Case Analysis Of Elderly Patients With Refractory Diffuse Large B-cell Lymphoma And Literature Review

BackgroundDiffuse large-B cell lymphoma accounts for approximately30%-45%of non-Hodgkin’lymphoma,which is the common subtype in adult.More than50%patients can achieve5-years survival with combined chemotherapy containing anthracycline.After the addition of rituximab, the efficacy of the treatment will be further improved and the survival of patients with diffuse large-B cell lymphoma has been prolonged. The international prognostic index is widely used in evaluating the patient’s prognosis.Retuximab combined with CHOP regimen is the first-line therapy for the patients with diffuse large-B cell lymphoma. High-dose chemotherapy with autologous stem cell transplantation can improve the response rate and overall survival of the patients. The purpose of salvage chemotherapy is to improve quality of life and to prolong survival, in particular. DHAP,ICE,GEMOX are available salvage regimens. We hope that this report may provide additional treatment for refractory and relapse patients, with intolerable high-dose on chemotherapy.A brief introduction of the caseThis is a64-year-old female patient, whose chief complaint was to have subcutaneous nodules on the right thigh for2months and right eye has been blurred vision for1month.2months ago, the patient accidentally touched subcutaneous nodules on the right thigh. Soon after, multiple subcutaneous nodules were found in other sites,including chest, back, waist and head. The patient got blurred vision, accompanying pain. She had a weight loss of6kg.The initial Pathological diagnosis:small cell malignant tumor.Mammary gland biopsy:diffuse large B-cell lymphoma.Physical examination:KPS70, BSA1.53m2. There were multiple subcutaneous nodules on chest, back, waist and bilateral thigh, they were hard, fixed, dark red and prominent on the skin surface, with1cm×1cm to2cm×2cm insize. The mass in the left breast was3cm in diameter.Diagnosis:diffuse large B-cell lymphoma(stage IVB,involving skin, eye ball, mammary gland, IPI score-4, high risk).Treatment:The patient received DICE regimen in the first-line therapy. She got partial remission after1cycle of DICE regimen. A progression of disease was considered after2cycles CHOP in the other department. The salvage therapy included DICE and GemOX regimens. Unfortunately, the patient did not achieve complete response. Etoposide, prednisone, thalidomide, cyclophosphamide, methotrexate were taken orally as maintenance treatment. The patient kept in a partial remission state. Rituximab combined with HD-MTX,DXM was used subsequently. The patient achieved complete response after3cycles treatment.Then she accepted etoposide, prednisone, thalidomide, retinoids as maintenance treatment. She occurred recurrence after3months and was treated with pemetrexed in the subsequent therapy and achieved partial remission again.Thalidomide at daily oral combined with etoposide was used as maintenance treatment. She survived in one year after diagnosing of refractory lymphoma and died in May2011.Conclusion1. Efficacy of antifolate and oral maintenance treatment are available on salvage regimens.2. For patients with refractory lymphoma and with poor PS, the treatment should be individualized.