Mantle Cell Lymphoma

Transcription

1 Mantle Cell Lymphoma

2 Clinical Case A 56 year-old woman complains of pain and fullness in the left superior abdominal quadrant for the last 8 months. She has lost 25 kg, and lately has had night sweats. There is bilateral cervical lymph node enlargement, and a massively enlarged spleen. ECOG PS=1. CT scans showed diffuse abdominal and retroperitoneal lymphadenopathy, as well as splenomegaly. Hg 11 g/dl, WBC 4,800, platelet count 145,000. LDH is 1.5 times the upper limit of normal. A biopsy of a cervical lymph node was performed.

3 Germinal Center Mantle zone

4 Mantle GC Mantle GC Bcl2 + Mantle Mantle zone pattern proliferation GC Ki67

5 CD20 (+)

6 CD5 (+) Cyclin D1 (+)

7 CD5 (+) CD3 (-)

8 Bone marrow Intersticial infiltration by small cells

9 Diagnosis: Mantle Cell Lymphoma Immuno: CD20+, CD79a + sig M/ IgD CD5 + CD23-, CD 10- Genetics: t(11;14), cyclin D1 + MCL GC GC MCL

10 Cytological variants of Mantle Cell Lymphoma. British Journal of Haematology, 2005;131, (A) classical type; (B) small cell type (C) pleomorphic type; (D) blastic type; (E, F) classical + pleomorphic

11 Blastoid variant

12 Mantle Cell Lymphoma- NCI Series Clinical Significance of Blastic Subtype Typical MCL Blastic MCL Lardelli et al. Am J Surg Pathol, 1990

13 Blastoid variant Cyclin D1 (+) Ki67 (70%)

14

15 Lymphomatous polyposis

16 Am J Surg Pathol, 2006;30:

17 Expression of D-type cyclins in cyclin D1-negative MCL D2 D3

18 Leukemic phase of mantle cell lymphoma. Peripheral blood. Small to medium sized lymphoid cells with slightly to markedly irregular nuclear contour. The nuclei have moderately dispersed chromatin bur inconspicuous nucleoli. From a patient with 46,XX,t(11;14)(q13;q32) - Courtesy Georges Flandrin.

19 Differential diagnosis chronic lymphoproliferative diseases

20 Clinical Presentation

21 Bone marrow biopsy Cells have scant cytoplasm and abnormally folded nuclei

22 N= 455 advanced MCL 0-3 LR 6-11 HR 4-5 IR Stage IVB Age < 60 LDH 1,5x 3 factors Blood, 2008 PS=1 Leucocytes normal MIPI

23

24 Treatment Conventional chemotherapy does not provide long-term control of the disease: only minor advantage of CHOP over COP.

25 Treatment Dose-intensified regimens Autologous stem cell transplantantion

26 Dose-intensified regimens Various study groups reported promising results for high-dose Ara-C: MD Anderson GELA Nordic Group

27 3-y-OS 82% 3-y FFS 64% N=97 Median FUP=40 months Romaguera JE, JCO,2005

28 EFS At 3 y: 83% OS At 3 years: 90% N=28 CHOP + DHAP + ABMT Rare patients in CR after CHOP Median FUP= 47 months Lefrère F, Leukemia, 2002

29 N=160 pts (MCL-2) Geisler CH, Blood, 2008

30 ORR=96% CR=54% 6y-OS:70% 6y-EFS=56% 6-y-PFS=66% No relapses after 5 years The 2 MAIN factors leading to improvements: Cytarabine and rituximab Geisler CH, Blood, 2008

31 4-6 cycles de CHOP CR or PR DEXA-BEAM and Auto- BMT 2 CHOP + Maintenance INF Dreyling M et al. Blood 2005;105:

32 . Dreyling M et al. Blood 2005;105:

33 Other approaches Bendamustine Bortezomib Thalidomide and lenalidomide Allogeneic stem cell transplantation

34 Kiel Lymphoma study group Historical comparison of patients with advanced nonblastoid MCL in 2 periods OS significantly increased from 2.7y up to 4.8y German low grade study group Improvement in diagnostic tests, progress in therapeutical options, anthracycline-regimens and use of antibody or stem cell transplantation probably play an important role JCO, 2009

35 Mantle cell lymphoma - NY Hospital Median = 7.1 years Martin et al, Ann Oncol 2008

36 Retrospective Study 97 pts MCL Patients were divided in observation group and early treatment on the basis of time to treatment The decision to initiate treatment was based on clinical decision. No specific predefined criteria. 31 pts observation (after 3 months) 66 early-treatment JCO, Martin P, 2009

37 Final Comments Younger patients without significant comorbidities should be treated aggressively, either with myeloablative regimens followed by ASCT after initial CHOP- or DHAP- like induction therapy, or with up-front dose intensification (HyperCVAD plus rituximab). A close observation strategy with deferred therapy in selected asymptomatic patients with newly diagnosed MCL is reasonable. Prospective studies are needed