DR FRIEDBERG: This is a patient I saw about 8 months ago. He’s 77 years old. He had a CABG in the past. He actually had a history of colon cancer and was status post colectomy. And he presented a couple of years ago with rash and inguinal swelling, was followed for a while, and eventually had a lymph node biopsy, which was read out initially as follicular lymphoma, but then they did FISH studies and they showed the presence of the 11:14 translocation and revised the diagnosis to mantle-cell lymphoma.
Bone marrow biopsy showed involvement. And the patient had 6 cycles of bendamustine and rituximab, and he tolerated it very well and obtained a complete response. And my question for the faculty is, do you extrapolate from the German data in a setting like this, which I think is a very common setting in the United States? Would you give maintenance rituximab in patients treated with BR as up-front for mantle-cell lymphoma?
DR LOVE: Chris?
DR FLOWERS: I think that’s always a challenging question. I typically go through the usual debate of how we extrapolate data from other trials and use of maintenance rituximab, both in my discussions about mantle-cell lymphoma, which usually are a little bit easier, and in discussions about follicular lymphoma.
I would say, in general, I would tend to use maintenance rituximab in this setting, but it’s always an individual patient discussion.
DR LOVE: So, add on a subquestion to that. For how long?
DR FLOWERS: And for no more than 2 years.
DR LOVE: Jon? Do you agree with that?
DR FRIEDBERG: Yes. In mantle-cell lymphoma, I do in the older-age population. I think I might feel differently in follicular lymphoma. I will say the data for maintenance rituximab in mantle-cell lymphoma does suggest that the induction regimen seems to impact how well maintenance works. And maintenance really works best in the patients who are treated with R-CHOP as compared to a fludarabine-containing regimen. So we don’t know where bendamustine and rituximab really would fall in, but with all those caveats, given the risk of mantle-cell lymphoma and at least until ibrutinib is approved, the really lack of great salvage options for a 77-year-old, I tend to give maintenance rituximab for two years in this setting. That’s what he got.
DR LOVE: So, I want to ask the rest of the faculty, but just to clarify, am I correct in saying that in the European study that was done, it was given until progression?
DR FRIEDBERG: That’s correct. Right.
DR LOVE: So why do we flip back to 2 years?
DR FRIEDBERG: I think that’s our experience in follicular lymphoma. And I think that there clearly are toxicity concerns. But I’d be interested also to see if other people would give it for longer.
DR LOVE: Mike?
DR WILLIAMS: Yes. So our current approach for patients like this is we tend to use BR now as our front-line regimen. And virtually all of these patients are getting rituximab maintenance. And although you’re correct that the Kluin-Nelemans paper in The New England Journal a year ago gave it indefinitely, we usually stop at 2 years and then follow them at that point.