LAUSR

Treatment of relapsed mantle cell lymphoma (MCL) patients is challenging. Disease behavior has typically been described to be largely heterogeneous [1]. The MANTLE-FIRST study, the first patient-level analysis of outcomes of relapsed-refractory (r/r) MCL after rituximab and cytarabine containing induction therapy, has clearly divided patients’ outcome depending on time to first relapse (earlyversus late-POD) [2, 3]. While the latter experienced good expectations in terms of survival irrespective of the second line treatment, early-POD patients had significantly better outcome when treated with ibrutinib. This study, together with several independent observations [4, 5], has established ibrutinib as the new standard second line therapy in early-POD patients. For late-POD patients the impact of treatment choice still needs to be clarified. In our study [2] bendamustine-based regimen (rituximab-bendamustine, R-B, and rituximab-bendamustine plus cytarabine, R-BAC) conferred similar survival rates to ibrutinib in this subgroup. We consider R-B, R-BAC or VR-CAP (bortezomib, rituximab, cyclophosphamide, doxorubicin, and prednisone) as reasonable time limited-treatment choice for patients with prior chemo-sensitive disease. However, given the expected response duration to BTKi in second line setting [5] and the generally favorable BTKi side effect profile relative to chemoimmunotherapy (CIT), unless major contraindications, we consider ibrutinib as standard second line therapy at any age. The predictive significance of early-POD following less intensive frontline treatment, such as bendamustinebased induction regimen, is not well established. A recent Editorial