Treatment paradigm in Waldenström macroglobulinemia: frontline therapy and beyond

Abstract

Waldenström macroglobulinemia (WM) is an indolent lymphoplasmacytic lymphoma. Recent strides made in the genomic profiling of patients with WM have led to the identification of many novel therapeutic targets. Patients with WM can present with asymptomatic disease and not all patients require treatment. When criteria for initiating systemic therapy are met, the choice of therapy depends on the tumor genotype (MYD88 and CXCR4 mutation status), patient preference (fixed versus continuous duration therapy, oral versus intravenous route, cost), associated medical comorbidities, and adverse effect profile of the treatment. In the absence of head-to-head comparison between chemoimmunotherapy and Bruton's tyrosine kinase inhibitors in otherwise fit patients with a MYD88 ^L265P mutation, our preference is fixed duration therapy with four to six cycles of chemoimmunotherapy with bendamustine-rituximab. In this review, we discuss the role of MYD88 and CXCR4 mutation in treatment selection, and current data for frontline and salvage treatment options in patients with WM.

Keywords: BTK; CXCR4; DRC; MYD88; bendamustine–rituximab; ibrutinib; lymphoplasmacytic lymphoma.

Figure 1.

Algorithm for management of newly diagnosed Waldenström macroglobulinemia. BTK, Bruton tyrosine kinase; BR, bendamustine-rituximab; BDR, bortezomib-rituximab-cyclophosphamide; CXCR4MUT, CXCR mutated; CXCR4WT, CXCR wild type; DRC, dexamethasone-rituximab-cyclophosphamide; WM, Waldenström Macroglobulinemia ^#Symptoms of hyperviscosity include, but are not limited to, headaches, visual disturbance, abnormal bleeding, altered mental status, strokes and acute coronary syndrome. ^*Include ibrutinib, acalabrutinib, zanubrutinib. ^¥ In case of serum IgM > 4000 mg/dl, consider omitting rituximab from BR for first couple of cycles to avoid IgM flare from rituximab.