PMC6554495_01
Computed tomography. (A) At the start of treatment with afatinib showing the primary lesion of the lung cancer. (B) At 32 months after the start of treatment showing the primary lesion that had decreased in size. (C) At the start of treatment showing intra-abdominal lymphadenopathy. (D) At 24 months after the start of treatment showing hepatosplenomegaly. (E, F) At 32 months after the start of treatment showing abdominal distension, hepatosplenomegaly, and intra-abdominal lymphadenopathy.
gr1.jpg
PMC6554495_01_gr1.jpg
fig1
A 64-year-old woman was diagnosed with stage IVB (T4N3M1c) LAD expressing mutant EGFR (exon 19 deletion) (Fig. 1-A). Terminology Criteria for Adverse Events version 4.0). Therefore, the afatinib dose was reduced to 20 mg/day until twenty-three months from starting afatinib, maintaining a partial response of the LAD (Fig. 1-B). At the time of diagnosis of LAD, we detected abdominal lymphadenopathies by abdominal computed tomography (CT) imaging; however, we assessed them as metastases from the LAD (Fig. 1-C). During treatment with afatinib, abdominal lymphadenopathies and splenomegaly continued to increase on the CT image (Fig. 1-D). We detected hepatosplenomegaly, ascites, and intra-abdominal lymphadenopathies by abdominal CT (Fig. 1-E, F).
(A) May Giemsa staining for peripheral blood cells showing atypical lymphocytes (high-power field). (B-E) Immunohistochemistry of cell blocks from peripheral blood cells; lymphoid cells showing diffuse positive results for (B) CD10, (C) CD20, (D) CD79a, and (E) Bcl-2 (high-power field). (F) Fluorescence in situ hybridization from ascites showing translocation of IGH and BCL2.
gr2.jpg
PMC6554495_01_gr2.jpg
fig2
The complete blood count revealed elevated white blood cell (24900/muL) and lymphocyte counts (21370/muL), including 87% of atypical lymphocytes that appeared small and cleaved typically (Fig. 2-A); Hemoglobin decreased to 9.3 g/dL, and thrombocyte count to 63000/muL. Immunohistochemistry of atypical lymphocytes in peripheral blood revealed that they were positive for CD10, CD19, CD20, CD79a, and BCL-2 (Fig. 2-B, C, D, E), and negative for CD3, CD4, CD5, and CD8 (not shown). Fluorescence in situ hybridization of ascites revealed the translocation of IGH and BCL2 (Fig. 2-F).
Computed Tomography at the completion of the induction chemotherapy for follicular lymphoma. (A) Lung cancer: the primary lesion remained decreased in size, but multiple small lung metastases developed. (B) Follicular lymphoma: abdominal distension and hepatosplenomegaly improved.
gr3.jpg
PMC6554495_01_gr3.jpg
fig3
The primary lesion of the LAD maintained reduced size but multiple small LAD metastases occurred in both lung fields (Fig. 3-A). T790M mutation of the EGFR was detected by liquid biopsy, and therefore we administered osimertinib as a second line treatment. Treatment of the FL resulted in the disappearance of lymphoma cells in peripheral blood, reduction of hepatosplenomegaly, and shrinking of swollen intra-abdominal lymph nodes (Fig. 3-B), therefore we assessed that she achieved a partial response.