70 year old male with past medical history of hypothyroidism, hyperlipidemia who presented with left neck swelling. Underwent Dermatology evaluation. S/P left lateral posterior neck excision biopsy performed 2022 with pathology showing dermal atypical lymphoid infiltrate with IHC consistent with MCL [cyclin D1 and SOX11 positive]. Ki-7 30%. No peripheral blood involvement. CT neck and CTA chest showed left neck adenopathy. Underwent staging evaluation at MD Anderson Houston including negative EGD/colonoscopy and BM Biopsy. PET/CT demonstrated left cervical adenopathy. No other dx. He was considering clinical trial [Calquence plus Rituximab] but opted tx locally. Excellent PS. ECOG 0. What front-line therapy would you recommend?
This is a challenging case because he has features suggestive of indolent disease (Asymptomatic, Stage 1) but a few suggestive of a potential to turn aggressive (Ki-67 30% and SOX11 positive). In his evaluation, was TP53 or deletion 17 p status evaluated ? If this was done and is negative, I do not recommend initiation of treatment now for such a patient. I repeat a PET scan in 3-6 months and then again in 12 months to see if there is an increase in size or sites of disease. If at any time point treatment is needed, Bendamustine plus rituximab for 6 cycles continues to be standard practice for age > 65 years and those who are transplant ineligible. If the patient wants treatment and does not prefer chemotherapy, radiation is the second alternative for Stage 1 disease. Thank you for this interesting dilemma and question.