Dr. Mukherjee on Maintenance Rituximab in MCL

Akash Mukherjee, MD, assistant professor, Department of Internal Medicine, Division of Hematology and Oncology, University of Arkansas for Medical Sciences, discusses the use of post-transplant maintenance rituximab (Rituxan) in patients with mantle cell lymphoma (MCL) who have received autologous stem cell transplant (ASCT) and considerations for using bendamustine/rituximab (BR) or BR plus cytarabine (R-BAC) in elderly patients who are unfit for transplant.

MCL is a subset of non-Hodgkin lymphoma in which maintenance rituximab following ASCT has been shown to improve survival outcomes, Mukherjee says. In the phase 3 LyMa trial (NCT00921414), maintenance rituximab after R-DHAP (rituximab, dexamethasone, cytarabine, and cisplatin) induction and ASCT led to a 4-year progression-free survival (PFS) rate of 83% and an overall survival rate of 89%, vs 64% and 80%, respectively, in patients who received observation after ASCT. Although the optimal duration of maintenance rituximab treatment is debated, treating patients with rituximab maintenance every 2 months for at least 2 years after transplantation is 1 approach, Mukherjee explains.

When using maintenance rituximab, it is important to be aware of the potential for acquired hypogammaglobulinemia and check immunoglobulin (IgG) levels, Mukherjee emphasizes. Patients can receive intravenous IgG replacement therapy as needed to maintain IgG levels above 400 mg/dL, Mukherjee notes.

For elderly patients with MCL who are not fit for transplant, 6 cycles of BR followed by maintenance rituximab is a common treatment approach, Mukherjee says. Additionally, the phase 2 FIL-RBAC500 trial (NCT01662050) used R-BAC, with cytarabine at a low dose of 500 mg/m2, which led to a 2-year PFS rate of 81%, Mukherjee explains. Patients who can tolerate cytarabine can receive R-BAC, although they may also need growth factor support and appropriate prophylactic antibiotics to minimize the risk of neutropenic fever, Mukherjee notes. Although the addition of low-dose cytarabine to the BR backbone is a promising approach in transplant-unfit patients, more head-to-head data with BR and R-BAC are needed to determine which regimen is superior, Mukherjee concludes.