Complete Metabolic Response After Frontline Bendamustine, Rituximab and Acalabrutinib in a Frail Elderly Patient with High-Risk Mantle Cell Lymphoma: A Real-World Case from Guatemala
Mantle cell lymphoma (MCL) predominantly affects older adults and often presents with advanced-stage disease, posing significant therapeutic challenges in patients who are ineligible for intensive chemoimmunotherapy. The phase III ECHO trial established bendamustine, rituximab, and acalabrutinib as an effective frontline treatment option for transplant-ineligible patients with MCL. We describe the real-world use of this regimen in an elderly patient with high-risk disease and significant cardiac comorbidity.
Materials and Methods/Case Presentation/Objective:
A 76-year-old man presented with fatigue, dyspnea, severe anemia (hemoglobin 5.1 g/dL), thrombocytopenia, generalized lymphadenopathy, splenomegaly, elevated lactate dehydrogenase, and bone marrow infiltration. Lymph node biopsy confirmed mantle cell lymphoma (cyclin D1-positive, Ki-67 15%). Disease was Ann Arbor stage IV with high-risk MIPI/MIPI-c scores. Baseline echocardiography demonstrated heart failure with a left ventricular ejection fraction of 48%, precluding intensive chemoimmunotherapy.
Results/Description/Main Outcome Measure(s):
The patient received six cycles of bendamustine, rituximab, and acalabrutinib. Bendamustine dose was reduced after cycle two because of a localized soft tissue infection, whereas acalabrutinib was continued throughout treatment without interruption or dose modification. Adverse events consisted of one localized soft tissue infection, grade 2 neutropenia with oral candidiasis, and two red blood cell transfusions early during treatment attributable to bone marrow infiltration. Progressive improvement in anemia and thrombocytopenia was observed during therapy. End-of-treatment PET/CT demonstrated complete metabolic response (Deauville score 2). After six months of follow-up, the patient remains in complete clinical remission receiving maintenance rituximab plus acalabrutinib without cardiovascular toxicity, bleeding events, or disease progression.
Conclusion(s).:
This case supports the feasibility of frontline bendamustine, rituximab, and acalabrutinib for carefully selected frail patients with high-risk mantle cell lymphoma who are ineligible for intensive therapy. Durable complete metabolic remission, sustained treatment exposure without acalabrutinib interruption, and an acceptable safety profile highlight the potential value of this approach in routine clinical practice. To our knowledge, this is the first reported real-world use of this regimen in Guatemala.
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