dlbcl lymphoma | MALIGNANT LYMPHOMA AND MULTICENTRIC LOCALIZATION-MIXED

MALIGNANT LYMPHOMA AND MULTICENTRIC LOCALIZATION-MIXED



1. PhD candidate, University of medicine and pharmacy, Gr. t. Popa "Iași, Romania
2. University of medicine and pharmacy, Gr. t. Popa "Iași, Romania
3. Student, University of medicine and pharmacy, Gr. t. Popa "Iași, Romania
MIXED MALIGNANT LYMPHOMA (HODGKIN'S AND NON HODGKIN TYPE) WITH
MULTIPLE DIGESTIVE LOCATIONS-CASE REPORT (ABSTRACT): Introduction. Hodgkin's
disease and non-Hodgkin's lymphomas malignant lymphoid disorders has of tissues, whose diagnosis is
strictly histopathological. The treatment of malignant lymphoma is multidisciplinary and has to be
adapted to each case. Material and methods. We report the case of a female patient 35 years old
initially diagnosed with Hodgkin's disease nodular sclerosis type with middle spleen location. After initial
surgical treatment, followed by chemotherapy, she developed non-Hodgkin's malignant diffuse
large B cell lymphoma with CD20 + located in long and then in the digestive tract (duodenum, jejunum)
and left adrenal gland. Conclusions. The peculiarity of this case is the association of two types of
Lymphoma, Hodgkin and non-Hodgkin's, located predominantly in the digestive tract. Poor prognosis
factors has analyzed.
KEYWORDS: LYMPHOMA, HODGKIN LYMPHOMA, NON-HODGKIN, SPLENECTOMY, PANCREATICODUODENECTOMY.

Correspondence: Dr. Maria Aniței-G, PhD University of medicine and pharmacy "Gr. t.
Popa "Iași, Romania: dr.mgabriela@gmail.com *
.
INTRODUCTION
Hodgkin's disease (BH) is a malignant disorder of lymphoid tissue, whose
diagnosis is based on a strictly morphological criteria: the presence of Reed-Sternberg cells
amid a lymphoid cell infiltrate changeling and changeable [1.2]. The disease has a
the maximum age for 30 years, a new growing with age
for 50 years [3]. The etiology of the disease cannot be impugned with certainty factor
genetic or environmental (Epstein-Bar), although recent studies highlight the presence
the viral genome in the tumor cells of the 20-30% of the investigated patients [1-3].
Hodgkin's disease onset is generally ganglia unicentric, and expansion
carried out for the purposes of physiological flow lymph lymph node adjacent to the territories.
Generalized forms are rare to begin with. Extending about marrow early
It is rare, this explaining the invasion without reaching the splenic lymph node stations
intermediate. In this way appear release extraganglionare (40%): MedullaryLung, liver, brain, skin, digestive.
 *
 received date: 21.02.2011
accepted: 24.04.2011 clinical cases Journal of Surgery, 2011, vol. 7, Nr. 2 [ISSN 1584-9341]
265
Malignant non-hodgkin lymphomas (LMNH) represents cellular proliferation
malignant monoclonal, taking as its starting point the lymphoid tissue. Are affected
B and T lymphocytes, with a spontaneous evolution and expression widely varied depending
Edition form.
Unlike the Hodgkin's disease at onset are affected several territories
lymph node involvement, and the territories of extraganglionare is more common (unica
showing in some cases). Extending LMNH is less orderly than BH.
Thus, it suggests a multicentric origin (not multicentric) and also a different way
dissemination. The natural evolution of the disease is shorter and, in the absence of treatment,
evolution is usually lethal [1, 2,4].
Histological diagnosis is strictly LMNH. REAL/Who Classification (Revised
Classification of European-American Limphoid Neoplasm) is based on the principles of
immunological lymphomas recognized by Lennert, Lukes and Collins. This includes
all lymphoid malignancies described her at the time of the occurrence.
Once the diagnosis is necessary to achieving a fixed balance sheet expansion as
more complete identification of all situsurilor the initial tumor, and prognosis
the orientation of the therapeutic attitude [5.6]. This is done according to the classification
Anatomic-clinical stadiale Cotswold for Hodgkin's disease, i.e. Ann Arbor for
LMNH.
Current therapeutic management carried out in a healing minor, but
with important opportunities to extend survival and improve quality
life [4.7].
PRESENTATION CASE
D.V. patient aged 35 years, urban, with personal history
physiological and pathological, presented in March 2007 cutaneous pruritus
generalized and decreasing weight gain (10 Kg in 4 months). In September 2007 it is addressed
the clinic of internal medicine accusing the intense pain in the upper abdominal floor with
posterior, accompanied by irradiation of appetite and nausea. Biologically it highlights
hiperamilazemie and hiperamilazurie, with increased values than that involuează in dynamic
Leukocytosis and hypercholesterolemia.
Imaging investigations (abdominal computer tomography examination) discloses
aspects of acute pancreatitis, and edematoasă form at the level of variability splenic describes a
sink with dimensions of 7/6/5, 5 cm, interpreted as the splenic hematoma/heart attack
the context of acute pancreatitis (rare complications), but cannot be excluded a
expansive solid.

The patient has received medical treatment, with favorable evolution
being released from the hospital with the recommendation to address the purpose of surgery service
reassessment and surgical treatment of splenic lymphocytes formation.
In October 2007 the patient is presented again for pain
hipocondrul, generalized pruritus, weight loss, without tangible adenopatii
superficially, with the internment of diagnosicul splenic tumor. Biologically it highlights
slightly anemic syndrome, inflammatory syndrome (GA = 10 600/mm3
; VSH 1 h = 61
mmHg; VSH 2 h = 106 mmHg). Chest x-ray shows no pathological aspects.
After preoperative preparation of the elective surgical intervention, exploring
intraoperative tumour centrosplenică highlighting a sink. Practice
Splenectomy with a favorable postoperative evolution.
Clinical cases Journal of Surgery, 2011, vol. 7, Nr. 2 [ISSN 1584-9341]
266
Histopathological diagnosis of surgical piece was Hodgkin's lymphoma with
nodulară fibrosis. Such a case is evidence of Hodgkin's disease with its unusual location
splenic. Examination by Immunohistochemistry using carried type 2 Hodgkin's disease shows sclerosis
nodulară.
In November 2007 the patient addresses Hematology Clinic for
adjuvant therapy. In order to establish the balance sheet expansion, the patient performs CT
thoraco-abdominal natively and with contrast substance which shows a level of lung
soft tissue mass with dimensions 5/2/2 cm. (antero-posterior/transverse/cranio-caudal)
located in the posterior lobe of apico-lower right and an image with nodulară
0.6 cm in diameter, well defined at the level of the middle lobe lateral segment
abdominal injuries as, without the risks.
These issues have allowed employment (according to anatomical-clinical Ann
Arbor-Cotswold) in Hodgkin's disease Amyotrophic type nodulară-E B (STAGE III Stage
III-ganglionară involvement on both sides of the diaphragmatic, invasion
an organ extralimfatic-lung, B-signs of evolution present: decreased
weight gain, night sweats, fever).
Initiating treatment chimioterapic ABVD-6 type cure: Adriablastina 40 mg;
Bleomycin 15 mg; Vincristina 2 mg; Dacarbazina 600 mg, with the phenomena of intolerance
digestive moderate.
In February 2008, in order to assess the response to chemotherapy, practice
Thoraco-abdominal CT maintaining pulmonary image described above. Exam
PET-CT SCANS performed in June 2008, confirms soft tissue mass located at the level of
pulmonului straight segment 6, dorsomedial, 3.2/2 cm, Avid for radiotrasor, without
other hipercaptare zones or signs of Hodgkin's disease in the rest of the body. Patient
It is directed by a service of thoracic surgery where they practice segmentectomie
typical segment Fowler, with atypical rezecție lob with postoperative evolution
favorable, with pulmonary reexpansionare. The results of such
the pathology of pulmonary parenchyma shows with infiltration of neoplastic LMNH with
large cell B, CD 20 +. Thus arises the dilemma: was the initial diagnosis of the disease
The splenic localization error with Hodgkin's, or we are before an extremely unusual case
Lymphoma Malignant mixed?

The patient has received medical treatment, with favorable evolution
being released from the hospital with the recommendation to address the purpose of surgery service
reassessment and surgical treatment of splenic lymphocytes formation.
In October 2007 the patient is presented again for pain
hipocondrul, generalized pruritus, weight loss, without tangible adenopatii
superficially, with the internment of diagnosicul splenic tumor. Biologically it highlights
slightly anemic syndrome, inflammatory syndrome (GA = 10 600/mm3
; VSH 1 h = 61
mmHg; VSH 2 h = 106 mmHg). Chest x-ray shows no pathological aspects.
After preoperative preparation of the elective surgical intervention, exploring
intraoperative tumour centrosplenică highlighting a sink. Practice
Splenectomy with a favorable postoperative evolution.
Clinical cases Journal of Surgery, 2011, vol. 7, Nr. 2 [ISSN 1584-9341]
266
Histopathological diagnosis of surgical piece was Hodgkin's lymphoma with
nodulară fibrosis. Such a case is evidence of Hodgkin's disease with its unusual location
splenic. Examination by Immunohistochemistry using carried type 2 Hodgkin's disease shows sclerosis
nodulară.
In November 2007 the patient addresses Hematology Clinic for
adjuvant therapy. In order to establish the balance sheet expansion, the patient performs CT
thoraco-abdominal natively and with contrast substance which shows a level of lung
soft tissue mass with dimensions 5/2/2 cm. (antero-posterior/transverse/cranio-caudal)
located in the posterior lobe of apico-lower right and an image with nodulară
0.6 cm in diameter, well defined at the level of the middle lobe lateral segment
abdominal injuries as, without the risks.
These issues have allowed employment (according to anatomical-clinical Ann
Arbor-Cotswold) in Hodgkin's disease Amyotrophic type nodulară-E B (STAGE III Stage
III-ganglionară involvement on both sides of the diaphragmatic, invasion
an organ extralimfatic-lung, B-signs of evolution present: decreased
weight gain, night sweats, fever).
Initiating treatment chimioterapic ABVD-6 type cure: Adriablastina 40 mg;
Bleomycin 15 mg; Vincristina 2 mg; Dacarbazina 600 mg, with the phenomena of intolerance
digestive moderate.
In February 2008, in order to assess the response to chemotherapy, practice
Thoraco-abdominal CT maintaining pulmonary image described above. Exam
PET-CT SCANS performed in June 2008, confirms soft tissue mass located at the level of
pulmonului straight segment 6, dorsomedial, 3.2/2 cm, Avid for radiotrasor, without
other hipercaptare zones or signs of Hodgkin's disease in the rest of the body. Patient
It is directed by a service of thoracic surgery where they practice segmentectomie
typical segment Fowler, with atypical rezecție lob with postoperative evolution
favorable, with pulmonary reexpansionare. The results of such
the pathology of pulmonary parenchyma shows with infiltration of neoplastic LMNH with
large cell B, CD 20 +. Thus arises the dilemma: was the initial diagnosis of the disease
The splenic localization error with Hodgkin's, or we are before an extremely unusual case
Lymphoma Malignant mixed?

Examination by Immunohistochemistry using the 2 pieces (spleen and formation
It confirms the presence of a pulmonary) Malignant lymphoma: Hodgkin's disease type joint sclerosis
nodulară with centrosplenică location and Diffuse large B cell lymfoma CD20 + with
pulmonary localization. The case became so extremely unusual in two respects:
Hodgkin's disease with poor subdiafragmatică and only has 2 different lymphomas Association
occurring at the same time or at a short interval of time between them.
After the surgery, the patient is receiving chemotherapy for LMNH line in
Hematology Clinic: 5 R-CHOP cures (Rituximab, Cyclophosphamide, Doxorubicin,
Adriamicin), Vincristin (Oncovin) and Prednisolone) and R-2 cures CEOP (Cyclophosphamide,
Epirubicin, Vincristin [Oncovin] and Prednisone). Evaluation of response to chemotherapy
It was done by thoracic CT-abdomen which showed the absence of adenopatiilor
Mediastinal and abdominal and pelvic adenopatiilor absence. But it was the objective
treatment achieved? Complete remission is obtained?
At one year after the initial diagnosis, the patient is completely asymptomatic
clinical and imaging reassessed. CT appearance is suggestive for infiltration limfomatoasă
of the duodenum, the first chance and adrenal gland jejunale left.
Clinical cases Journal of Surgery, 2011, vol. 7, Nr. 2 [ISSN 1584-9341]
267
Endoscopic biopsy confirms the diagnosis of duodenum LMNH II cell
big B, diffuse localized intraabdominală.
Subsequent developments becomes unfavourable, with the altered state and
modification of biological samples: hepatocitoliză, cholestasis and increasing LDH. Patient
2 polichimioterapie cures effected by the second line for LMNH, including:
Cisplatin, Gemzar, Mabthera. The disease situation is unfavorable to it being added
and the side effects of chemotherapy: sclero-jaundice skin, fatigue,
significant weight loss.
In February 2009, the patient is referred to the clinic of surgery, with a
General subject, jaundice, vomiting sclero-skin food, discreet
hepatomegalie, pain on palpation in hipocondrul with irradiation.
Biologically inflammatory syndrome is found, slightly anemic syndrome, syndrome
cholestasis and hepatocitoliză (FA = 296; TGP = 305; TGO = 112; BT = 13.64;
BD = 12.13; GGT = 1200).
Thoraco-abdominal CT scan shows tumor measurements at the level
the wall of the duodenum and of an adrenal gland anse jejunale, left; block
adenopatic in the root of the mesentery and rectum. Intraoperative surgical intervention, it
divides a duodenal tumor DII-locally advanced, with JIMMY invasion
liver cleansing of angle, good chance tumor of adrenal gland tumor jejunal derivation and
left side (fig. 1). We practice the cephalic pancreatectomy with preservation of the pylorus cefalică;
pancreatico-gastroanastomoză; hepatic segmental colectomy angle;
suprarenalectomie left; segmental enterectomie. The invasion of colon tumor
duodenal imposed necessity colectomia segmental liver cleansing of angle
(devascularizare iatrogenic).
After the surgery, the patient has benefited from the support and monitoring unit
Intensive care for 4 days. Day 9-a postoperative fistula occurred
colon anastomosis.
Fig. 1 positioning the level LMNH DII-MAT, the first good chance
jejunal derivation and adrenal gland
Clinical cases Journal of Surgery, 2011, vol. 7, Nr. 2 [ISSN 1584-9341]
268
It was the day of surgical reintervenit 10-Rd, was practiced when conducting
Ileostomy fistula and protection. Further evolution was slow, patient
externându-be cured surgically.
Histopathological examination of the song of rezecție the diagnosis of Lymphoma reconfirms:
malignant non Hodgkin's diffuse large B-cell. A particular aspect is the
CD marker 20, negativity that can be regarded as the consequence of treatment with
Rituximab.
A week at the hospital, the patient returned to the clinic for surgery showing
clinically palpator Occlusive syndrome and a tough, bulky mass in mezogastru/left flank.
Be important, highlighting anemic syndrome renal insufficiency syndrome
inflammatory.

Imaging, Ultrasound shows the peritoneum than ingroșat, up to 25
mm, palpable from left flank being represented by a mass of bowel loops
agglutinated, uretero-degree hydronephrosis kidney level right at them. Radiography
abdominal on empty shows lending levels horizontal small-bowel.
Surgical intervention in emergencies, exploring navigation highlighting the masses
bulky tumor-white yellow and increased consistency, disseminated to
the parietal peritoneum and visceral level. Gland tumor is practised with the release
chance of thin bowel injuries requiring volume wall closure plan
Cutaneous. Postoperative evolution is unfavourable, the patient was released from being able
compounded. Histological diagnosis was non-Hodgkin's malignant Lymphoma cells
Type B with high mitotic rate (in the context of the previous immunohistochemical tests).
DISCUSSION AND CONCLUSIONS
New therapeutic modalities have changed the development and prognosis of patients
diagnose with lymphomas. Prognostic factors obtained by statistical analysis
Multivariate analysis of numerous groups of patients in different specialized centres, play a role
important in the modulation of the therapeutic attitude to optimize therapeutic response
[8] recent therapeutic Protocols take into account a prognostic index of simple,
on the basis of clinical and biological data, thereby allowing the creation of an International Index
Prognosis (IPI) [8.9].
The treatment of lymphomas requires multidisciplinary collaboration, with the participation of
hemato-oncologists, surgeons and radioterapeuţilor [4, 7,10]. The main objective is
obtaining of remission, defined as the disappearance of any sign of illness from the territories
involved at the time of diagnosis [4, 7, 11]. It is considered that the treatment of
maintenance of the response is not important in the case of lymphomas (unlike
leukemias). Complete remission does not equate with cure, becoming essential
surveillance of patients for up to five years after remission through periodic checks at
they grow progressively intervals [1.7].
The surgeon's role in the management of malignant lymphomas becomes important in
setting sheet diagnosis (lymph node biopsies) [12.13], but especially in treatment,
with Visa via splenectomiilor curative in splenic lymphocytes lymphomas are strictly
localized [3.10] and rezecțiilor segmentation in lymphomas, digestive or palliative
extended forms, to prevent subsequent chemotherapy or perforațiile under the
stenozelor postradioterapie [1.14].
The particularity of this case presented consists in associating with unusual BH
localization only stage III subdiafragmatică-E and diffuse large cell LMNH type B-
CD20 +.
Clinical cases Journal of Surgery, 2011, vol. 7, Nr. 2 [ISSN 1584-9341]
269
According to IPI, the case presented is an aggregation of prognostic factors
negative: age under 40 years of age, the presence of clinical signs of evolution, the presence of
localizations extralimfatice (lung, digestive tube, adrenal), anatomical-clinical stage
STAGE IV (the extended form of supra-and subdiafragmatic), histopathological type-LMNH with
large cell type B is classified as having intermediate malignancy. These issues have
unfavourable trends in fulminant competed and rapid remission after recăderea
initial.