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case_images: (A) The timeline of symptoms, imaging changes, and clinical interventions since diagnosis of post-transplant lymphoproliferative disorder (PTLD). (B) The clinical treatment process of PTLD after hematopoietic stem cell transplantation (HSCT) and the changes of PB/BM/CSF EBV-DNA titer.
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case_images: During this period, the BM consistently exhibited positivity for EBV (Figure 1A). A PET-MRI on October 12 confirmed a complete metabolic response (CMR) (Figure 1E). The latest MRI on July 9 continued to show CMR (Figure 1F). As for CSV EBV load, it experienced a transient increase during immunochemotherapy but began to decrease during acalabrutinib maintenance (Figure 1A). The timeline of symptoms, imaging changes, and clinical interventions are summarized in Figure 1B.
case_images: Brain images of central nervous system-post-transplant lymphoproliferative disorder (CNS-PTLD). (A) Emergence of CNS-PTLD. Positron emission tomography-computed tomography (PET-CT) revealed unevenly increased lesions in fluorodeoxyglucose (FDG) metabolism in the right temporal lobe (yellow arrow). The lesion measured was approximately 4.3 x 3.9 x 4.0 cm, SUVmax of 8.0, and central metabolism with SUVmax of 4.7. (B) Following R-MD+orelabrutinib treatment for CNS-PTLD. FDG metabolism in the right temporal lobe displayed irregularly heightened levels and a mixed-density mass, consistent with lymphoma combined with hemorrhage. The intracranial lesions were smaller in size and slightly higher in metabolic activity than before: 1. the lesion measured was approximately 3.6 x 3.1 x 3.7 cm; 2. FDG uptake was unevenly increased with nodular-like elevation, with SUVmax of 10.8 at the edge and slightly decreased central metabolism with SUVmax of 4.3. (C) Following immunochemotherapy +WBRT, nodular and patchy mixed signal shadows were observed in the right parietal lobe, indicating no further hemorrhage. (D) Three months after WBRT, abnormal signal shadows were visible in the right temporal lobe, with irregular morphology, measuring approximately 1.9x1.7x3.4 cm, which demonstrated partial remission. (E) After one cycle of TEDDi-R treatment, abnormal signal shadows were observed in the right insular and temporal lobes, with no significant increase in FDG uptake, achieving CMR in the patient. (F) No significant enhancement was observed in the lesion by contrast-enhanced MRI, which was similar to the MRIs on May 14, March 5, February 16, 2024, and November 10, 2023 (See Figure S1).
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case_images: Positron emission tomography-computed tomography (PET-CT) in the emergency department showed a mixed high-density lesion with surrounding edema in the right temporal lobe (Figure 2A). Furthermore, the fluorodeoxyglucose (FDG) metabolism in the right temporal lobe displayed irregularly heightened levels and a mixed-density mass, consistent with lymphoma combined with hemorrhage, potentially linked to orelabrutinib (Figure 2B). A follow-up brain Contrast-enhanced MRI (CE-MRI) on July 26 showed a decrease in lesion size without any ongoing hemorrhage (Figure 2C). Subsequent CE-MRI on August 9 indicated partial remission of the case (Figure 2D).
case_images: Pathological findings of stereotactic biopsy of the right temporal lobe lesion (January 11, 2023) (A) HE staining at 400x magnification. (B) HE staining at 100x magnification.
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case_images: On January 11, a stereotactic brain lesion biopsy was performed, which showed a few medium-sized atypical lymphoid cells with irregular karyotypes in a large area of necrotic tissue (intracranial mass in the right temporal lobe) (Figure 3).
case_images: Cytological morphology of concentrated body fluid smear to detect tumor cells, which showed no tumor cells.
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case_images: Tumor cells were not detected in either cytological morphology or flow cytometry (FCM) (Figure 4).