A Case Report: Remission of Gray Zone Lymphoma on R-CHOP and Adjuvant Radiation Treatment
Article Information
Melissa Hodeib1, Ilene Tsui1, Abed Sinno1,2, Nisha Bansal1 and Joshua G. Cohen1*
1Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA, USA
2Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Olive View-UCLA Medical Center, Sylmar, CA, USA
*Corresponding Author: Joshua G. Cohen, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California Los Angeles, Los Angeles, CA 90095, USA
Received: 27 October 2017; Accepted: 24 November 2017; Published: 04 December 2017
Citation: Stella Pak. A Case Report: Remission of Gray Zone Lymphoma on R-CHOP and Adjuvant Radiation Treatment. Journal of Cancer Research 1 (2017): 19-21.
View / Download Pdf Share at FacebookAbstract
Gray zone lymphoma (GZL) is a rare hematological malignancy known to usually occur in young men. GZL has features intermediate between diffuse large B-cell lymphoma and classical Hodgkin’s lymphoma. This case report describes a 55-years old woman with GZL. Remission was achieved through R-CHOP chemotherapy and adjuvant radiation treatment over 22 months. This case is exemplary for successful management of GZL with R-CHOP chemotherapy.
Keywords
Gray zone lymphoma, B-cell lymphoma, R-CHOP chemotherapy, Adult granulosa cell tumor
Gray zone lymphoma articles Gray zone lymphoma Research articles Gray zone lymphoma review articles Gray zone lymphoma PubMed articles Gray zone lymphoma PubMed Central articles Gray zone lymphoma 2023 articles Gray zone lymphoma 2024 articles Gray zone lymphoma Scopus articles Gray zone lymphoma impact factor journals Gray zone lymphoma Scopus journals Gray zone lymphoma PubMed journals Gray zone lymphoma medical journals Gray zone lymphoma free journals Gray zone lymphoma best journals Gray zone lymphoma top journals Gray zone lymphoma free medical journals Gray zone lymphoma famous journals Gray zone lymphoma Google Scholar indexed journals B-cell lymphoma articles B-cell lymphoma Research articles B-cell lymphoma review articles B-cell lymphoma PubMed articles B-cell lymphoma PubMed Central articles B-cell lymphoma 2023 articles B-cell lymphoma 2024 articles B-cell lymphoma Scopus articles B-cell lymphoma impact factor journals B-cell lymphoma Scopus journals B-cell lymphoma PubMed journals B-cell lymphoma medical journals B-cell lymphoma free journals B-cell lymphoma best journals B-cell lymphoma top journals B-cell lymphoma free medical journals B-cell lymphoma famous journals B-cell lymphoma Google Scholar indexed journals R-CHOP chemotherapy articles R-CHOP chemotherapy Research articles R-CHOP chemotherapy review articles R-CHOP chemotherapy PubMed articles R-CHOP chemotherapy PubMed Central articles R-CHOP chemotherapy 2023 articles R-CHOP chemotherapy 2024 articles R-CHOP chemotherapy Scopus articles R-CHOP chemotherapy impact factor journals R-CHOP chemotherapy Scopus journals R-CHOP chemotherapy PubMed journals R-CHOP chemotherapy medical journals R-CHOP chemotherapy free journals R-CHOP chemotherapy best journals R-CHOP chemotherapy top journals R-CHOP chemotherapy free medical journals R-CHOP chemotherapy famous journals R-CHOP chemotherapy Google Scholar indexed journals Adult granulosa cell tumor articles Adult granulosa cell tumor Research articles Adult granulosa cell tumor review articles Adult granulosa cell tumor PubMed articles Adult granulosa cell tumor PubMed Central articles Adult granulosa cell tumor 2023 articles Adult granulosa cell tumor 2024 articles Adult granulosa cell tumor Scopus articles Adult granulosa cell tumor impact factor journals Adult granulosa cell tumor Scopus journals Adult granulosa cell tumor PubMed journals Adult granulosa cell tumor medical journals Adult granulosa cell tumor free journals Adult granulosa cell tumor best journals Adult granulosa cell tumor top journals Adult granulosa cell tumor free medical journals Adult granulosa cell tumor famous journals Adult granulosa cell tumor Google Scholar indexed journals Hodgkin’s lymphoma articles Hodgkin’s lymphoma Research articles Hodgkin’s lymphoma review articles Hodgkin’s lymphoma PubMed articles Hodgkin’s lymphoma PubMed Central articles Hodgkin’s lymphoma 2023 articles Hodgkin’s lymphoma 2024 articles Hodgkin’s lymphoma Scopus articles Hodgkin’s lymphoma impact factor journals Hodgkin’s lymphoma Scopus journals Hodgkin’s lymphoma PubMed journals Hodgkin’s lymphoma medical journals Hodgkin’s lymphoma free journals Hodgkin’s lymphoma best journals Hodgkin’s lymphoma top journals Hodgkin’s lymphoma free medical journals Hodgkin’s lymphoma famous journals Hodgkin’s lymphoma Google Scholar indexed journals malignancy articles malignancy Research articles malignancy review articles malignancy PubMed articles malignancy PubMed Central articles malignancy 2023 articles malignancy 2024 articles malignancy Scopus articles malignancy impact factor journals malignancy Scopus journals malignancy PubMed journals malignancy medical journals malignancy free journals malignancy best journals malignancy top journals malignancy free medical journals malignancy famous journals malignancy Google Scholar indexed journals hematological articles hematological Research articles hematological review articles hematological PubMed articles hematological PubMed Central articles hematological 2023 articles hematological 2024 articles hematological Scopus articles hematological impact factor journals hematological Scopus journals hematological PubMed journals hematological medical journals hematological free journals hematological best journals hematological top journals hematological free medical journals hematological famous journals hematological Google Scholar indexed journals tomography articles tomography Research articles tomography review articles tomography PubMed articles tomography PubMed Central articles tomography 2023 articles tomography 2024 articles tomography Scopus articles tomography impact factor journals tomography Scopus journals tomography PubMed journals tomography medical journals tomography free journals tomography best journals tomography top journals tomography free medical journals tomography famous journals tomography Google Scholar indexed journals aortopulmonary articles aortopulmonary Research articles aortopulmonary review articles aortopulmonary PubMed articles aortopulmonary PubMed Central articles aortopulmonary 2023 articles aortopulmonary 2024 articles aortopulmonary Scopus articles aortopulmonary impact factor journals aortopulmonary Scopus journals aortopulmonary PubMed journals aortopulmonary medical journals aortopulmonary free journals aortopulmonary best journals aortopulmonary top journals aortopulmonary free medical journals aortopulmonary famous journals aortopulmonary Google Scholar indexed journals articles Research articles review articles PubMed articles PubMed Central articles 2023 articles 2024 articles Scopus articles impact factor journals Scopus journals PubMed journals medical journals free journals best journals top journals free medical journals famous journals Google Scholar indexed journals
Article Details
1. Introduction
Gray zone lymphoma (GZL) is a distinct type of B-cell lymphoma with features intermediate between diffuse large B-cell lymphoma and classical Hodgkin’s lymphoma (HL) [1]. GZL is extremely rare and occur mostly in young men [2]. Herein, we present a case of a middle-aged woman with GZL to add to the scant body of knowledge for this rare disease.
2. Case Presentation
A 55-years old woman presented with 6 weeks’ history of dull aching abdominal and back pain. She also has been experiencing tingling and numbness from her feet all the way up to her navel. She reported multiple episodes of fall due to sudden loss of coordination. Her medical history was significant for rheumatoid arthritis and atrial fibrillation. A computerized tomography (CT) with contrast demonstrated filling defects in the liver and spleen, consistent with lymphoma. Multiple small lymph nodes (LNs).
The largest LN measured about 2.9 cm in the right axilla. The LNs varied in size between 4.6 to 9.6 mm at the periaortic and aortopulmonary window. The LNs at the axillary regions were palpable and felt firm and rubbery in the physical examination. Excisional biopsy performed for a LN (1.5 cm) in the left axilla to further explore the abnormal findings.
The H&E stained section showed a LN in which the normal nodal architecture has been diffusely effaced by a proliferation of small lymphocytes and histiocytes in a highly vascular background. Scattered throughout the lymphoid infiltrates are large atypical cells with convoluted nuclear contours and prominent nucleoli; some of these cells resembled Reed-Sternberg cells. Immunochemical study showed that the diffusely scattered large atypical cells strongly express CD 45 and CD 20. An anti CD-3 stain showed that greater than 90% of the lymphocytes are small T-cells. These immunomorphologic findings were consistent with Diffuse Large B-Cell Lymphoma (DLBCL). Her bone marrow (BM) biopsy was taken from her hip on both sides. The left BM had no hematopoietic cells.
The right BM was hyperplastic and showed diffuse infiltrates of lymphoid cells mixed with small numbers of eosinophil and plasma cells. The number of lymphoid cells accounted for 24% of the hematopoietic cells. Nonetheless, other hematopoietic cells were moderately reduced in numbers. Iron store was also reduced in amount. These characteristics are consistent with nodular sclerosis type of Hodgkin’s disease.
Combining the LN and BM findings, this neoplasm was classified as gray zone lymphoma. The patient was treated with a regimen known as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Following 22 months of systemic chemotherapy with adjuvant radiation treatment, the gray zone lymphoma eventually went into remission.
3. Discussion
Our case is exemplary for successful management of gray zone lymphoma (GZL). Our patient had excellent therapeutic outcome to R-CHOP chemotherapy and adjuvant radiation treatment. By reporting this case, we hope to help expanding the knowledge on therapeutic options for GZL. Since the formal identification of GZL by World Health Organization (WHO) in 2008, definition of this disease is still rapidly evolving [2]. The pathophysiology underlying this disease remains poorly understood due to its recent recognition in the medical community and rarity. For the same reason, there is no well-established treatment for this malignancy.
However, like our case, some oncologists had good outcome by adding rituximab to standard chemotherapy regimens, such as DA-EPOCH (etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin) and CHOP, for GZL positive for CD20 [3]. Another chemotherapeutic regiment reported to be effective in GZL is doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) with rituximab [4].
Hematopoietic stem cell transplantation (HSCT) is reserved for patients with GZL refractory to chemoradiotherapy. Brentuximab vedotin is a monoclonal anti-CD30 antibody that can be used to treat relapsing GZL [5]. There is no sufficient evidence to support the efficacy of adjuvant radiotherapy for GZL.
However, the use of radiotherapy is generally recommended for GZL localized to mediastinum or bulky mass of GZL with diameter greater than 10 cm [4, 5]. Autologous peripheral blood stem cell transplantation is an alternative option available for adjunctive treatment [6]. At the time of diagnosis, majority of GZL mass is larger than 10 cm in diameter and confined to mediastinum. Early detection and intervention is critical as the mass can cause superior vena cava syndrome and progress to involve distant sites, such as kidneys, liver, adrenal glands, brain, and spinal cord [7]. In our patient, GZL was found after it spread to multiple organs. However, she could achieve remission with R-CHOP chemotherapy and adjuvant radiation treatment.
References
- Wilson WH, Pittaluga S, Nicolae A, et al. A prospective study of mediastinal gray-zone lymphoma. Blood 124 (2014): 1563-1569.
- Harris NL. Shades of gray between large B-cell lymphomas and Hodgkin lymphomas: differential diagnosis and biological implications. Mod Pathol 26 (2013): S57-70.
- Grant C, Dunleavy K, Eberle FC, et al. Primary mediastinal large B-cell lymphoma, classic Hodgkin lymphoma presenting in the mediastinum, and mediastinal gray zone lymphoma: what is the oncologist to do? Curr Hematol Malig Rep 6 (2011): 157-163.
- Pilichowska M, Kritharis A, Evens AM. Gray Zone Lymphoma: Current Diagnosis and Treatment Options. Hematol Oncol Clin North Am 30 (2016):1251-1260.
- Kritharis A, Pilichowska M, Evens AM. How I manage patients with grey zone lymphoma. Br J Haematol 174 (2016): 345-350.
- Minami J, Dobashi N, Asai O, et al. Two cases of mediastinal gray zone lymphoma. J Clin Exp Hematop 50 (2010): 143-149.
- Dunleavy K, Grant C, Eberle FC, et al. Gray zone lymphoma: better treated like hodgkin lymphoma or mediastinal large B-cell lymphoma? Curr Hematol Malig Rep 7 (2012): 241-247.