TE, Geyer SM, Ghobrial I, Inwards DJ, Fonseca R, Kurtin P, Ansell SM, Luyun R, Flynn PJ, Morton RF, Dakhil SR, Gross H, Kaufmann SH. Phase II trial of single-agent temsirolimus (CCI-779) for relapsed mantle cell lymphoma. J Clin Oncol. 2005 Aug 10;23(23):5347-56. Epub 2005 Jun 27. link to original article contains verified protocol PubMed
  2. Ansell SM, Inwards DJ, Rowland KM Jr, Flynn PJ, Morton RF, Moore DF Jr, Kaufmann SH, Ghobrial I, Kurtin PJ, Maurer M, Allmer C, Witzig TE; North Central Cancer Treatment Group. Low-dose, single-agent temsirolimus for relapsed mantle cell lymphoma: a phase 2 trial in the North Central Cancer Treatment Group. Cancer. 2008 Aug 1;113(3):508-14. link to original article contains verified protocol link to PMC article PubMed
  3. Hess G, Herbrecht R, Romaguera J, Verhoef G, Crump M, Gisselbrecht C, Laurell A, Offner F, Strahs A, Berkenblit A, Hanushevsky O, Clancy J, Hewes B, Moore L, Coiffier B. Phase III study to evaluate temsirolimus compared with investigator's choice therapy for the treatment of relapsed or refractory mantle cell lymphoma. J Clin Oncol. 2009 Aug 10;27(23):3822-9. Epub 2009 Jul 6. link to original article contains verified protocol PubMed
  4. RAY: Dreyling M, Jurczak W, Jerkeman M, Silva RS, Rusconi C, Trneny M, Offner F, Caballero D, Joao C, Witzens-Harig M, Hess G, Bence-Bruckler I, Cho SG, Bothos J, Goldberg JD, Enny C, Traina S, Balasubramanian S, Bandyopadhyay N, Sun S, Vermeulen J, Rizo A, Rule S. Ibrutinib versus temsirolimus in patients with relapsed or refractory mantle-cell lymphoma: an international, randomised, open-label, phase 3 study. Lancet. 2016 Feb 20;387(10020):770-8. Epub 2015 Dec 4. Erratum in: Lancet. 2016 Feb 20;387(10020):750.link to original article contains verified protocol PubMed
    1. HRQoL analysis: Hess G, Rule S, Jurczak W, Jerkeman M, Santucci Silva R, Rusconi C, Caballero D, Joao C, Witzens-Harig M, Bence-Bruckler I, Cho SG, Zhou W, Goldberg JD, Trambitas C, Enny C, Vermeulen J, Traina S, Chiou CF, Diels J, Dreyling M. Health-related quality of life data from a phase 3, international, randomized, open-label, multicenter study in patients with previously treated mantle cell lymphoma treated with ibrutinib versus temsirolimus. Leuk Lymphoma. 2017 Dec;58(12):2824-2832. Epub 2017 May 30. link to original article PubMed
    2. Update: Rule S, Jurczak W, Jerkeman M, Rusconi C, Trneny M, Offner F, Caballero D, Joao C, Witzens-Harig M, Hess G, Bence-Bruckler I, Cho SG, Thieblemont C, Zhou W, Henninger T, Goldberg J, Vermeulen J, Dreyling M. Ibrutinib versus temsirolimus: 3-year follow-up of patients with previously treated mantle cell lymphoma from the phase 3, international, randomized, open-label RAY study. Leukemia. 2018 Aug;32(8):1799-1803. Epub 2018 Feb 2. link to original article link to PMC article PubMed

Relapsed or refractory, non-randomized or retrospective data

Acalabrutinib monotherapy

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Regimen

FDA-recommended dose
Study Years of enrollment Evidence Efficacy
Wang et al. 2017 (ACE-LY-004) 2015-2016 Phase II (RT) ORR: 81% (95% CI: 73-87)

Targeted therapy

Continued indefinitely

References

  1. ACE-LY-004: Wang M, Rule S, Zinzani PL, Goy A, Casasnovas O, Smith SD, Damaj G, Doorduijn J, Lamy T, Morschhauser F, Panizo C, Shah B, Davies A, Eek R, Dupuis J, Jacobsen E, Kater AP, Le Gouill S, Oberic L, Robak T, Covey T, Dua R, Hamdy A, Huang X, Izumi R, Patel P, Rothbaum W, Slatter JG, Jurczak W. Acalabrutinib in relapsed or refractory mantle cell lymphoma (ACE-LY-004): a single-arm, multicentre, phase 2 trial. Lancet. 2018 Feb 17;391(10121):659-667. Epub 2017 Dec 11. link to original article contains protocol PubMed

Arsenic trioxide & Chlorambucil

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Regimen

Study Years of enrollment Evidence Efficacy
Gill et al. 2014 2003-2011 Phase II ORR: 49%

Chemotherapy

Supportive medications

6-week course

Subsequent treatment

References

  1. Gill H, Au WY, Cheung WW, Lee EY, Kwong YL. Oral arsenic trioxide-based regimen as salvage treatment for relapsed or refractory mantle cell lymphoma. Ann Oncol. 2014 Jul;25(7):1391-7. Epub 2014 Apr 12. link to original article contains verified protocol PubMed

BeRT

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BeRT: Bendamustine, Rituximab, Temsirolimus

Regimen

Study Evidence
Hess et al. 2015 (Mz-341) Phase I/II, <20 pts reported

The temsirolimus dose was the maximum dose used in the phase I portion of the trial; no DLT were observed.

Chemotherapy

Targeted therapy

28-day cycle for up to 4 cycles

References

  1. Mz-341: Hess G, Keller U, Scholz CW, Witzens-Harig M, Atta J, Buske C, Kirschey S, Ruckes C, Medler C, van Oordt C, Klapper W, Theobald M, Dreyling M. Safety and efficacy of Temsirolimus in combination with Bendamustine and Rituximab in relapsed mantle cell and follicular lymphoma. Leukemia. 2015 Aug;29(8):1695-701. Epub 2015 Mar 13. link to original article contains verified protocol PubMed

BDR

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BDR: Bortezomib, Dexamethasone, Rituximab
BORID: BOrtezomib, RItuximab, Dexamethasone

Regimen

Study Evidence
Lamm et al. 2011 (MCL 03) Phase II, <20 pts reported

Targeted therapy

Chemotherapy

21-day cycle for 6 cycles

Subsequent treatment

References

  1. MCL 03: Lamm W, Kaufmann H, Raderer M, Hoffmann M, Chott A, Zielinski C, Drach J. Bortezomib combined with rituximab and dexamethasone is an active regimen for patients with relapsed and chemotherapy-refractory mantle cell lymphoma. Haematologica. 2011 Jul;96(7):1008-14. Epub 2011 Apr 12. link to original article contains verified protocol link to PMC article PubMed

Bortezomib monotherapy

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Regimen variant #1, 1.3 mg/m2

Study Years of enrollment Evidence
Fisher et al. 2006 (PINNACLE) 2003-NR Phase II (RT)

Targeted therapy

21-day cycles "up to 17 cycles or four cycles beyond initial reporting of CR/CRu, discontinuing for progressive disease (PD) or unacceptable toxicity, or by patient/investigator decision."

Regimen variant #2, 1.5 mg/m2

Study Evidence
O'Connor et al. 2005 Phase II, <20 pts reported

Targeted therapy

Supportive medications

  • "Use of antiemetics, erythropoietin, and Filgrastim (Neupogen) was allowed if deemed necessary by the treating physician."

21-day cycles

References

  1. O'Connor OA, Wright J, Moskowitz C, Muzzy J, MacGregor-Cortelli B, Stubblefield M, Straus D, Portlock C, Hamlin P, Choi E, Dumetrescu O, Esseltine D, Trehu E, Adams J, Schenkein D, Zelenetz AD. Phase II clinical experience with the novel proteasome inhibitor bortezomib in patients with indolent non-Hodgkin's lymphoma and mantle cell lymphoma. J Clin Oncol. 2005 Feb 1;23(4):676-84. Epub 2004 Dec 21. link to original article contains verified protocol PubMed
  2. PINNACLE: Fisher RI, Bernstein SH, Kahl BS, Djulbegovic B, Robertson MJ, de Vos S, Epner E, Krishnan A, Leonard JP, Lonial S, Stadtmauer EA, O'Connor OA, Shi H, Boral AL, Goy A. Multicenter phase II study of bortezomib in patients with relapsed or refractory mantle cell lymphoma. J Clin Oncol. 2006 Oct 20;24(30):4867-74. Epub 2006 Sep 25. link to original article contains verified protocol PubMed
    1. Update: Goy A, Bernstein SH, Kahl BS, Djulbegovic B, Robertson MJ, de Vos S, Epner E, Krishnan A, Leonard JP, Lonial S, Nasta S, O'Connor OA, Shi H, Boral AL, Fisher RI. Bortezomib in patients with relapsed or refractory mantle cell lymphoma: updated time-to-event analyses of the multicenter phase 2 PINNACLE study. Ann Oncol. 2009 Mar;20(3):520-5. Epub 2008 Dec 12. link to original article contains protocol link to PMC article PubMed

Cladribine monotherapy

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Regimen

Study Evidence
Inwards et al. 2008 (NCCTG 95-80-53) Phase II, <20 pts

Chemotherapy

28-day cycle for up to 6 cycles

References

  1. NCCTG 95-80-53: Inwards DJ, Fishkin PA, Hillman DW, Brown DW, Ansell SM, Kurtin PJ, Fonseca R, Morton RF, Veeder MH, Witzig TE. Long-term results of the treatment of patients with mantle cell lymphoma with cladribine (2-CDA) alone (95-80-53) or 2-CDA and rituximab (N0189) in the North Central Cancer Treatment Group. Cancer. 2008 Jul 1;113(1):108-16. link to original article contains verified protocol link to PMC article PubMed

Everolimus monotherapy

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Regimen

Study Evidence
Renner et al. 2012 (SAKK 36/06) Phase II
Wang et al. 2014 (PILLAR-1) Phase II

Targeted therapy

28-day cycles

References

  1. SAKK 36/06: Renner C, Zinzani PL, Gressin R, Klingbiel D, Dietrich PY, Hitz F, Bargetzi M, Mingrone W, Martinelli G, Trojan A, Bouabdallah K, Lohri A, Gyan E, Biaggi C, Cogliatti S, Bertoni F, Ghielmini M, Brauchli P, Ketterer N; SAKK; GOELAMS; European Mantle Cell Lymphoma Network. A multicenter phase II trial (SAKK 36/06) of single-agent everolimus (RAD001) in patients with relapsed or refractory mantle cell lymphoma. Haematologica. 2012 Jul;97(7):1085-91. Epub 2012 Feb 7. link to original article contains verified protocol link to PMC article PubMed
  2. PILLAR-1: Wang M, Popplewell LL, Collins RH Jr, Winter JN, Goy A, Kaminski MS, Bartlett NL, Johnston PB, Lister J, Fanning SR, Tuscano JM, Beck JT, Kaya H, Robeva A, Fan J, Klimovsky J, Cheung W, Cherfi A, O'Connor OA. Everolimus for patients with mantle cell lymphoma refractory to or intolerant of bortezomib: multicentre, single-arm, phase 2 study. Br J Haematol. 2014 May;165(4):510-8. Epub 2014 Mar 2. link to original article contains verified protocol PubMed

Ibrutinib & Rituximab

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Regimen

Study Evidence Efficacy
Wang et al. 2015 (MDACC 2013-0090) Phase II ORR: 88% (95% CI 76-95.5)

Targeted therapy

  • Ibrutinib (Imbruvica) 560 mg PO once per day
  • Rituximab (Rituxan) as follows:
    • Cycle 1: 375 mg/m2 IV once per day on days 1, 8, 15, 22
    • Cycle 2: no rituximab
    • Cycles 3 to 7: 375 mg/m2 IV once on day 1
    • Cycle 8 onwards: 375 mg/m2 IV once on day 1

28-day cycle for 7 cycles, then 8-week cycles (up to 2 years for rituximab)

References

  1. MDACC 2013-0090: Wang ML, Lee H, Chuang H, Wagner-Bartak N, Hagemeister F, Westin J, Fayad L, Samaniego F, Turturro F, Oki Y, Chen W, Badillo M, Nomie K, DeLa Rosa M, Zhao D, Lam L, Addison A, Zhang H, Young KH, Li S, Santos D, Medeiros LJ, Champlin R, Romaguera J, Zhang L. Ibrutinib in combination with rituximab in relapsed or refractory mantle cell lymphoma: a single-centre, open-label, phase 2 trial. Lancet Oncol. 2016 Jan;17(1):48-56. Epub 2015 Nov 28. link to original article contains verified protocol PubMed

Ibrutinib & Venetoclax

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Regimen

Study Evidence Efficacy
Tam et al. 2018 (AIM) Phase II ORR: 71% (95% CI 49-87)

Note: the venetoclax dosing is based on a mid-protocol amendment.

Targeted therapy

  • Ibrutinib (Imbruvica) 560 mg PO once per day
  • Venetoclax (Venclexta) as follows:
    • Week 5: 50 mg PO once per day
    • Week 6: 100 mg PO once per day
    • Week 7: 200 mg PO once per day
    • Weeks 8 to 15: 400 mg PO once per day
    • Week 16 onwards:
      • CR achieved: 400 mg PO once per day
      • CR not achieved: 800 mg PO once per day

Continued indefinitely

References

  1. AIM: Tam CS, Anderson MA, Pott C, Agarwal R, Handunnetti S, Hicks RJ, Burbury K, Turner G, Di Iulio J, Bressel M, Westerman D, Lade S, Dreyling M, Dawson SJ, Dawson MA, Seymour JF, Roberts AW. Ibrutinib plus venetoclax for the treatment of mantle-cell lymphoma. N Engl J Med. 2018 Mar 29;378(13):1211-1223. link to original article contains verified protocol PubMed

Lenalidomide & Rituximab

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Regimen variant #1, 10/375

Study Evidence
Chong et al. 2015 (UPCC 02408) Phase II, <20 pts in subgroup

Targeted therapy

28-day cycles

Regimen variant #2, 25/375

Study Evidence
Wang et al. 2012 (MDACC 2005-0461) Phase I/II

Targeted therapy

28-day cycles

References

  1. MDACC 2005-0461: Wang M, Fayad L, Wagner-Bartak N, Zhang L, Hagemeister F, Neelapu SS, Samaniego F, McLaughlin P, Fanale M, Younes A, Cabanillas F, Fowler N, Newberry KJ, Sun L, Young KH, Champlin R, Kwak L, Feng L, Badillo M, Bejarano M, Hartig K, Chen W, Chen Y, Byrne C, Bell N, Zeldis J, Romaguera J. Lenalidomide in combination with rituximab for patients with relapsed or refractory mantle-cell lymphoma: a phase 1/2 clinical trial. Lancet Oncol. 2012 Jul;13(7):716-23. Epub 2012 Jun 6. link to original article contains protocol PubMed
  2. UPCC 02408: Chong EA, Ahmadi T, Aqui NA, Svoboda J, Nasta SD, Mato AR, Walsh KM, Schuster SJ. Combination of lenalidomide and rituximab overcomes rituximab resistance in patients with indolent B-cell and mantle cell lymphomas. Clin Cancer Res. 2015 Apr 15;21(8):1835-42. Epub 2015 Jan 28. link to original article contains verified protocol PubMed

Obinutuzumab monotherapy

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Regimen

Study Evidence
Salles et al. 2012 (GAUGUIN) Phase I/II

Note: this is the phase II dosing used in the subgroup analysis by Morschhauser et al. 2013.

Targeted therapy

  • Obinutuzumab (Gazyva) as follows:
    • Cycle 1: 1600 mg (diluted to 10 mg/mL) IV once per day on days 1 & 8
    • Cycles 2 to 8: 800 mg IV once on day 1
    • Initial infusion rate is 50 mg/hour. In the absence of infusion-related reactions (IRRs), the rate is then increased by 50 mg/hour every 30 minutes, up to a maximum of 400 mg/hour.

Supportive medications

  • Acetaminophen (Tylenol) or paracetamol 650 to 1000 mg PO once per infusion, 30 minutes prior to Obinutuzumab (Gazyva)
  • An antihistamine once per infusion, 30 minutes prior to Obinutuzumab (Gazyva)
    • If there were no infusion-related reactions (IRRs) requiring medication or infusion interruption, antihistamine could be omitted for subsequent infusions
  • Premedication with corticosteroids recommended for patients at high risk of infusion-related reactions (IRRs)
  • Use of G-CSF allowed for severe neutropenia
  • Antibiotic prophylaxis allowed

21-day cycle for 8 cycles

References

  1. GAUGUIN: Salles G, Morschhauser F, Lamy T, Milpied N, Thieblemont C, Tilly H, Bieska G, Asikanius E, Carlile D, Birkett J, Pisa P, Cartron G. Phase 1 study results of the type II glycoengineered humanized anti-CD20 monoclonal antibody obinutuzumab (GA101) in B-cell lymphoma patients. Blood. 2012 May 31;119(22):5126-32. Epub 2012 Mar 19. link to original article PubMed
    1. Subgroup analysis: Morschhauser FA, Cartron G, Thieblemont C, Solal-Céligny P, Haioun C, Bouabdallah R, Feugier P, Bouabdallah K, Asikanius E, Lei G, Wenger M, Wassner-Fritsch E, Salles GA. Obinutuzumab (GA101) monotherapy in relapsed/refractory diffuse large B-cell lymphoma or mantle-cell lymphoma: results from the phase II GAUGUIN study. J Clin Oncol. 2013 Aug 10;31(23):2912-9. Epub 2013 Jul 8. link to original article contains verified protocol PubMed
    2. Subgroup analysis: Salles GA, Morschhauser F, Solal-Céligny P, Thieblemont C, Lamy T, Tilly H, Gyan E, Lei G, Wenger M, Wassner-Fritsch E, Cartron G. Obinutuzumab (GA101) in patients with relapsed/refractory indolent non-Hodgkin lymphoma: results from the phase II GAUGUIN study. J Clin Oncol. 2013 Aug 10;31(23):2920-6. Epub 2013 Jul 8. link to original article contains verified protocol PubMed
    3. Subgroup analysis: Cartron G, de Guibert S, Dilhuydy MS, Morschhauser F, Leblond V, Dupuis J, Mahe B, Bouabdallah R, Lei G, Wenger M, Wassner-Fritsch E, Hallek M. Obinutuzumab (GA101) in relapsed/refractory chronic lymphocytic leukemia: final data from the phase 1/2 GAUGUIN study. Blood. 2014 Oct 2;124(14):2196-202. Epub 2014 Aug 20. link to original article contains verified protocol PubMed

PEP-C

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PEP-C: Prednisone, Etoposide, Procarbazine, Cyclophosphamide

Protocol

Study Evidence
Coleman et al. 2008MCL Non-randomized

Chemotherapy, induction phase

Supportive medications

Continue until WBC count less than 3 x 109/L, hold until WBC count recovery, then titrate in maintenance phase per paper (see publication for details)

Chemotherapy, maintenance phase

  • Same medications and doses given per day as used in the induction phase, but the number of days per week they are used is titrated to maintain a WBC count of at least 3; for example, 5 out of 7 days, every other day, once per week, etc.

References

  1. Coleman M, Martin P, Ruan J, Furman R, Niesvizky R, Elstrom R, George P, Leonard J, Kaufmann T. Low-dose metronomic, multidrug therapy with the PEP-C oral combination chemotherapy regimen for mantle cell lymphoma. Leuk Lymphoma. 2008 Mar;49(3):447-50. link to original article contains verified protocol PubMed

R-BL

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R-BL: Rituximab, Bendamustine, Lenalidomide
R2B: Revlimid (Lenalidomide), Rituximab, Bendamustine

Regimen

Study Evidence
Zaja et al. 2017 Phase II

Targeted therapy

Chemotherapy

28-day cycle for 4 cycles

Subsequent treatment

References

  1. Zaja F, Ferrero S, Stelitano C, Ferrari A, Salvi F, Arcari A, Musuraca G, Botto B, Spina M, Cellini C, Patti C, Liberati AM, Minotto C, Pileri SA, Ceccarelli M, Volpetti S, Ferranti A, Drandi D, Montechiarello E, Ladetto M, Carmichael J, Fanin R. Second-line rituximab, lenalidomide, and bendamustine in mantle cell lymphoma: a phase II clinical trial of the Fondazione Italiana Linfomi. Haematologica. 2017 May;102(5):e203-e206. Epub 2017 Jan 12. link to original article link to PMC article contains verified protocol PubMed

RT-PEPC

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RT-PEPC: Rituximab, Thalidomide, Prednisone, Etoposide, Procarbazine, Cyclophosphamide

Protocol

Study Evidence
Ruan et al. 2010a Non-randomized

Induction phase

Targeted therapy

Chemotherapy

Supportive medications

  • Aspirin 81 mg PO once per day "after 2 episodes of DVT occurred."

3-month course, followed by:

Maintenance phase

Targeted therapy

Chemotherapy

  • PEPC: Same medications and doses given per day as used in the induction phase, but titrated to maintain ANC of at least 2000/uL.

Supportive medications

  • Aspirin 81 mg PO once per day "after 2 episodes of DVT occurred."

4-month cycles

References

  1. Ruan J, Martin P, Coleman M, Furman RR, Cheung K, Faye A, Elstrom R, Lachs M, Hajjar KA, Leonard JP. Durable responses with the metronomic rituximab and thalidomide plus prednisone, etoposide, procarbazine, and cyclophosphamide regimen in elderly patients with recurrent mantle cell lymphoma. Cancer. 2010 Jun 1;116(11):2655-64. link to original article contains verified protocol link to PMC article PubMed

Temsirolimus & Rituximab

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Regimen

Study Evidence
Ansell et al. 2011 (N038H) Phase II

Targeted therapy

28-day cycle up to 12 cycles

References

  1. N038H: Ansell SM, Tang H, Kurtin PJ, Koenig PA, Inwards DJ, Shah K, Ziesmer SC, Feldman AL, Rao R, Gupta M, Erlichman C, Witzig TE. Temsirolimus and rituximab in patients with relapsed or refractory mantle cell lymphoma: a phase 2 study. Lancet Oncol. 2011 Apr;12(4):361-8. link to original article contains verified protocol link to PMC article PubMed

VR

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VR: Velcade (Bortezomib), Rituximab

Regimen

Study Evidence
Baiocchi et al. 2011 (OSU-0430) Phase II, <20 pts

Bortezomib dose was initially 1.5 mg/m2 but was reduced due to excess grade 3 neurotoxicity.

Targeted therapy

21-day cycle for up to 5 cycles

Subsequent treatment

References

  1. OSU-0430: Baiocchi RA, Alinari L, Lustberg ME, Lin TS, Porcu P, Li X, Johnston JS, Byrd JC, Blum KA. Phase 2 trial of rituximab and bortezomib in patients with relapsed or refractory mantle cell and follicular lymphoma. Cancer. 2011 Jun 1;117(11):2442-51. Epub 2010 Dec 14. link to original article contains verified protocol link to PMC article PubMed

Zanubrutinib monotherapy

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Regimen

FDA-recommended dose
Study Evidence
See note Phase II

Note: results for MCL are not yet published, to our knowledge.

Targeted therapy

Continued indefinitely

References

  1. BGB-3111-AU-003: CT.gov
  2. BGB-3111-206: CT.gov

Consolidation after second-line therapy

BFR, then allo HSCT

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BFR: Bendamustine, Fludarabine, Rituximab

Regimen

Study Evidence
Khouri et al. 2014 (MDACC 2008-0246) Phase II, <20 pts in this subgroup

Chemotherapy

Targeted therapy

GVHD prophylaxis

  • See article for GVHD prophylaxis information



Immunotherapy

Stem cells transfused on day 0

References

  1. MDACC 2008-0246: Khouri IF, Wei W, Korbling M, Turturro F, Ahmed S, Alousi A, Anderlini P, Ciurea S, Jabbour E, Oran B, Popat UR, Rondon G, Bassett RL Jr, Gulbis A. BFR (bendamustine, fludarabine, and rituximab) allogeneic conditioning for chronic lymphocytic leukemia/lymphoma: reduced myelosuppression and GVHD. Blood. 2014 Oct 2;124(14):2306-12. Epub 2014 Aug 21. link to original article contains verified protocol link to PMC article PubMed

FluBuCy, then allo HSCT

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FluBuCy: Fludarabine, Busulfan, Cyclophosphamide

Regimen

Study Evidence
Glass et al. 2014 (DSHNHL R3) Phase II

Chemotherapy

Immunosuppressive therapy

GVHD prophylaxis



Immunotherapy

Stem cells transfused on day 0

References

  1. DSHNHL R3: Glass B, Hasenkamp J, Wulf G, Dreger P, Pfreundschuh M, Gramatzki M, Silling G, Wilhelm C, Zeis M, Görlitz A, Pfeiffer S, Hilgers R, Truemper L, Schmitz N; German High-Grade Lymphoma Study Group. Rituximab after lymphoma-directed conditioning and allogeneic stem-cell transplantation for relapsed and refractory aggressive non-Hodgkin lymphoma (DSHNHL R3): an open-label, randomised, phase 2 trial. Lancet Oncol. 2014 Jun;15(7):757-66. Epub 2014 May 11. link to original article link to original protocol (in German) contains verified protocol PubMed

Lenalidomide & Rituximab

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Regimen

Study Evidence
Zaja et al. 2017 Phase II

Preceding treatment

Targeted therapy

28-day cycle for 2 cycles

Subsequent treatment

References

  1. Zaja F, Ferrero S, Stelitano C, Ferrari A, Salvi F, Arcari A, Musuraca G, Botto B, Spina M, Cellini C, Patti C, Liberati AM, Minotto C, Pileri SA, Ceccarelli M, Volpetti S, Ferranti A, Drandi D, Montechiarello E, Ladetto M, Carmichael J, Fanin R. Second-line rituximab, lenalidomide, and bendamustine in mantle cell lymphoma: a phase II clinical trial of the Fondazione Italiana Linfomi. Haematologica. 2017 May;102(5):e203-e206. Epub 2017 Jan 12. link to original article link to PMC article contains verified protocol PubMed

Maintenance after second-line therapy

Arsenic trioxide & Chlorambucil

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Regimen

Study Years of enrollment Evidence
Gill et al. 2014 2003-2011 Phase II

Preceding treatment

Chemotherapy

Supportive medications

Continued indefinitely

References

  1. Gill H, Au WY, Cheung WW, Lee EY, Kwong YL. Oral arsenic trioxide-based regimen as salvage treatment for relapsed or refractory mantle cell lymphoma. Ann Oncol. 2014 Jul;25(7):1391-7. Epub 2014 Apr 12. link to original article contains verified protocol PubMed

Lenalidomide monotherapy

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Regimen variant #1, 15 mg 21/28, 18 months

Study Evidence
Zaja et al. 2017 Phase II

Preceding treatment

Targeted therapy

28-day cycle for up to 20 cycles (18 months)

Regimen variant #2, 15 mg 21/28, indefinite

Study Evidence
Eve et al. 2012 Phase II

Preceding treatment

Targeted therapy

28-day cycles

References

  1. Eve HE, Carey S, Richardson SJ, Heise CC, Mamidipudi V, Shi T, Radford JA, Auer RL, Bullard SH, Rule SA. Single-agent lenalidomide in relapsed/refractory mantle cell lymphoma: results from a UK phase II study suggest activity and possible gender differences. Br J Haematol. 2012 Oct;159(2):154-63. Epub 2012 Aug 9. link to original article contains verified protocol PubMed
  2. Zaja F, Ferrero S, Stelitano C, Ferrari A, Salvi F, Arcari A, Musuraca G, Botto B, Spina M, Cellini C, Patti C, Liberati AM, Minotto C, Pileri SA, Ceccarelli M, Volpetti S, Ferranti A, Drandi D, Montechiarello E, Ladetto M, Carmichael J, Fanin R. Second-line rituximab, lenalidomide, and bendamustine in mantle cell lymphoma: a phase II clinical trial of the Fondazione Italiana Linfomi. Haematologica. 2017 May;102(5):e203-e206. Epub 2017 Jan 12. link to original article link to PMC article contains verified protocol PubMed

Rituximab monotherapy

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Regimen variant #1

Study Years of enrollment Evidence Comparator Comparative Efficacy
Forstpointner et al. 2004 1998-2001 Phase III (E-esc) Observation Seems to have superior response duration

Preceding treatment

  • FCM x 4 versus R-FCM x 4, followed in 3 months by:

Targeted therapy

3-month cycle for 2 cycles

Regimen variant #2

Study Evidence
Lamm et al. 2011 (MCL 03) Phase II, <20 pts

Preceding treatment

Targeted therapy

8-week cycle for 4 cycles

References

  1. Forstpointner R, Dreyling M, Repp R, Hermann S, Hänel A, Metzner B, Pott C, Hartmann F, Rothmann F, Rohrberg R, Böck HP, Wandt H, Unterhalt M, Hiddemann W; German Low-Grade Lymphoma Study Group. The addition of rituximab to a combination of fludarabine, cyclophosphamide, mitoxantrone (FCM) significantly increases the response rate and prolongs survival as compared with FCM alone in patients with relapsed and refractory follicular and mantle cell lymphomas: results of a prospective randomized study of the German Low-Grade Lymphoma Study Group. Blood. 2004 Nov 15;104(10):3064-71. Epub 2004 Jul 29. link to original article contains verified protocol PubMed
    1. Update: Forstpointner R, Unterhalt M, Dreyling M, Böck HP, Repp R, Wandt H, Pott C, Seymour JF, Metzner B, Hänel A, Lehmann T, Hartmann F, Einsele H, Hiddemann W; German Low Grade Lymphoma Study Group. Maintenance therapy with rituximab leads to a significant prolongation of response duration after salvage therapy with a combination of rituximab, fludarabine, cyclophosphamide, and mitoxantrone (R-FCM) in patients with recurring and refractory follicular and mantle cell lymphomas: Results of a prospective randomized study of the German Low Grade Lymphoma Study Group (GLSG). Blood. 2006 Dec 15;108(13):4003-8. Epub 2006 Aug 31. link to original article contains verified protocol PubMed
  2. MCL 03: Lamm W, Kaufmann H, Raderer M, Hoffmann M, Chott A, Zielinski C, Drach J. Bortezomib combined with rituximab and dexamethasone is an active regimen for patients with relapsed and chemotherapy-refractory mantle cell lymphoma. Haematologica. 2011 Jul;96(7):1008-14. Epub 2011 Apr 12. link to original article contains verified protocol link to PMC article PubMed

VR

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VR: Velcade (Bortezomib), Rituximab

Regimen

Study Evidence
Baiocchi et al. 2011 (OSU-0430) Phase II, <20 pts

Preceding treatment

Targeted therapy

6-month cycle for up to 4 cycles (2 years)

References

  1. OSU-0430: Baiocchi RA, Alinari L, Lustberg ME, Lin TS, Porcu P, Li X, Johnston JS, Byrd JC, Blum KA. Phase 2 trial of rituximab and bortezomib in patients with relapsed or refractory mantle cell and follicular lymphoma. Cancer. 2011 Jun 1;117(11):2442-51. Epub 2010 Dec 14. link to original article contains verified protocol link to PMC article PubMed

Investigational agents

These are drugs under study with at least some promising results for this disease.

Prognosis

Mantle cell lymphoma international prognostic index (MIPI)

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Calculation generally require a calculator such as the one provided by BloodRef. The MIPI is calculated using the following formula: [0.03535 × age (in years)] + 0.6978 (if ECOG PS greater than 1) + [1.367 × log10(LDH/ULN)] + [0.9393 × log10(white cells per uL blood)]. Risk factors include:

  • Age
  • ECOG Performance Status
  • Serum LDH level (note that reference ranges can vary widely!)
  • Number of nodal sites
  • WBC count

Risk stratification:

  • Less than 5.7 points: Low risk
  • 5.7 to less than 6.2 points: Intermediate risk
  • Greater than or equal to 6.2 points: High risk

References

  1. Hoster E, Dreyling M, Klapper W, Gisselbrecht C, van Hoof A, Kluin-Nelemans HC, Pfreundschuh M, Reiser M, Metzner B, Einsele H, Peter N, Jung W, Wörmann B, Ludwig WD, Dührsen U, Eimermacher H, Wandt H, Hasford J, Hiddemann W, Unterhalt M; German Low Grade Lymphoma Study Group; European Mantle Cell Lymphoma Network. A new prognostic index (MIPI) for patients with advanced-stage mantle cell lymphoma. Blood. 2008 Jan 15;111(2):558-65. Epub 2007 Oct 25. Erratum in: Blood. 2008 Jun 15;111(12):5761. link to original article PubMed
  2. Hoster E, Klapper W, Hermine O, Kluin-Nelemans HC, Walewski J, van Hoof A, Trneny M, Geisler CH, Di Raimondo F, Szymczyk M, Stilgenbauer S, Thieblemont C, Hallek M, Forstpointner R, Pott C, Ribrag V, Doorduijn J, Hiddemann W, Dreyling MH, Unterhalt M. Confirmation of the mantle-cell lymphoma International Prognostic Index in randomized trials of the European Mantle-Cell Lymphoma Network. J Clin Oncol. 2014 May 1;32(13):1338-46. Epub 2014 Mar 31. link to original article PubMed

Response criteria

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