A 76-Year-Old Woman With High Risk Mantle Cell Lymphoma - Episode 2

Assessing Risk Stratification in Mantle Cell Lymphoma

Kami Maddocks, MD: There are several things that you can look at for risk-stratified patients. The 1 with the most evidence is the Mantle Cell Prognostic Index, or MIPI. This has 4 clinical risk factors: age; LDH [lactate dehydrogenase]; leukocytes, or white blood cell count; and performance status, and it calculates the prognosis of outcomes and divides them into 3 groups: low, intermediate, and high risk. Patients with high risk having an overall survival of only 29 months. This has been validated with several treatments, in both younger and older patients, more aggressive and less intensive approach.

The MIPI is nice in that it is prognostic with all these facts. The downside to the MIPI is that it doesn’t really help you decide therapy. We do not use it to decide if a patient needs therapy. A patient who is symptomatic, has bulky disease, and has bad blood count is going to need therapy regardless of their MIPI score. You’re going to treat them more based on their age and comorbidities as far as deciding therapy than you are going to treat them based on MIPI.

There are a small number of patients who are in an age range or have comorbidities for which you’re not quite sure if you want to use or should use a less intensive or more intensive approach. In that setting sometimes I may let MIPI decide if I have a patient who is borderline age for intensive therapy or transplant. If they have low-risk MIPI, I’m going to use a less intensive approach in those patients. It’s used more for prognostic.

Transcript edited for clarity.


Case: A 76-Year-Old Woman with High Risk Mantle Cell Lymphoma

Initial presentation

  • A 76-year-old woman presented with a 2-month history of occasional night sweats, intermittent fatigue and decreased appetite
  • PMH: DM, medically controlled; GERD controlled on OTC medication
  • PE: bilateral cervical lymphadenopathy, splenomegaly

Clinical workup

  • LDH 405 U/I, ANC 3200/mm3, beta-2-microglobulin 4.1 µg/L, leukocytes, 5.42 X 109/L, hemoglobin 9.1 gm/dL
  • FISH: t(11;14)
  • Immunocytochemistry: cyclin D1+, CD5+, CD20+, CD43+, CD10-, CD23-
  • Bone marrow biopsy positive for lymphoid cells with cyclin D1
  • PET/CT scan showed widespread lymphadenopathy including inguinal node (5.1 cm) and splenomegaly
  • Ann Arbor stage IV; MIPI score 6.4; ECOG PS 0

Treatment

  • She was started on bendamustine + rituximab
    • Achieved PR
    • Continued on maintenance rituximab q8W
  • At 18 months the patient had clinical disease relapse, including an unintentional 7-lb weight loss
    • She was started on ibrutinib 560 mg PO qDay
    • Imaging at 10-week follow-up showed substantial decrease in disease burden