PMC8128509_01
Different treatment periods of cranial MRI. (A-C) Multiple enhancing masses were shown in the corpus callosum and around the ventricles before our interventions. (D-F) Partial response after two cycles of treatment. (G-I) No obvious masses after finishing our treatment. (J-L) 30 months follow-up.
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Without any positive physical neurological examinations, a contrast-enhanced magnetic resonance imaging (MRI) scan of the brain suggested multiple enhancing masses in the corpus callosum and around the ventricles (Figure 1A-C). The masses in her head were significantly reduced, which was judged as a PR (partial response) according to the Response Evaluation Criteria in Lymphoma (RECIL) 2017 standards (Figure 1D-F), and she recovered from an unbearable headache. After finishing treatment, MRI was conducted again to evaluate the status in her head, and images revealed that the corpus callosum and ventricle lesions were much smaller than they were initially, and our patient was judged as complete response (Figure 1G-I) and our patient checked the MRI again after 30 months follow-up (Figure 1J-L).
(A) Haematoxylin-eosin (H&E) staining of biopsy samples (40x magnification). Immunohistochemical staining showed that tumor cells were positive for CD20 (B), PAX-5 (C) and MUM1 (E), but not for CD30 (D) and Cyclin D1 (F).
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Schematic representation of chemotherapy regimens. Chemotherapy regimen A was applied to our patient in the first cycle and chemotherapy regimen B was adapted in the second to sixth cycle.
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Extranodal Lymphoma Study Group (IELSG) and we decided to combine two standardized chemotherapy regimens, high dose methotrexate-based regimen (MT-R: methotrexate, temozolomide and rituximab) for intracranial lesions and traditional R-CHOP (rituximab, vincristine, cyclophosphamide, prednisone and anthracycline) immunochemotherapy regimen for extracranial lesions. Eventually, the details of the first cycle treatment for our patient were as follows: rituximab (375 mg/m2, day (d) 0); high-dose intravenous MTX (3.5 g/m2, d1) with leucovorin for rescue, as previously described; vincristine (2 mg, d3); cyclophosphamide (0.75 g/m2 once per day, d3-4); prednisone (60 mg, d3-7); and temozolomide (150 mg/m2 once per day, d3-7) for the first chemotherapy cycle (Figure 3, chemotherapy regimen A). Finally, we designed a new combination called chemotherapy regimen B (Figure 3, chemotherapy regimen B). In summary, we changed our protocol to ibrutinib (420 mg once per day); rituximab (375 mg/m2, d0); vincristine (2 mg, d3); cyclophosphamide (0.75 g/m2 once per day, d3-4); prednisone (60 mg, d3-7); fotemustine (140 mg/m2, d3) and teniposide (65 mg/m2 once a day, d1-3) (Figure 3, chemotherapy regimen B).
CT images after respiratory failure happened. Mediastinal emphysema was occurred after receiving invasive mechanical ventilation. Mediastinal window (A) and lung window (B).
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Her CT lung screening revealed pulmonary consolidation in the inferior lobes surrounded by a wide range of ground-glass opacity effusions on both sides (Figure 4).
The changes of FDG uptake before and after treatment. FDG uptake signals disappeared in brain (A), axillary lymph nodes (B), lymph nodes around the kidney area (C) and right femoral neck (D) after our interventions. The red arrows showed a solitary lesion outside the ventricle, which was also disappeared after our treatment.
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There was no abnormal FDG uptake in the region that previously had high metabolic activity (Figure 5).
A Chart of the patient's medical procedures.
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All the treatment procedures were shown in Figure 6.