From Pages to Practice

By Karen Sokal-Gutierrez, MD

Published September 27, 2017


A 60-year-old patient who was recently diagnosed with mantle-cell lymphoma meets with his oncologist and says, “Doc, I read about this disease online. I know that it’s not good, and I’ll probably get very sick and die from it. But my first grandchild was just born and I want to stay as healthy as possible for as long as possible for her. I want to play with her, watch her grow up, and attend her preschool graduation in 4 years. What’s the best treatment that you have to get me there?”

This patient likely read that mantle-cell lymphoma, which accounts for approximately 6% of adult non-Hodgkin’s lymphomas, is usually incurable. Despite high response rates after initial immunochemotherapy followed by autologous stem-cell transplantation, patients generally experience relapses and disease progression. Typically, relapses become more difficult to treat and more frequent over time. The good news is that many clinical trials are testing the efficacy of therapies to prevent and treat relapses in mantle-cell lymphoma.

This week, NEJM published the results of a randomized controlled trial that examined the efficacy of rituximab maintenance therapy following standard induction immunochemotherapy and autologous stem-cell transplantation. Rituximab, a monoclonal antibody targeting CD20, has been found to be effective in the treatment of various B-cell lymphomas.

In all, 240 patients aged 18 to 66 years completed the standard four courses of immunochemotherapy induction with rituximab, dexamethasone, cytarabine, and a platinum derivative (R-DHAP) every 3 weeks, followed by autologous stem-cell transplantation. Patients with partial response to immunochemotherapy received additional rescue induction therapy with four courses of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), followed by autologous stem-cell transplantation. After transplantation, patients were randomized to either standard observation or rituximab maintenance therapy every 2 months for 3 years. The primary end point was event-free survival after transplantation (an event was defined as relapse, disease progression, severe infection or allergy, or death).

After a median follow-up of 50.2 months from randomization, 4-year event-free survival was 79% in the rituximab maintenance group versus 61% in the observation group (P=0.001). Rates of 4-year progression-free survival were 83% versus 64%, respectively (P=0.001) and rates of overall survival were 89% versus 80%, respectively (P=0.04).

The authors concluded that rituximab maintenance treatment for 3 years after immunochemotherapy and autologous stem cell transplant can prolong event-free, progression-free, and overall survival in patients younger than 66 years with mantle-cell lymphoma.

Returning to the question posed by the 60-year-old patient with mantle-cell lymphoma: The oncologist might explain that research is underway to improve the health and prolong survival of people with mantle-cell lymphoma. In fact, a new study showed significantly prolonged disease-free survival in patients who received rituximab maintenance therapy following standard chemotherapy treatment. If the patient chooses this treatment course, he very likely will remain healthy during the next 4 years, enjoy time with his granddaughter, and attend her preschool graduation.

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Karen is a 2017-2018 NEJM Editorial Fellow, Clinical Professor at UC Berkeley-UCSF Joint Medical Program and UC Berkeley School of Public Health, researcher on children’s nutrition and oral health, and member of American Academy of Pediatrics.