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Although the mutational profile of MCL has been extensively studied, there is a lack of understanding of resistance mechanisms and genetic factors that impact the response to novel treatments. Since patients relapsing on targeted treatment experience poor clinical outcomes, understanding the genetic foundation of resistance mechanisms in MCL is essential. In this study, we aimed to scrutinize the copy number profile and clonal dynamics of double\u2010resistant MCL patients treated sequentially with Bruton's tyrosine kinase inhibitor (BTKi) and venetoclax using low\u2010coverage whole genome sequencing (lcWGS). Samples obtained after systemic therapy showed more copy number alterations (CNAs) (<jats:italic>p<\/jats:italic>\u2009=\u20090.039; Wilcoxon) compared to samples collected before treatment initiation. Patients showing early progression on BTKi demonstrated CNAs affecting cytobands encompassing the coding regions of <jats:italic>NOTCH1<\/jats:italic>, <jats:italic>TRAF2<\/jats:italic>, <jats:italic>BIRC2<\/jats:italic>, <jats:italic>BIRC3<\/jats:italic>, and <jats:italic>ATM<\/jats:italic>. A deletion in chromosome 9p21.3 was identified in two out of three venetoclax\u2010resistant patients. For patient MCL2, progressing on ibrutinib but showing venetoclax resistance, a 9p21.3 deletion was found throughout the disease course, with acquired <jats:italic>SMARCA4<\/jats:italic>\u2010del(19)(p13.3\u2013q13.11) and <jats:italic>DLC1<\/jats:italic>\u2013del(8)(p23.2\u2013q11.1) observed at relapse, highlighting their role in disease progression and therapy resistance. Using lcWGS, an innovative genome\u2010wide approach, this study revealed novel putative primary and acquired resistance mechanisms in BTKi and venetoclax double\u2010resistant MCL patients. \u00a9 2025 The Author(s). <jats:italic>The Journal of Pathology<\/jats:italic> published by John Wiley &amp; Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.<\/jats:p>","DOI":"10.1002\/path.6434","type":"journal-article","created":{"date-parts":[[2025,5,15]],"date-time":"2025-05-15T07:15:21Z","timestamp":1747293321000},"page":"395-404","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Resistance mechanisms and clonal dynamics in mantle cell lymphoma treated with sequential <scp>BTKi<\/scp> and venetoclax 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