Case 10

C. P., female, 57 years old

Symptoms : progressive fatigue from
January 2008
June 2008 : CBC with WBC
8.000/mmc with 80% lymphocytes;
abdominal ultrasound - splenomegaly
She was addressed for a
hematological examination
Clinical picture

Normal color of skin

No superficial lymphadenopathies
Normal lungs
Normal blood pressure
Liver + 3 cm under rib margin
Spleen palpable at 10 cm under rib
margin
Investigations

CBC : WBC=8.800/mmc with 87%

lymphocytes; Hb=9,5 g/dl,
PLT=120.000/mmc.
Blood smear : mature lymphocytes
ESR=18 mm per hour
Coagulation – normal, normal
fibrinogen
Investigations

Biochemistry : BUN, creatinine –

normal; normal liver function, normal
LDH, normal Na, K and calcium
AgHBs, Ac anti HCV, HIV - negative
How do u investigate further ?

1. BM biopsy
2. CT scan – thorax , abdominal
3. flow-cytometry of peripheral blood
4. flow-cytometry of bone marrow
aspirate
5. splenectomy and hystopathological
examination of spleen
CT scan
Normal lungs – no lesions
No tumor mass in mediastinum, no
mediastinal adenopathies
Normal liver
Large spleen , with inferior pole under left
iliac crest
Small abdominal adenopathies ( under 1
cm)
Normal pancreas, kidneys
No peritoneal effusion
Flow-cytometry

Peripheral blood : 70% population of

lymphocytes with CD45+, CD 5+, CD
20+, CD 23 +/-
Bone marrow biopsy
Hystopathologic : hypercellular BM
with important diffuse lymphoid
infiltration – 80%, with small cells
lymphocytic –type, which is replacing
the normal hematopoiesis
Imunohystochemical tests : CD20+ in
tumor cells, CD5 positive in tumor
cells, CD 23 low positive in tumor
cells
Possible diagnosis

Hodgkin’s disease
Diffuse large B-cell NH lymphoma
Small B-cell NH lymphoma
Chronic lymphocytic leukemia
Acute lymphoid leukemia
Diagnosis

Small B-cell nonHodgkin lymphoma

Therapy
Chemotherapy : 6 courses of FC
( Fludarabine + Cyclophosphamide)
regimens – July 2008 – January 2009
Preventive antiviral and anti
Pneumocystis carinii
Granulocyte stimulating factor – if
neutropenia
Substitutive therapy ( transfusion ) – if
needed
Evaluation after therapy – february
2009
Clinic : no superficial adenopathies, normal
liver, spleen + 3 cm under rib margin
CBC : WBC=3000/mmc with neutrophils
28, eosinophils 2, lymphocytes 54,
monocytes 16 , Hb=11 g/dl,
PLT=60.000/mmc
ESR=40 mm per hour
CT scan – spleen with 16 cm long ax
BM biopsy - 30% small lymphocytes
Attitude ?

1. complete remission and monitor

the patient
2. partial response and second-line
therapy
3. partial response and continuing
with the same treatment until
complete response
Second line therapy

Monoclonal antibodies – Rituximab

( anti CD 20) in combination with
chemotherapy

We apply the file for Rituximab

( approval from National Comitee of
Health )
June 2009
Symptoms : profuse sweats, fatigue,mild pallor of
skin, jaundice, dark urine
CBC : WBC=1100/mmc with Mi 2, S 12, E 1, Li 22,
Mo 13 ( formula on 50 elements), Hb=11 g/dl,
PLT=45.000/mmc.
Biochemistry : normal BUN, creatinina, total
proteins, normal Na, K and calcium; total
bilirubine 3 mg/dl, unconjugated bil. 1,3 mg/dl,
conjugated bilirubine 1,7 mg/dl,alkaline
phosphatase 243 U/l(NR→120), AST 834 U/l
(NR→45) , ALT 865 U/l (NR→40), LDH 446
U/l(NR→190), GGT 206 U/l (NR→80).
Diagnosis

Hepatocytolysis and colestasis

syndrome
What could be the etiology ?

1. Acute hepatitis post medication

(chemotherapy)
2. Acute viral hepatitis
3. Chronic viral hepatitis
The patient was sent to Infectious Diseases
Hospital.

She was diagnosed with reactivation of HBV

infection.

Treatment with Lamivudine (Zeffix) 100

mg/day.
For how long she should continue
the antiviral therapy ?

1. indefinitely
2. until the viremia become negative
3. before chemotherapy ( she suppose
to receive again chemotherapy),
during and after she ends
chemotherapy
Correct therapy

At least 2 month before she restarts

chemotherapy, during and at least 12
month after chemotherapy

The major risk is the viral reactivation

and lethal acute hepatitis
 Start therapy again in November 2009 –
when viremia was negative
R-CVP ( Rituximab, Cyclophosphamide,
Vincristin, Dexamethasone) regimens –
every 28 days
Preventive antiviral ( Acyclovir), Biseptol –
indicated in Rituximab treatment
Zeffix 100 mg daily
Growth factors – if nedeed
Careful monitoring of CBC , liver tests and
coagulation
Particularity of the case

Association with hepatitis viral

infection
Previous B viral infection, not
detected at usual test, reactivated
after chemotherapy
Hepatitis C is more frequent
associated with NHL than B