Abstract
The standard of care for fit patients with Mantle Cell Lymphoma (MCL) includes cytarabine containing induction treatment and consolidation with BEAM (Carmustine, Etoposide, Cytarabine and Melphalan). Chemo-refractory cases have a poorer prognosis and are candidates for allogenic stem cell transplantation (allo-SCT). Targeted therapy, such as BTK-inhibitors or BCL-mimetics can be used to bridge patients to SCT. COVID-19, a novel coronavirus has the potential to cause life threatening immune dysregulation and cytokine release syndrome (CRS) resulting in respiratory failure. Haematology patients, particularly post allogenic stem cell transplant, are high risk for developing CRS due to T-lymphopenia. PD, a 55-year-old male, with chemo-refractory MCL tested positive for COVID-19 day + 45 post allo-SCT after presenting with mild gastrointestinal symptoms and remained positive for 70 days. At day + 92 relapse was confirmed by CT and axillary node biopsy. Ibrutinib, a BTK inhibitor, was commenced with resolution of symptoms and a negative test within 20 days. With minimal reduction in adenopathy, Ibrutinib was stopped at day +110, while Cytarabine and Venetoclax (BCL-mimetic) were commenced with Donor lymphocyte infusion at day +145 resulting in complete remission. Ibrutinib’s therapeutic role against COVID-19 is now being investigated in clinical trials.
Highlights
Ara-C (Cytarabine) containing induction treatment and high dose consolidation with BEAM (Carmustine, Etoposide, Cytarabine and Melphalan) is the standard of care for fit patients with Mantle Cell Lymphoma (MCL) resulting in survivals of 65-75% at 5 years [1, 6] and 64% at 10 years [3]
COVID-19 is a novel corona virus with a variable clinical presentation from an asymptomatic to life threatening disease caused by immune dysregulation resulting in a cytokine release syndrome (CRS) with elevated inflammatory cytokine levels of IL-2, IL-6, IL-10 and TNF-α causing respiratory failure [7]
In summary PD was Coronavirus infected from days 45 to 110 of an alemtuzumab-based RIC-matched unrelated donor (MUD) allo-SCT for chemo-refractory MCL causing low-grade gastrointestinal symptoms and prolonged viral shedding, which resolved within 20 days of starting Ibrutinib in keeping with its anti-COVID-19 effects
Summary
Ara-C (Cytarabine) containing induction treatment and high dose consolidation with BEAM (Carmustine, Etoposide, Cytarabine and Melphalan) is the standard of care for fit patients with Mantle Cell Lymphoma (MCL) resulting in survivals of 65-75% at 5 years [1, 6] and 64% at 10 years [3]. Patients with chemo-refractory disease have a poor prognosis, are candidates for allogenic stem cell transplantation (allo-SCT) [12] and can be bridged to SCT with either targeted therapy (BTK-inhibitor or BCL2-mimetic) or alternative chemo-immunotherapy. In contrast BTK inhibitors appear to have a protective effect and clinical trials on their use in COVID-19 infected patients without B-lymphoid malignancies is currently being explored [13, 15]. James Dillon et al.: Relapsed Mantle Cell Lymphoma, Allogenic Stem Cell Transplantation and COVID-19
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