What is the optimal initial management of the younger mantle cell lymphoma patient?

The last 20 years has seen considerable advances made in the management of younger patients with mantle cell lymphoma. The use of high dose cytarabine and rituximab in induction therapy, usually followed by autologous stem cell transplant consolidation, has become established practice and the median overall survival now exceeds 10 years. However, this high intensity upfront approach is not necessarily appropriate for all newly diagnosed patients. A minority exhibit disease that behaves in an indolent fashion with no proven benefit from early intervention, and at the opposite end of the spectrum a high-risk group exists who do poorly with conventional treatment. This review considers the role of watch and wait strategies in indolent presentations, examines the evidence behind current induction approaches and considers ways to modify these for those young patients presenting with adverse features. It concludes with an assessment of the emerging role of novel agents and the search for robust risk-adapted treatment strategies.