Dr. Nagourney's Blog

Never Too Old To Be Cured - Stage 4 Mantle Cell Lymphoma

By Robert A. Nagourney, MD

Surviving Mantle Cell Lymphoma Stage 4

Youre_Never_Too_OldJust a year ago a colleague referred a patient for consultation.

This 80 year old gentleman, himself a physician, presented with extensive lymphadenopathy.

Lymph node and bone marrow biopsies established mantle cell lymphoma stage 4 with over 40% marrow infiltration. The PET/CT confirmed large volume retroperitoneal disease. As we discussed options, I explained that laboratory analysis might help us to select the most active treatments. 

Mantle cell lymphoma is a subtype of non-Hodgkin's lymphoma constituting approximately 6% of all cases diagnosed in the U.S. It is associated with a specific genetic translocation known as the t(11;14) that upregulates the protein cyclin D1 causing rapid cell turnover.

It is considered among the most aggressive of the B-cell neoplasms and the treatments, among them one known as hyper CVAD, can be very toxic. Hoping to avoid excessive toxicity we conducted our functional profile to explore treatment options.

The results were highly gratifying. In addition to activity for Bortezomib, the patient had a very favorable profile for Bendamustine. 

Mantle_cell_lymphoma_-_intermed_magWith our laboratory results in hand, I suggested the relatively mild combination of Rituxan plus Bendamustine. This combination which was found active in the patient's tissue culture had been reported by a German group to provide good results when compared with R-CHOP. 

After three cycles of treatment, there was much improvement. 

After six cycles still more, the question then became: Should we change to an alternative treatment?

After conferring with a consultant, I opted to complete eight total cycles and then moved to maintenance Rituxan. With three months additional follow up (off Bendamustine) the recent PET-CT is entirely normal. All parameters have normalized. 

Soon to be 81, the patient continued to practice medicine and maintained an extremely active lifestyle throughout his entire therapy.

He was able to receive a simple combination that provided durable benefit but very little toxicity.

My initial concern that I might be undertreating him was put to rest by our laboratory analysis that gave me the confidence to use this comparatively mild combination.

Even with a diagnosis as grave as mantle cell lymphoma Stage 4, this patient was not too old to be cured.  

As always, I appreciate your thoughts and comments.