Conference Abstracts - 2025 Summit on Hematologic Cancers
Vol. 5, Issue Supplement 1, 2025 · S1-2
When cancer is the answer, tissue is the issue: Diagnosing Advanced Mantle Cell Lymphoma in a patient presenting with pancytopenia
Soham Nadkarni, MBBS,Sidharth Mahajan, MD,Clark Cutrer, MD,George Sneed, DO
Submission received: 2025-07-11 / Accepted: 2025-07-28 / Published: 2025-09-16
Background
Mantle cell lymphoma (MCL) is a rare subtype of mature B cell non-Hodgkin lymphoma, comprising 5–7% of all lymphomas, which often presents at an advanced stage with bone marrow involvement.[1] Diagnosis can be challenging due to its variable and frequently asymptomatic initial presentation.
Case Discussion
A 71-year-old man presented to an outside hospital with weight loss of 20 pounds over 2 years, fatigue, night sweats and leg cramps. Labs revealed pancytopenia with hemoglobin 9.4, platelet count 87, white blood cell count of 3.7 with absolute neutrophil count (ANC) 1.5 and absolute lymphocyte count (ALC) 2.1. Imaging revealed a nodular liver, splenomegaly as well as cervical, retroperitoneal and mesenteric lymphadenopathy, and a 4mm apical lung nodule. Bone marrow biopsy showed Mantle Cell Lymphoma with 95% cellularity and immunophenotype CD20+, PAX5+, CD5+, Bcl-2+, cyclin D1+ and partial CD23+. Ki-67 was 50% and SOX11was positive.
Shortly after diagnosis, the patient developed a transfusion-dependent anemia and was referred to University of Tennessee for further evaluation. Treatment options of MCL- bendamustine, rituximab with consideration of high-dose cytarabine or BTK inhibitor were discussed. However, he opted to enroll in a clinical trial investigating rituximab and Zanubrutinib as first-line treatment for MCL in patients over 70.
Image 1: Peripheral blood smear with atypical lymphoid cells present.
Image 2: Bone Marrow markedly infiltrated by an abnormal population of lymphoid cells.
Image 3: Retroperitoneal Lymph Node biopsy: abnormal B cell population with positive cyclin D1 reactivity.
Image 4: Retroperitoneal LN biopsy: abnormal B cell population showing co-expression with CD5.
Conclusion
In elderly patients presenting with pancytopenia, the differential is broad to include hematologic malignancy, infection and various nutritional deficiencies. In addition to nutritional and infectious work-up, bone marrow biopsy should be considered promptly, particularly if other systemic symptoms are present. Mortality rates for advanced stage mantle cell lymphoma, particularly in patients over 65 years are higher, with 5 and 10 year survival rates being ~50% and 35%, respectively [2,3]. Hence appropriate work-up and treatment should be initiated immediately once there is concern. This case highlights the critical importance of timely hematology/oncology referral and comprehensive evaluation, including bone marrow biopsy in patients with unexplained cytopenias.
References
1. Armitage JO, Longo DL. Mantle-Cell Lymphoma. N Engl J Med. 2022 Jun 30;386(26):2495-2506. doi: 10.1056/NEJMra2202672. PMID: 35767440.
2. Harmanen M, Hujo M, Sund R, Sorigue M, Khan M, Prusila R, Klaavuniemi T, Kari E, Jantunen E, Sunela K, Rajamäki A, Alanne E, Kuitunen H, Sancho JM, Jukkola A, Rönkä A, Kuittinen O. Survival of patients with mantle cell lymphoma in the rituximab era: Retrospective binational analysis between 2000 and 2020. Br J Haematol. 2023 Apr;201(1):64-74. doi: 10.1111/bjh.18597. Epub 2022 Dec 13. PMID: 36513500.
3. Cencini E, Calomino N, Franceschini M, Dragomir A, Fredducci S, Esposito Vangone B, Lucco Navei G, Fabbri A, Bocchia M. Survival Outcomes of Patients with Mantle Cell Lymphoma: A Retrospective, 15-Year, Real-Life Study. Hematol Rep. 2024 Jan 18;16(1):50-62. doi: 10.3390/hematolrep16010006. PMID: 38247996; PMCID: PMC10801596.