Case report of a patient with synchronous Non-Hodgkin’s lymphoma-Diffuse Large B-Cell type and Lymphocyte rich classic Hodgkin’s lymphoma

Purpose: There have been reports of synchronous and composite lymphomas which predict the possiblity of a common cell of origin and clonal progression , with the cells undergoing common and distinct transforming events.Therefore , planning treatment in synchronous Non-Hodgkins and Hodgkins lymphoma might involve overlapping treatment strategies in the absence of guidelines for this cohort of patients.

We describe the case of a 61-year-old male with synchronous NHL -DLBCL(Non-Hodgkins Lymphoma -Diffuse Large Bcell ) and LRCHL (Lymphocyte Rich Classical Hodgkins Lymphoma) who underwent chemotherapy followed by radiation to the residual nodal sites.

Methodology: We describe the case of a 61-year-old male who presented with generalized lymphadenopathy and B symptoms.Initial biopsy from right supraclavicular node was reported as LRCHL(Lymphocyte Rich Classical Hodgkins Lymphoma) PET- CT evaluation showed a huge variation in the range of SUV uptake in nodal stations above and below the diaphragm.Correlating with the clinical history and PET CT findings , another biopsy was taken from inguinal region which was suggestive of NHL - DLBCL (Diffuse Large B Cell Lymphoma).There was skeletal involvement on PETCT.
Since NHL –DLBCL is more aggressive and has more chances of failure in the future ,initial chemotherapy with RCHOP, which is first line for NHL , was chosen .CHOP is also an acceptable alternative schedule for classical hodgkins lymphoma in the elderly.
Six cycles of chemotherapy with RCHOP (Inj Rituximab –375mg /m2, Inj Cyclophosphamide 750 mg/m2, Inj Doxorubicin 50 mg/m2, Inj Vincristine 1.4 mg/m2 and Tab Prednisolone 100mg oral D1-D5) was taken every 3 weeks . Post-chemotherapy PET CT reassessment showed response with a Deauville Score of 1 in the supra-diaphragmatic nodal stations . However , there was higher metabolic activity in bilateral iliac and mesenteric nodes with a Deauville Score of 4.Hence extended field ISRT(Involved site Radiation) using 3D CRT technique was delivered to the initial bulky and post -PET residual nodal stations- bilateral inguinal, common iliac and external iliac stations to a dose of 36 Gy over 18 Fractions using an Elekta Synergy LINAC meeting dose constraints to the OARs.

Results: Our patient with synchronous lymphoma , after chemotherapy with RCHOP and ISRT to residual nodal stations that showed a Deauville Score of 4, is on follow up. We are planning for reassesment PETCT 6 months after radiation and a re-biopsy of any residual nodal disease , to help direct further management.

Conclusions: Management of patients with synchronous Non-Hodgkins and Hodgkins lymphoma involves prioritizing treatment of the more aggressive subtype initially , as well as consideration of chemotherapy regimens which might be applicable for both subtypes. Also , there might arise the necessity for re-biopsy of residual nodal sites following a reassesment with PET CT post -chemotherapy , to make further treatment decisions for these patients.

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