Case report – Patient 2:
A 52-year-old male patient ex-smoker since 3 months (cumulative 30
pack/years) was admitted to our hospital in June 2020 presenting with
dry cough since January 2020 and restricted physical resilience
including dyspnea since April 2020. He denied B-symptoms. The laboratory
evaluation revealed an isolated mild anemia with hemoglobin value of
11.4 g/dL (range, 13.5-17.5 g/dl) and an elevated C-reactive protein
(CRP) of 86.45 mg/L (range, <5 mg/l. Chest X-ray showed
bilateral infiltrates, particularly in the left lower lung. An
antibiotic therapy with piperacillin/tazobactam was initiated with a
decline of the CRP to 16.48 mg/L after 10 days of therapy. The first
bronchoscopy with transbronchial biopsy revealed a highly florid and
erosive inflammation with high-grade regenerative hyperplasia of the
epithelium, which was CD20 and CD3 positive. The molecular clonality
analysis detected immunoglobulin gene rearrangements of IGHA, IGHB and
IGHC in 41, 278 and 146 base pairs, respectively. The subsequent CT scan
showed still existing bi-pulmonary solid infiltrates in all lobes of the
lung (Figure 3, Panels A and C). The suspicion of a BALT lymphoma was
substantiated by further bronchoscopy with histopathology analysis
showing a sub-mucosal stroma with B-cell containing infiltrates without
a specific immunophenotype. A CT-based pulmonary biopsy confirmed a CD20
positive B-cell population without co-expression of CD5, BCL-2, CD10 or
CD23 (Figure 4). Based on these results staging analysis containing bone
marrow evaluation and extended CT scan were performed. Bone marrow
histology showed no lymphatic infiltration. CT scan showed paraaortic,
iliac and inguinal affected lymph nodes resulting in an Ann Arbor
stadium IIIA.
A combined immunochemotherapy containing rituximab (375
mg/m2, day 0) and bendamustine (90
mg/m2, day 1-2) was initiated. The first cycle was
well tolerated under standard supportive care without any serious
adverse events or allergic reactions. During the hospitalization, the
patient developed hypoxia at rest. Thus, he received oxygen up to 4 L/h
via nose prongs. After the first cycle of immunochemotherapy, the
unproductive cough improved and the oxygen therapy could be stopped. The
immunochemotherapy was repeated every four weeks for in total six
cycles; CT stagings were performed after three and six cycles. The
intermediate CT scan showed no significant changes of the BALT lymphoma
and the affected lymph nodes as compared to diagnosis. However, the
clinical condition improved significantly. Therefore, the
immunochemotherapy was continued. After six cycles a native CT scan was
performed showing a reduction of the BALT lymphoma and normalization of
the lymph nodes. Unfortunately, the patient denied a positron emission
tomography–CT. According to the CT scan at least a partial remission
(PR) was achieved (Figure 3, Panels B and D). Thus, maintenance therapy
with rituximab is planned.