Late Relapse of ALK-Positive Anaplastic Large Cell Lymphoma Successfully Cleared by Crizotinib
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2021-01-23
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Front Oncol. 2020 Oct 2;10:585830. doi: 10.3389/fonc.2020.585830.
A 54-year-old previously healthy man complained about pain in the right upper back. Physical examination revealed a palpable induration located at the right shoulder. Magnetic resonance imaging (MRI) showed a tumor mass with infiltration of the right humerus (Figure 1A) and the right pleura (Figure 1B). After computed tomography (CT)-guided biopsy and subsequent histological examination, the diagnosis of anaplastic large cell T cell lymphoma (ALCL) was made. The ensuing molecular analysis revealed the presence of a translocation t(2;5) indicating ALK-positive ALCL. Furthermore, bone marrow biopsy showed infiltration with lymphoma cells. Therapeutically, chemotherapy according to the CHOEP-14 protocol (cyclophosphamide, doxorubicin, vincristine, etoposide, prednisone administered biweekly) was started. After eight cycles of chemotherapy, the patient entered into a complete remission without residual ALCL presence visible on CT-imaging and bone marrow examination. During chemotherapy, no relevant side-effects, such as serious infections or polyneuropathy, were observed. Following 14 years of normal follow-up care without any signs of relapse, the patient reported nighttime sweating accompanied by fever and increasing pain emanating from the left thorax. FDG-Positron emission tomography (FDG-PET) revealed multiple hypermetabolic osteolytic lesions affecting the spine (Figure 2A), several ribs (Figure 2A) and the right scapula (Figure 2B). Additionally, pathological tracer uptake was observed in periaortic and iliac lymph nodes. CT-guided biopsy of a hypermetabolic lesion located in the eighth rib of the left hemithorax revealed a relapse of the previously known ALK-positive ALCL nearly 14 years after chemotherapy. Due to the long time to relapse chemotherapy with CHOEP was repeated after a brief cyclophosphamide pre-phase. Moreover, denosumab was added for skeletal support. Upon six cycles of chemotherapy FDG-PET-imaging showed complete regression of all ALCL lesions. Fifteen months later, the patient presented to the emergency room with fever and pain in the left foot. Physical examination revealed a red and swollen left forefoot with tenderness upon palpation (Figure 3A). Magnetic resonance imaging of the left foot showed a cutaneous mass without involvement of muscles or bones. Dermatohistopathological examination of skin biopsy confirmed the second relapse of ALK-positive ALCL. Subsequent staging via FDG-PET revealed tracer uptake in the left forefoot (Figure 3B) as well as pathological lymph-nodes in the left groin. No serious comorbidities were present apart from vincristine-induced sensory polyneuropathy (paresthesia and digital numbness without serious limitations in instrumental activities of daily living corresponding to polyneuropathy grade 2), which started after the last cycle of relapse chemotherapy. At second relapse, the patient was not considered eligible for high-do
A 54-year-old previously healthy man complained about pain in the right upper back. Physical examination revealed a palpable induration located at the right shoulder. Magnetic resonance imaging (MRI) showed a tumor mass with infiltration of the right humerus (Figure 1A) and the right pleura (Figure 1B). After computed tomography (CT)-guided biopsy and subsequent histological examination, the diagnosis of anaplastic large cell T cell lymphoma (ALCL) was made. The ensuing molecular analysis revealed the presence of a translocation t(2;5) indicating ALK-positive ALCL. Furthermore, bone marrow biopsy showed infiltration with lymphoma cells. Therapeutically, chemotherapy according to the CHOEP-14 protocol (cyclophosphamide, doxorubicin, vincristine, etoposide, prednisone administered biweekly) was started. After eight cycles of chemotherapy, the patient entered into a complete remission without residual ALCL presence visible on CT-imaging and bone marrow examination. During chemotherapy, no relevant side-effects, such as serious infections or polyneuropathy, were observed. Following 14 years of normal follow-up care without any signs of relapse, the patient reported nighttime sweating accompanied by fever and increasing pain emanating from the left thorax. FDG-Positron emission tomography (FDG-PET) revealed multiple hypermetabolic osteolytic lesions affecting the spine (Figure 2A), several ribs (Figure 2A) and the right scapula (Figure 2B). Additionally, pathological tracer uptake was observed in periaortic and iliac lymph nodes. CT-guided biopsy of a hypermetabolic lesion located in the eighth rib of the left hemithorax revealed a relapse of the previously known ALK-positive ALCL nearly 14 years after chemotherapy. Due to the long time to relapse chemotherapy with CHOEP was repeated after a brief cyclophosphamide pre-phase. Moreover, denosumab was added for skeletal support. Upon six cycles of chemotherapy FDG-PET-imaging showed complete regression of all ALCL lesions. Fifteen months later, the patient presented to the emergency room with fever and pain in the left foot. Physical examination revealed a red and swollen left forefoot with tenderness upon palpation (Figure 3A). Magnetic resonance imaging of the left foot showed a cutaneous mass without involvement of muscles or bones. Dermatohistopathological examination of skin biopsy confirmed the second relapse of ALK-positive ALCL. Subsequent staging via FDG-PET revealed tracer uptake in the left forefoot (Figure 3B) as well as pathological lymph-nodes in the left groin. No serious comorbidities were present apart from vincristine-induced sensory polyneuropathy (paresthesia and digital numbness without serious limitations in instrumental activities of daily living corresponding to polyneuropathy grade 2), which started after the last cycle of relapse chemotherapy. At second relapse, the patient was not considered eligible for high-do
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