A 68-Year-Old Man With Mantle Cell Lymphoma - Episode 5

Administration of BTK Inhibitors for Mantle Cell Lymphoma

Jonathon B. Cohen, MD, MS

Jonathon Cohen, MD, MS: We’re very lucky, at the present time, to have a number of different therapy options available for relapsed mantle cell lymphoma. Ibrutinib and the other BTK [Bruton tyrosine kinase] inhibitors are administered orally at home. Some are given once daily, and others are given twice daily. Then we also have other therapies that are administered intravenously, like bendamustine-rituximab, which is sometimes used in the relapsed setting, especially in a patient who hasn’t received that regimen previously. That’s administered in the infusion center by IV [intravenous].

There are advantages to both. Many patients think the idea of doing an oral therapy is a huge improvement over having to come into an infusion center to receive IV therapy. I tend to agree that this is a major benefit with this type of therapy. What’s important to keep in mind is that oral therapy is not necessarily for everybody. There can be financial concerns with regard to having to obtain that medication through a prescription drug plan, and there can be challenges with adherence. Anybody who takes a daily medication knows that it’s very difficult to take that medication every single day. I myself take an allergy medication, and I can tell you that probably once every week or 2 I forget to take it. When you’re talking about a medication like ibrutinib, it’s important that patients remain on therapy and take it every day. It requires a lot of counseling and a lot of reinforcement to patients that they take their medication every single day without fail.

In some patients, this is just a really challenging thing to do. Maybe they’re taking care of ill family members, or maybe they live in a situation where there’s a lot going on and they may just not have that opportunity to take a second medication every day. Again, it requires a real consideration of the patient, their home situation, and whether they’re going to be able to manage taking a daily oral medication. In some cases, coming to the infusion center once a month or every so often to get an IV infusion is a little easier for patients. They know they come for their appointment, get their treatment, and don’t have to worry about it when they go home.

Transcript edited for clarity.


Case: A 68-Year-Old Male with Mantle Cell Lymphoma

Initial presentation

  • A 68-year-old man presented with generalized lymphadenopathy, fatigue and an unintentional 8-lb weight loss
  • PMH: HTN, medically controlled
  • PE: abdominal distention, splenomegaly

Clinical workup

  • LDH 345 U/I, ANC 3500/mm3, beta-2-microglobulin 4.4 µg/L, leukocytes, 5.98 X 109/L, hemoglobin 9.6 gm/dL
  • FISH: t (11;14)
  • Immunocytochemistry: cyclin D1+, CD5+, CD20++
  • BMB positive for lymphoid cells with cyclin D1
  • PET/CT scan showed widespread lymphadenopathy in numerous nodal regions including left mesenteric (3.4 cm), bilateral axillary (3.9 cm, 5.3 cm), and cervical (5.1 cm)
  • Ann Arbor stage IV; MIPI score 6.3; ECOG PS 1

Treatment

  • Patient was started on bendamustine + rituximab
    • Achieved PR
    • Continued on maintenance rituximab q8W
  • At 9 months the patient had clinical disease relapse
    • He was started on ibrutinib 560 mg PO qDay
    • Imaging at 12-week follow-up showed no evidence of disease