In the past 6 or 7 years I have not been actively caring for patients with WM. I would prefer not to comment for that reason.

A 63-year-old patient with normal renal function and without peripheral neuropathy would be a candidate for R-CHOP therapy.

I usually have a discussion with referring physicians about what induction regimen to use. A recent article by Dimopoulos and colleagues discusses treatment recommendations for patients with WM. For patients with neuropathy, regimens that did not include bortezomib were usually preferred. With recent data, bendamustine/rituximab or dexamethasone/rituximab/cyclophosphamide are considered good options.

I was part of the Waldenström Treatment Guidelines team. It’s difficult to obtain a consensus in WM with numerous opinions regarding best treatment options. We do not have a gold standard for WM, but rituximab/cyclophosphamide/dexamethasone was the most accepted standard for front-line therapy and that’s the reason I typically use it up front with the consideration of adding either bortezomib or a purine analog.

WM tends to be more indolent than some other diseases, such as diffuse large B-cell lymphoma. Fortunately, patients generally fare well because the disease tends not to be aggressive. We have encouraging data with both ibrutinib and oprozomib in this disease, and these agents are probably going to be a future standard therapy. However, as of now, rituximab/ cyclophosphamide/dexamethasone is still the standard. For some patients, a stem cell transplant could be considered.

We have several possibilities for the front-line treatment of WM. We can use fludarabine and rituximab or bendamustine and rituximab. FCR or chlorambucil are also options. It would depend on whether the patient wants to receive treatment in an outpatient setting or not. The cyclophosphamide/dexamethasone/rituximab combination could be administered also. I believe that rituximab should be incorporated as part of the regimen and other drugs could be added. A Phase II study by the European Myeloma Network evaluated the activity of bortezomib, dexamethasone and rituximab and showed good responses. However, we are lacking Phase III data on up-front treatment regimens with this disease.

I do not treat WM and do not feel comfortable answering this question.

The cyclophosphamide/dexamethasone/rituximab combination as published by Dimopoulos and colleagues can be administered for this patient with WM requiring treatment. Alternatively, rituximab/bortezomib/dexamethasone can be used. I would use either of these regimens unless the patient had significant neuropathy. Many patients with WM have preexisting neuropathy. In those situations I would hold off on bortezomib-based regimens and consider cyclophosphamide/dexamethasone/rituximab.

I do not treat WM and therefore prefer not to comment.