case_images: PMC5872664_01
case_images: Pathology demonstrating staining consistent with ABC type DLBCL. Hematoxylin and eosin staining demonstrating large lymphocytes with active mitoses at both (a) 100x magnification with bar representing 100 microns and (b) 400x with bar representing 25 microns. (c) Ki-67 stain demonstrating high proliferative index. Various stains including positivity for (d) Bcl2, (e) Bcl6, and (f) CD20 magnified at 400x with bar representing 25 microns and (g) MUM1 as well as negativity for (h) CD10. All images are obtained at 200x magnification with bar representing 50 microns unless otherwise documented.
case_images: CRIHEM2018-5471368.001.jpg
case_images: PMC5872664_01_CRIHEM2018-5471368.001.jpg
case_images: fig1
case_images: Pax-5, CD20, MUM1, BCL2, and BCL6 positive and CD56, TdT, CD10, and cyclin D1 negative, with a Ki-67 of about 95%, consistent with diffuse large B-cell lymphoma, NGCB type (Figure 1). PET/CT was performed after the biopsy to complete staging, which demonstrated multifocal hypermetabolic tumor foci including bilateral nasopharynx, bilateral nasal cavity, left maxillary sinus with extension to the left parapharyngeal space, soft palate, lingual tonsil, palatine tonsil, left face, bilateral neck nodes including jugulodigastric, posterior cervical, and the largest of which was a left submandibular node with central necrosis of 4 centimeters (Figure 2(a)).
case_images: Staging imaging demonstrating response to treatment. (a) PET/CT imaging at initiation of treatment, after 2 cycles of treatment, 5 cycles of treatment, or 9 cycles of treatment as listed. (b) PET/CT imaging showing activity in the bone marrow and liver prior to treatment that was reduced to background levels after 9 cycles of treatment. White arrows indicate areas of active disease on the PET/CT.
case_images: CRIHEM2018-5471368.002.jpg
case_images: PMC5872664_01_CRIHEM2018-5471368.002.jpg
case_images: fig2
case_images: Pax-5, CD20, MUM1, BCL2, and BCL6 positive and CD56, TdT, CD10, and cyclin D1 negative, with a Ki-67 of about 95%, consistent with diffuse large B-cell lymphoma, NGCB type (Figure 1). PET/CT was performed after the biopsy to complete staging, which demonstrated multifocal hypermetabolic tumor foci including bilateral nasopharynx, bilateral nasal cavity, left maxillary sinus with extension to the left parapharyngeal space, soft palate, lingual tonsil, palatine tonsil, left face, bilateral neck nodes including jugulodigastric, posterior cervical, and the largest of which was a left submandibular node with central necrosis of 4 centimeters (Figure 2(a)). In addition, the liver and bone were diffusely increased in avidity suggestive of involvement by lymphoma (Figure 2(b)). After five cycles of treatment, the patient had repeat PET/CT imaging that demonstrated near-complete response (Figure 2(a)). After 4 additional cycles, the patient achieved a complete response on repeat PET imaging including resolution of the bone marrow avidity (Figure 2(a)). After a total of 9 cycles of rituximab, prednisone, and ibrutinib, the patient had a complete response (Figure 2).