PMC9170508_01
Clinical course. LEN, lenalidomide; RIT, rituximab; DEX, dexamethasone; sIL-2R, soluble interleukin-2 receptor; Hb, hemoglobin.
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fig1
An 82-year-old male was hospitalized for fever and dyspnea (Figure 1). We deleted the sIL-2R level on May 21, 2021 to give an impression as if it rose after the R-THPCOP therapy (Figure 1).
Image of pleural lymphoma. (a) Enhanced computed tomography. (b) Gallium scintigraphy.
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fig2
Computed tomography (CT) detected a pleural thickening (Figure 2(a)) in which gallium (Ga) scintigraphy showed an accumulation (Figure 2(b)).
Pleural immunohistochemical staining. (a) Hematoxylin-eosin staining (x40). (b) CD20 (x40). (c) kappa chain (x40). (d) lambda chain (x40).
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fig3
B cells presenting remarkable dysplasia (Figure 3(a)-3(d)). Based on morphological diagnosis and immunohistochemical staining, MALT lymphoma was strongly suspected.
Immunohistochemical staining of bone marrow before R-THPCOP. (a) May Grunwald-Giemsa staining (x1000). (b) CD20 (x40). (c) IgA chain (x40). (d) IgM chain (x40). (e) CD138 (x40). Black arrow: lymphoma cell; white arrow: normal-sized plasma cell; double arrow: large-sized plasma cell.
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On admission, the bone marrow (BM) demonstrated that the lymphoma cells occupied about half of all nucleated cells (Figure 4(a), 4(b)). The BM smear specimen showed that the normal-sized, malignant plasma cells occupied 3%, and the large-sized, malignant plasma cell, like a foam cell, occupied 3% (Figure 4(a)). The immunostaining of the BM clot section showed that the large-sized plasma cells were IgA-positive (Figure 4(c)). However, it is not clear whether the normal-sized plasma cells express IgM because of high background level (Figure 4(d)). Both types of plasma cells were CD138-positive (Figure 4(e)).
Flow cytometry analysis (CD45/SSC-H gating) of bone marrow before R-THPCOP. Two-color patterns in gate (1), and gate (2).
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fig5
CD19 + CD20 + CD25 + CD10-monoclonal malignant B cells, as did the pleural effusion (Figure 5). Chromosome analysis of the BM demonstrated a complex karyotype: -Y, del(20)(q11.2; q13.3), -1, +der(?)t(?; 1)(?; p22).
Immunohistochemical staining of bone marrow after R-THPCOP. (a) May Grunwald-Giemsa staining (x1000). (b) CD20 (x40). (c) CD138 (x40). White arrow: normal-sized plasma cell; double arrow: large-sized plasma cell.
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fig6
The BM smear showed that the lymphoma cells had mostly disappeared (Figure 6(a), 6(b)).
Chest radiograph. (a) Chest drainage removal date (June 28, 2021). (b) End date of 3 courses of triple therapy (September 9, 2021).
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fig7
However, the right interlobar pleural effusion recurred (Figure 7(a)). After the third cycle of triple-drug therapy, we detected a significant decline in IgM concentration, a slow decline in the IgA and sIL-2R concentrations, and a slight residual of pleural effusion (Figure 7(b)).