IntroductionMantle cell lymphoma (MCL) is an aggressive subtype of B-cell lymphoma that accounts for 5%-7% of cases of non-Hodgkin lymphoma. Despite good responses with first-line treatments for newly diagnosed, untreated MCL patients, 1-3 MCL patients often relapse and demonstrate highly refractory responses to common antilymphoma chemotherapy, which results in inevitable chemoresistance and poor clinical outcomes. [4][5][6][7] Bortezomib (Velcade), a reversible inhibitor of the 26S proteasome, first gained United States Food and Drug Administration approval as a single-agent treatment in patients with relapsed or refractory MCL. 8 Bortezomib inhibits the ubiquitin-proteasome pathway and alters multiple cellular signaling cascades, including those regulating cell growth, differentiation, and survival. [9][10][11] For example, proteasome inhibition prevents the degradation of proapoptotic factors, which facilitates the activation of programmed cell death in neoplastic cells; however, the precise mechanisms of action are controversial.One of the known bortezomib targets for inhibition is NF-B and its related pathway. Constitutive NF-B expression has been reported in MCL cell lines and primary cells. 12 However, therapies such as bortezomib targeting NF-B have shown limited effects in MCL. [13][14][15] Bortezomib was also reported to elicit the unfolded protein response, which is activated when the physiologic environment of the endoplasmic reticulum is altered. [16][17][18] The induction of endoplasmic reticulum stress induces reactive oxygen species, which affects treatment responses to bortezomib in MCL 18 and multiple myeloma. 19 In addition, some studies have suggested that bortezomib could increase NF-B activity 20,21 or the presence of bortezomib-resistant NF-B activity in MCL. 13 The resistance to drugs such as bortezomib in MCL suggest the presence of drug-resistant populations in MCL. In a previous study, we prospectively identified stem-like cells in MCL, which we have termed MCL-initiating cells (MCL-ICs). 22 The stem-like MCL cells (CD45 ϩ CD19 Ϫ CD34 Ϫ CD3 Ϫ ) were highly tumorigenic and display self-renewal capacities in NOD/SCID mice. In contrast, the majority of the tumor population contains CD45 ϩ CD19 ϩ MCL cells, which show no self-renewal capacity and have greatly reduced tumorigenicity. 22 We also demonstrated that these CD45 ϩ CD19 Ϫ MCL-ICs confer drug resistance properties to MCL. MCL-ICs were highly resistant in vitro to clinically relevant anti-MCL chemotherapeutic regimens compared with bulk CD45 ϩ CD19 ϩ MCL cells. 23 Moreover, CD45 ϩ CD19 Ϫ MCL-ICs were resistant to bortezomib and bortezomib-based chemotherapeutic regimens despite constitutive NF-B expression. 24 Bortezomibbased regimens targeted CD45 ϩ CD19 Ϫ MCL-ICs less efficiently compared with CD45 ϩ CD19 ϩ bulk MCL cells. Based on these findings, a new strategy is required to overcome bortezomib resistance in MCL.Recent studies have demonstrated that perillyl alcohol (POH), a naturally occurring monoterpene that inhibits L-type ...