PMC4074177_01
FDG-PET/CT images before and after chemotherapy with BV-DHAP.. Notes: (A) FDG-PET/CT performed as restaging prior to salvage chemotherapy shows massively enhanced glucose uptake by the known lymphoma in the cardia region of the stomach (black arrows). Two additional nodules cranial to the primary tumor with enhanced glucose utilization were considered as affected lymph nodes (grey arrow). (B) FDG-PET/CT images obtained after two cycles of the BV-DHAP regimen showed tumor regress, while a discrete lesion with enhanced glucose metabolism remained detectable (white arrow).. Abbreviations: BV-DHAP, brentuximab vedotin and cisplatin/cytarabine; CT, computed tomography; FDG, fludeoxyglucose; PET, positron emission tomography.
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Two additional nodules cranial to the primary tumor with enhanced glucose uptake were considered as affected lymph nodes (Figure 1A). A second PET-CT scan after cycle two showed further tumor regression, both morphologically and with regards to glucose uptake (Figure 1B).
Histopathology of the biopsied gastric mucosa.. Notes: Hematoxylin and eosin (HE) staining and immunohistochemistry using the indicated antibodies. The large tumor cells stain positive for CD30, the cytotoxic marker perforin, ALK, and CD3 while CD5 remains negative.. Abbreviation: ALK, anaplastic lymphoma kinase.
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A second endoscopic mucosal biopsy showed infiltration by highly-proliferating lymphoid cells, staining positive for CD30 and CD3 with nuclear and cytoplasmic expression of ALK and negativity for CD19, CD79a, and CD38 (Figure 2), again showing ALK-positive large cell lymphoma, Ann Arbor stage IIE, age-adjusted IPI low risk. Reference pathology finally confirmed the diagnosis of ALCL against ALK-positive LBCL (Figure 2).
Schematic overview of the timing and dosing of the BV-DHAP regimen.. Notes: Dosage in cycle 1 was reduced to 75%. Cycle 2 was administered at 100% as indicated.. Abbreviations: BV-DHAP, brentuximab vedotin and cisplatin/cytarabine; d, day; iv, intravenous; po, per os; sc, subcutaneous.
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Considering the primary refractoriness towards standard CHOP treatment and the possibility of ALK-positive LBCL, which is associated with a poor prognosis, we discussed with the patient an individual treatment plan, consisting of the anti-CD30 drug conjugate, brentuximab vedotin and the classical lymphoma salvage regimen DHAP (brentuximab vedotin 1.2 mg/kg [day 0], cisplatin 70 mg/m2 [day 1] over a period of 22 hours, cytarabine [2 x 2,000 mg/m2 on day 2] and dexamethasone [40 mg on days 2-5]) (Figure 3).