Mantle Cell Lymphoma Introduction Highlights
Transcription
Mantle Cell Lymphoma Introduction Highlights
Mantle Cell Lymphoma Facts No. 4 in a series providing the latest information for patients, caregivers and healthcare professionals www.LLS.org • Information Specialist: 800.955.4572 Highlights lMantle cell lymphoma (MCL) is one of several subtypes of B-cell non-Hodgkin lymphoma. lMCL usually begins with lymph node enlargement; it can spread to other tissues such as the marrow and liver. lMCL can sometimes begin in a lymphocyte outside a lymph node, such as in the gastrointestinal tract. lMCL is distinguished by overexpression of cyclin D1 (a protein that stimulates cell growth) in almost all cases. The overexpression of cyclin D1 is usually caused by a translocation between chromosomes 11 and 14. lA number of chemotherapy plus rituximab (Rituxan®) combinations are used to treat MCL. Bortezomib (Velcade®) may be used to treat patients who have progressed disease. Clinical trials are underway to study potential improvements in current treatment approaches. lAutologous stem cell transplantation may be used to treat MCL. Treatment with allogeneic stem cell transplantation or reduced-intensity allogeneic stem cell transplantation may be beneficial for some patients, based on a medical evaluation and the availability of a matched related stem cell donor. Introduction Lymphoma is the general name for many related subtypes of cancer that arise in the lymphocytes (white blood cells). Lymphoma is divided into two major categories: Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL). Mantle cell lymphoma (MCL) is one of several subtypes of NHL. Lymphoma may arise in any one of three types of lymphocytes: B lymphocytes (B cells), T lymphocytes (T cells) and natural killer (NK) cells. B lymphocytes make antibodies to fight infection; T lymphocytes have many functions, including helping B lymphocytes make the antibodies that fight infection; and natural killer cells attack cancer cells and viruses. B-cell lymphomas are more common than T-cell lymphomas. Most lymphocytes are found in the lymphatic system, the major part of the body’s immune system. The lymphatic system consists of a network of organs, including the spleen, the lymph nodes (small bean-shaped structures located throughout the body), the lymphatic vessels and areas in the gastrointestinal tract. This fact sheet includes information about the diagnosis and management of MCL. It also provides specific information on the stages and treatment of the disease, new treatments undergoing investigation and support resources. For additional free information about NHL subtypes, please see The Leukemia & Lymphoma Society (LLS) publications Non-Hodgkin Lymphoma and The Lymphoma Guide: Information for Patients and Caregivers. About Mantle Cell Lymphoma Mantle cell lymphoma (MCL) results from a malignant transformation of a B lymphocyte in the outer edge of a lymph node follicle (the mantle zone). The transformed B lymphocyte grows in an uncontrolled way and the accumulated lymphoma cells form tumors in lymph nodes, which leads to their enlargement. The MCL cells can enter the lymphatic channels and the blood, and can spread to other lymph nodes or tissues, such as the marrow, liver and gastrointestinal tract. There are about 66,360 new cases of NHL in the United States each year. MCL patients represent about 6 percent of all new cases of NHL per year. MCL occurs more frequently in older adults—the average age-range at diagnosis is the FS4 Mantle Cell Lymphoma Facts I page 1 Revised July 2012 Mantle Cell Lymphoma Facts mid-60s; it is more often diagnosed in males than in females; and white males and females are at a higher risk than black males and females for an MCL diagnosis. Causes About 85 percent of patients with MCL have a genetic change of developing B lymphocytes that involves chromosome 11 and chromosome 14. This is called a “reciprocal translocation,” and is abbreviated as t(11;14). As a result, short segments of chromosome 11 and chromosome 14 exchange places. The exchange occurs at the site of the cyclin D1 gene on chromosome 11 and the site of a gene that controls the formation of antibody molecules on chromosome 14. The t(11;14) triggers an overproduction of cyclin D1, a protein that supports and directs cell division and growth. The overproduction of the cyclin D1 protein leads to masses (tumors) of transformed lymphocytes (MCL cells). In a sense, this translocation can be thought of as the cause of the disease, possibly independent of the effects of another factor. In a small proportion of patients t(11;14) is not present. In most of these patients, other genetic changes cause excess production of cyclin D1. Rarely, MCL arises from overexpression of other cyclin genes (e.g., cyclin D2 and cyclin D3). Signs, Symptoms and Complications Most patients with MCL have disease involving multiple lymph nodes and other sites of the body. These sites may include the spleen, marrow and blood, the lymph nodes in the throat (tonsils and adenoids), the liver or the gastrointestinal tract. MCL cells may enter the brain, lungs and spinal cord. Patients who have MCL may experience loss of appetite and weight loss, fever, night sweats, nausea and/or vomiting, indigestion, abdominal pain or bloating, a feeling of “fullness” or discomfort due to an enlarged tonsils, liver or spleen, pressure or pain in the lower back often extending down one or both legs, or fatigue due to developing anemia. Disease complications from disease progression may include lCytopenias (neutropenia [low white blood cell counts], anemia [low red blood cell counts] and/or thrombocytopenia [low numbers of platelets]) because the MCL is in the bone marrow. l Gastrointestinal, pulmonary, or central nervous system (CNS) complications because the MCL is extranodal (outside the lymph nodes and in organs). In the gastrointestinal tract a condition known as “multiple small-intestine polyps” may result from the lymphoma cell growth. l Leukocytosis (high white blood cell counts) in the event of progression to the leukemia phase of the disease. Diagnosis A patient with a potential diagnosis of lymphoma needs to make sure that his or her subtype has been correctly identified. Treatment depends on knowing the specific diagnosis. Each patient should be evaluated by a hematologist/oncologist who specializes in treating patients who have NHL. Lymphomas are diagnosed by the examination of affected tissue, obtained from a surgical biopsy, usually of a lymph node. Cells obtained from a fine needle aspiration are not enough to establish a diagnosis. Microscopic examination of tissue from the lymph node biopsy can determine that lymphoma is present. A diagnosis of MCL is made if additional examination of the tissue shows that the lymphoma cells lHave surface markers of B cells lOverexpress lContain the cyclin D1 protein within the cells the translocation 11;14. Blood tests and imaging scans may also be done. A hematopathologist (a doctor who specializes in examining tissue and diagnosing disease) will determine if the MCL is the common type (found in most patients) or a blastoid variant. In the blastoid variant, the cells are bigger; they grow and divide more rapidly, are more aggressive and more challenging to treat. The blastoid variant of MCL may be present at diagnosis or may emerge over time. Treatment Planning Many doctors who care for MCL patients use The Mantle Cell International Prognostic Index (MIPI) to help plan treatment. This index uses four independent prognostic factors that may correlate with prognosis. The factors are: age, performance status (ability to perform activities of daily life), LDH (lactate dehydrogenase) levels and leukocyte (white blood cell) count. Patients are assigned to a low-risk, intermediate-risk or high-risk category based on the number of points alloted to each factor. In addition, doctors stage MCL to help them assess the extent of the disease and decide on the best treatment plan. Staging is described in the next section. FS4 Mantle Cell Lymphoma Facts I page 2 Mantle Cell Lymphoma Facts Your treatment team may include more than one specialist. It is important for you and members of your medical team to discuss all treatment options, including treatments being studied in clinical trials. Figure 1. Lymphoma Stages STAGE I For more information about choosing a doctor or a treatment center, see the free LLS publication Choosing a Blood Cancer Specialist or Treatment Center. One lymph node region or a single organ. Staging Diaphragm Some tests that are useful in determining the extent of disease (staging) include lComplete blood cell counts, to assess the concentration of red cells, white cells and platelets lBone marrow aspiration and biopsy, to determine whether or not the disease has extended beyond the lymph nodes and into the marrow l Imaging studies, including computed tomography (CT) scans of the chest, abdomen and pelvis, to see whether the disease is present in the deep lymph nodes, liver, spleen or in other parts of the body (see Figure 1) to check levels of specific proteins in the blood, especially measurements of serum lactic dehyrogenase (LDH) and beta2-microglobulin, because these are indirect markers of disease extent and rate of progression. Diaphragm STAGE II Two or more lymph node regions on the same side of the diaphragm. lStudies For additional information about laboratory and imaging tests, see the free LLS publication Understanding Lab and Imaging Tests. STAGE III Two or more lymph node regions above and below the diaphragm. Diaphragm Diaphragm STAGE IV Widespread disease in lymph nodes and/or other parts of the body. FS4 Mantle Cell Lymphoma Facts I page 3 Mantle Cell Lymphoma Facts Treatment Most MCL patients receive treatment following diagnosis and staging. For a small number of patients who have slow-growing (indolent) MCL and are otherwise well, doctors may recommend a period of close observation, also called “watchful waiting,” before treatment is started. In these cases, the doctor will want to see the patient every 2 to 3 months, and do imaging tests done every 3 to 6 months. For patients with indolent MCL, therapy begins when symptoms become troublesome or there are signs of progression (for example, increasing lymph node size or new enlarged nodes). More intensive combinations include the following: Patients who are have symptoms at diagnosis are not appropriate candidates for watchful waiting, since prompt treatment typically resolves symptoms. For more aggressive disease, for instance, if the disease has spread to the central nervous system, drugs may be administered directly into the fluid bathing the spinal canal. This is referred to as “intrathecal therapy.” A number of chemotherapy and rituximab (Rituxan®) combinations (see below) are used to treat patients who have MCL. Rituxan is a approved by the US Food and Drug Administration (FDA) to treat NHL and certain other diseases. It is monoclonal antibody, made in the laboratory that targets and destroys cells with the CD20 antigen, including MCL cells. A number of studies show that patients who are treated with chemotherapy plus Rituxan have a higher initial response rate than the reponse rate achieved with chemotherapy alone. Types of Treatment Combination Therapies. Less intensive combinations include the following: R -CHOP [Rituxan, cyclophosphamide, hydroxydaunomycin (doxorubicin), Oncovin® (vincristine), and prednisone] M odified R-hyperCVAD [Rituxan, cyclophosphamide, vincristine, doxorubicin (Adriamycin®), and dexamethasone alternating with high-dose cytarabine and methotrexate] either with or without autologous stem cell transplantation R -CHOP [Rituxan, cyclophosphamide, hydroxydaunomycin (doxorubicin), Oncovin® (vincristine), and prednisone] plus radioimmunotherapies (see Treatments Under Investigation on page 5) R -FCM [Rituxan, fludarabine (Fludara®), cyclophosphamide and mitoxantrone] B+R [bendamustine (Treanda®) and Rituxan] R-CHOP [Rituxan, cyclophosphamide, hydroxydaunomycin (doxorubicin), Oncovin® (vincristine), and prednisone] with an autologous stem cell transplantation R-hyperCVAD [Rituxan, cyclophosphamide, vincristine, doxorubicin (Adriamycin®), and dexamethasone alternating with high-dose cytarabine and methotrexate] R-hyperCVAD [Rituxan, cyclophosphamide, vincristine, doxorubicin (Adriamycin®), and dexamethasone alternating with high-dose cytarabine and methotrexate] either with or without autologous stem cell transplantation R-DHAP [Rituxan, dexamethasone, cytarabine and cisplatin]. Knowing how a medication is administered can help patients prepare for their treatments. The following drugs from the listed combinations above are given intravenously (IV): Rituxan, doxorubicin, vincristine, fludarabine, mitoxantrone and cisplatin. Cyclophosphamide can be given either intravenously or by mouth. Prednisone, dexamethasone and methotrexate are given by mouth. Cytarabine can be given intravenously or by intramuscular or subcutaneous injection. More intensive chemotherapy treatments, such as hyperCVAD, may increase response rates, but these treatments can be very toxic and are typically reserved for healthier, often younger patients. However, younger patients may want to opt for a less intensive approach. For older, less fit patients, less intensive approaches are currently the only options. Single use of chlorambucil may be good for elderly patients or patients with serious comorbidities. A study of the drug combination Treanda and Rituxan showed that this combination is more effective and less toxic than the standard CHOP regimen and should be considered as initial treatment for elderly patients with MCL. The side effects of combination treatment will depend on many factors, including the type of treatment and dosage, the age of the patient and coexisting medical conditions. Therapy may induce fever or chills, fatigue, nausea, peripheral neuropathy (tingling, burning, numbness or pain in the hands or feet), changes in blood cell counts, infection, skin reactions, diarrhea, shortness of breath, temporary loss of hair and other side effects. Patients may be less fertile after undergoing certain cancer treatments. Stem Cell Transplantation. High-dose drug therapy and autologous stem cell transplantation (a procedure involving FS4 Mantle Cell Lymphoma Facts I page 4 Mantle Cell Lymphoma Facts the harvesting of the patient’s own stem cells, freezing the collection, then returning it to the patient after he or she has received intensive drug therapy) has resulted in high rates of clinical remission for MCL patients when used after first remission. Older patients who are in excellent physical condition are candidates for autologous stem cell transplantation. Autologous transplantation combined with R-CHOP may offer a longer remission and be an option for some younger patients. Allogeneic stem cell transplantation is the transfer of stem cells from a donor to the patient following high-dose chemotherapy or radiation therapy. This type of transplant is determined by the patient’s medical indications and availability of a suitable donor. There is no specific age cutoff for stem cell transplantation. Allogeneic stem cell transplantation is not commonly used to treat lymphoma patients, but is sometimes used to treat MCL patients. Reduced-intensity allogeneic transplantation may be an option for older patients. For more information, see the free LLS publication Blood and Marrow Stem Cell Transplantation. Talk to Your Doctor About Side Effects of Treatment. Side-effects management is important. If you are having any concerns about your side effects, talk to your doctor to get help. Most side effects can be managed with treatment that will not compromise treatment for your disease. In addition, most side effects are temporary and resolve when treatment is completed. Some of the side effects of specific drugs are discussed on page 4. For additional drug information, see the free LLS publication Understanding Drug Therapy and Managing Side Effects and the Food and Drug Administration (FDA) drug information webpage at www.fda.gov/drugs/resourcesforyou/consumers/default.htm. Also, see Treatments Under Investigation on this page. Treatment for Patients with Relapsed and/or Refractory MCL If a patient’s MCL returns, there are a number of different treatment options. For patients with relapsed MCL (return of the cancer), an allogeneic stem cell transplant may be an option. For patients with refractory MCL (the cancer resists treatment), a patient may try a chemotherapyregimen that was not used previously. For a listing of investigational agents currently being studied for relapsed and refractory MCL patients, please see Treatments Under Investigation. Treatments Under Investigation Research for MCL over the last several years has resulted in better treatment options for patients; new therapies are constantly emerging. Patients may have the opportunity to take part in clinical trials. These trials, conducted under rigorous guidelines, help clinicians and researchers to determine the beneficial and adverse effects of potential new treatments. Studies are also conducted to evaluate new indications for therapies that are already approved for other diseases. In addition, research to define predictive biomarkers to better identify MCL subtypes will help guide treatment decisions in the future, thereby improving patient outcomes. LLS is funding MCL research to study the role of the B-cell antigen receptor in MCL, novel proteasome inhibitors to treat MCL and other new therapies. For more information about clinical trials, see the free LLS publication Understanding Clinical Trials for Blood Cancers, visit www.LLS.org/clinicaltrials or call our Information Specialists. Some classes of novel therapies and drugs under investigation include l Cell cycle inhibitors–Drugs of this type interfere with the cell division process that enables tumors to grow. A treatment that is being studied is called PD-0332991. l Tyrosine kinase inhibitors–These drugs flip switches on the pathways of the cells that are important to the cell staying alive. Oral drugs that are being studied include a PI3 kinase inhibitor GS-1101 (CAL-101) and Bruton’s tyrosine kinase inhibitor ibrutinib (PCI-32765). l Monoclonal antibodies–These agents provide a type of targeted therapy directed at specific proteins. A number of new monoclonal antibodies are being investigated including bevacizumab (Avastin®), FDA approved for other types of cancer and being studied in combination with R-CHOP for untreated MCL; alemtuzumab (Campath®), an anti-CD52 agent and FDA approved for the treatment of chronic lymphocytic leukemia, which is being used as part of a conditioning regimen in allogeneic transplantation; and epratuzumab, an anti-CD22. l Maintenance Treatment–Patients who receive initial treatment with Rituxan, plus chemotherapy and then receive maintenance Rituxan may stay in remission longer than if they do not continue on Rituxan. One study of elderly patients who had responded to induction treatment, but were not able to receive chemotherapy and an autologous stem cell transplant, showed their duration of remission doubled after a FS4 Mantle Cell Lymphoma Facts I page 5 Mantle Cell Lymphoma Facts period of maintenance Rituxan. Rituxan is also being studied as a maintenance therapy following combination chemotherapy to prolong response duration in patients with recurring or refractory MCL. Clinical trials are underway to continue to evaluate this treatment approach. l Proteasome inhibitors–These drugs affect cell pathways by blocking the activity of proteins that are needed for cell growth and survival. Bortezomib (Velcade®) is being studied together with Rituxan and combination chemotherapy (R-EPOCH [Rituxan plus etoposide, prednisone, vincristine (Oncovin®), cyclophosphamide, hydroxydaunomycin (doxorubicin)], R-CHOP or R-hyperCVAD) in both untreated and refractory MCL. l Vaccines–Custom-made cancer vaccines, such as BiovaxID®, are patient-specific vaccines that do not prevent the disease but may stimulate the immune system’s attack on remaining MCL cells after initial therapy. l Stem cell transplantation–Reduced-intensity allogeneic stem cell transplantation, which uses less intensive conditioning therapy prior to transplanting donor cells is being compared to a standard allogeneic transplantation, and the results are being studied. Some patients showed prolonged disease-free survival. l mTOR inhibitors–Agents that may work to slow or inhibit MCL by downregulating (reducing) cell expression of cyclin D1. They have demonstrated activity in MCL either alone or in combination with other therapies. Examples of mTOR inhibitors currently under investigation include Temsirolimus (Torisel®) for relapsed mantle cell lymphoma. This agent is also being studied in combination with Rituxan® and bendamustine (Treanda®). Everolimus (Afinitor®) is being studied in patients with advanced, refractory or relapsed MCL. This is also being studied in combination with lenalidomide (Revlimid®) and as a single agent in older patients. l An alkylating agent–Bendamustine (Treanda®) is FDA approved to treat chronic lymphocytic leukemia (CLL) and indolent B-cell NHL that has progressed during or within six months of treatment with Rituxan or a Rituxan-containing regimen. This drug is being studied in combination with Rituxan and temsirolimus in patients with relapsed MCL and Rituxan and Revlimid in older patients who are previously untreated. l Immunomodulators–Thalidomide (Thalomid®) and Revlimid are both FDA approved to treat myeloma. They act by modulating the immune system and by blocking the growth of blood vessels that allow cancer cells to grow (antiangiogenesis).These drugs are being studied in combination with Rituxan and/or other agents in patients with relapsed or refractory MCL or patients who are previously untreated. l Radioimmunotherapy (RIT)–Radioisotope particles can be combined with a monoclonal antibody and other treatments to enhance its effectiveness. The radioactive compound attaches to the antibody and the radiation destroys neighboring cancer cells. Tositumomab iodine I-131-tositumomab (Bexxar®) and Yttrium-90 ibritumomab tiuxetan (Zevalin®), both given intravenously (IV), are FDA approved to treat some forms of NHL and are being studied for the treatment of MCL. A series of small molecules targeting cell death are being tested to treat MCL. Some of these investigational agents include: flavopiridol, an inhibitor of cyclin D1 kinases and oral suberoylanilide hydroxamic acid (SAHA), a new class of antitumor agents. Treatment Outcomes There has been noteworthy progress in the treatment of MCL over the last decades with a near doubling of overall survival, even though relapses are still common. Most patients respond well to initial chemotherapy (with or without stem cell transplantation). However, for most patients, the disease eventually progresses or returns. Treatment resistance may develop, which means that a patient may become less responsive to chemotherapy. The median progression-free period for patients with MCL is 20 months and the median overall survival is between 5 and 7 years. The prognosis for the blastoid variant of MCL is poor. This type of MCL typically progresses after chemotherapy treatment; better treatments are needed. Improvements in therapy take several years of observation to determine the results of these new approaches to treatment. Researchers continue to look for therapies that will prolong remissions and extend survival in patients with MCL. Outcome data cannot determine how any one person will respond. Talk to your doctor for more information. Acknowledgement LLS gratefully acknowledges Brad S. Kahl, MD Associate Professor of Medicine Director of UW Lymphoma Service Clinical Research Director for Hematologic Malignancies University of Wisconsin Paul P. Carbone Comprehensive FS4 Mantle Cell Lymphoma Facts I page 6 Mantle Cell Lymphoma Facts Cancer Center Madison, WI for his review of Mantle Cell Lymphoma Facts and for his important contributions to the material presented in this publication. We’re Here to Help LLS is the world’s largest voluntary health organization dedicated to funding blood cancer research, education and patient services. LLS has chapters throughout the country and in Canada. To find the chapter nearest you, enter your ZIP code into “Find your Chapter” at www.LLS.org or contact The Leukemia & Lymphoma Society 1311 Mamaroneck Avenue White Plains, NY 10605 Information Specialists: (800) 955-4572 Email: [email protected] Callers may speak directly with an Information Specialist Monday through Friday, from 9 a.m. to 6 p.m. ET. You may also contact an Information Specialist between 10 a.m. and 5 p.m. ET by clicking on “Live Chat” at www.LLS.org or by sending an email. Information Specialists can answer general questions about diagnosis and treatment options, offer guidance and support and assist with clinical-trial searches for leukemia, lymphoma, myeloma, myelodysplastic syndromes and myeloproliferative neoplasms. The LLS website has information about how to find a clinical trial, including a link to TrialCheck®, a clinical-trial search service. LLS also provides free publications that can be ordered via the 800 number or through the “Free Education Materials” option at www.LLS.org/resourcecenter. References Abbasi MR. Mantle cell lymphoma. Medscape. emedicine.medscape.com/article/203085-overview. Updated January 27, 2012. Accessed June 4, 2012. Harel S, Delarue R, Ribrag V, et al. Treatment of younger patients with mantle cell lymphoma. Seminars in Hematology. 2011;48(3):194-207. Hoster E, Dreyling M, Klapper W, et al. A new prognostic index (MIPI) for patients with advanced-stage mantle cell lymphoma. Blood. 2008;111(2):558-565. Howlader N, Noone AM, Krapcho M, et al (eds). SEER Cancer Statistics Review, 1975-2008, National Cancer Institute. Bethesda, MD, www.seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission, posted to the SEER website, 2011. Accessed June 4,2012. Inwards DJ, Witzig TE. Initial therapy of mantle cell lymphoma. Therapeutic Advances in Hematology. 2011;2(6):381-392. Kaufman, M. ASCO: Bendamustine held superior to CHOP in patients with follicular, indolent and mantle cell lymphoma. Cancer Network. www.cancernetwork.com/conference-re ports/asco2012/hematology/content/article/10165/2082009. June 12, 2012. Accessed July 24, 2012. Le Gouill S, Mohty M, Guillaume T, et al. Allogeneic stem cell transplantation in mantle cell lymphoma: where are we now and which way should we go? Seminars in Hematology. 2011;48(3):227-239. Leonard, JP. Mantle Cell Lymphoma Update. Teleconference of The Leukemia & Lymphoma Society, Past Patient Education Programs, Lymphoma, November 2, 2011. www.lls.org/resourcecenter/pastprograms/lymphoma/ 110211_mcl/. Accessed June 4, 2012. Martin P, Leonard J. Is there a role for “watch and wait” in patients with mantle cell lymphoma? Seminars in Hematology. 2011;48(3):189-193. Mato AR, Svoboda J, Feldman T, et al. Post-treatment (not interim) positron emission tomography-computed tomography scan status is highly predictive of outcome in mantle cell lymphoma patients treated with R-HyperCVAD. Cancer. 2011 Dec 16. McCall B. Rituximab of benefit in mantle cell lymphoma. Medscape Medical News. June 13, 2011. www.medscape.com/viewarticle/744453. Accessed June 4, 2012. Parekh S, Weniger MA, Wiestner A. New molecular targets in mantle cell lymphoma. Seminars in Cancer Biology. 2011;21(5):335-346. Romaguera JE, McLaughlin PW. “Chapter 102. Mantle Cell Lymphoma.” Lichtman MA, Kipps TJ, Seligsohn U, Kaushansky K, Prchal, JT eds. Williams Hematology, 8th ed. Available from: AccessMedicine. Accessed on June 4, 2012. Royo C, Salaverria I, Hartmann EM, et al. The complex landscape of genetic alterations in mantle cell lymphoma. Seminars in Cancer Biology. 2011;21(5):322-334. Warsch S, Hosein LS, Maeda LS, et al. A retrospective study evaluating the efficacy and safety of bendamustine in the treatment of mantle cell lymphoma. [published ahead of print January 31, 2012]. Leukemia & Lymphoma. FS4 Mantle Cell Lymphoma Facts I page 7 Mantle Cell Lymphoma Facts This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is distributed as a public service by The Leukemia & Lymphoma Society (LLS), with the understanding that The Leukemia & Lymphoma Society is not engaged in rendering medical or other professional services. FS4 Mantle Cell Lymphoma Facts I page 8