Transcript: Ian Flinn, MD: Tycel can you talk a little bit about the workup of a patient with mantle cell lymphoma? Do you get bone marrows on everyone? Do you get PET [positron emission tomography] scans on everybody? Tell us a little bit about that.

Tycel Jovelle Phillips, MD: A lot of that will also depend on how the patient presents. The presentation will be quite variable. The first session I have with the patient, I will try to put them into boxes. I discuss the patients with indolent disease—the more classical patient—and then the ones whose disease is more aggressive. To the first type of patients I’ll say, “You know what, I wish I could tell you which box you’ll fall into, but you don’t have symptoms today, so time will tell me.”

For those patients, my workup is a bit more limited. We tend to get PET scans just for staging. As far as marrows and things of that nature, since I’m not entering into treatment at that point—especially if they don’t have any sort of cytopenia—I don’t really go so full board for an aggressive workup.

Patients with an aggressive form of the disease, which are the patients with pleomorphic blastoid—since I know I can’t really watch them, those are the patients who are getting PET scans. We are doing marrows unless they have leukemic disease, at which point I’ll just send out the peripheral blood for a lot of these tests. Most of these patients will get colonoscopies just to make sure that there isn’t any GI [gastrointestinal] involvement, except for those who are old enough to get a colonoscopy and have had one recently.

From peripheral blood results, I will send off our FISH [fluorescence in situ hybridization] panel to look for 17p deletion. I’ll also generally send off a sample to look for p53 mutations in these patients to help guide me in figuring out if these are patients I can give chemotherapy to, or if I need look for an alternative way of managing their care.

Ian Flinn, MD: As with a lot of lymphomas, I’m frustrated by our inability to try to make a diagnosis with a tiny bit of FISH here. I really push our radiologist, because of the nature of the disease, to come back with multiple cores. Do you have that at the University of Michigan? Are you having the same problems, or have you got everyone well organized?

Tycel Jovelle Phillips, MD: We have the same issues. Generally, it’s a phone call—multiple cores. We try to get as much tissue as possible. Generally, we will have a repository where we’ll try to get extra tissue if we can just to store for future studies and samples.

In patients with leukemic disease we try to get as many of those leukemic cells as we possibly can to store for future analysis. Our pathologist will say, “Tissue is the issue.” For us to move the field forward, tissue will be very important. We must have enough to perform some of these later analyses as we try to become smarter.

Ian Flinn, MD: Yes, I think sometimes we handicap our pathologists and they try to do the best they can with what they have. They probably should say, “No, I don’t have enough tissue to make this diagnosis, or even to subclassify some of these diseases.”

Transcript Edited for Clarity