Case History

The patient is 17 years old female with diagnosis of Hodgkin’s lymphoma Nodular sclerosis including syncytial pattern Since Sep.17 2008 . Bone marrow aspiration was not involved. CT Scan showed mediastinal involvement, pulmonary involvement and questionable spleen involvement. Bone scan was negative. The patient had stage IV disease without B symptom. She was  treated with 12 courses of ABVD (DTIC 600 mgs , Bleomycin  15 mgs ,Vinblastin 10 mgs and Doxorubicine 40 mgs ) according to her BSA every  2 weeks for 12 courses. She had all tumor resolved but Gallium scan showed mediastinal and right neck area involvement. Radiotherapy consultation was done and remaining involved area received radiotherapy. The patient was free of symptom. She did not have evidence of remaining disease on April 2009.

She did not have any other ct scan but LDH and Beta macroglobulin and sedimentation rate all were normal.

A year after completion of radiotherapy she again had Mediastinal mass. A biopsy of Para tracheal nodes showed recurrence in this area and PET was positive in nasopharyngeal area and mediastinum.

The patient was given Etoposide 180 mg day 1- 2- 3 Carboplatin 650 mg day 3 holoxan 8 gms day 2  24 hours infusion  and GCSF in an attempt to give autologus transplantation after remission. Transplantation was hampered by many interruption of transplantation service. So Transplantation was referred to London. As a precaution for maintaining the remission the patient received   2 course of COPP (Cyclophosphamide 1000 mg 1-8, vincristine 2 mgs day 1and 8, procarbazine 150 mgs for 14 days for every 28 days treatment. Dose adjustment was done according to her WBC counts.

A PET Scan performed was negative after these treatment so she has what is described in the literature as a late relapse (with a previous remission lasting more than 12 months) and the
outlook for these patients seems to be very good with this approach.

But since she relapsed in the previous radiotherapy field, autologus transplant was suggested and performed. She was admitted for stem cell transplantation on 4^th August for high dose chemotherapy with BCNU, Etoposide, Cytarabine and Melphalan (BEAM) under the London Clinic Haematology team.  She had 1.25 x 106 CD 34 cells per kg of body weight harvested and these were infused on the 9^th August.

She suffered from significant mucositis and diarrhea and had a febrile episode on the 12^th August.  This was treated with Tazocin and Gentamycin but unfortunately the fever did not resolve and second line antibiotics with Teicoplanin and Meropenem were instituted on the 14^th August.

By day plus 7 following the autologous stem cell transplant her mucositis was resolving and she had become afebrile.

On the 22^nd August (Day plus 12) she showed signs of early myeloid engraftment, she was discharged on the 24^th August with the following blood count;

At the time of her final review on the 31^st August her results were:

She was afebrile and her line was removed and she was discharged for follow up in Iran on the following medications:

-           Lansoprazole 30 mg daily

-          Fluconazole 100 mg daily

-          Acyclovir 200 mg qds for 6 months

-          Co-Trimoxazole 960 mg (Mon, Wed and Friday) for 6 months

Unless she has any gastrointestinal upset she could stop taking Lansoprazole after one month, since she will no longer be at risk of fungal infection her Fluconazole could also stop in one month.

I would recommend she have  a chest X-ray and full blood count, liver function tests and thyroid function including TSH in one month and I would be grateful if she could have a post-evaluation PET scan in mid to late December 2011.

To be continued