Synchronous Hodgkin Lymphoma and Diffuse Large B Cell Lymphoma: A Rare Coexistence
Kayla Kendric*; Gaurav Goyal, MBBS and Gabriel Caponetti, MD, Creighton University School of Medicine, Omaha, NE
Keywords: Diffuse Large B Cell Lymphoma, Hodgkin Lymphoma and Synchronous Lymphoma
Case Presentation: A 79-year-old Caucasian female presented with recurrent abdominal pain. Her past medical history was significant for low-grade adenocarcinoma of the rectum and sigmoid colon that was resected one year ago. Four months prior to presentation, she was found to have an abscess in the mesentery of terminal ileum and appendicitis for which she underwent abscess drainage and appendectomy respectively. The patient continued to have recurrent right lower quadrant pain since that hospitalization. A computed tomography (CT) scan of the abdomen was done that showed a small bowel obstruction secondary to abnormal tissue extending from the terminal ileum. She underwent laparoscopic ileo-cecal resection with primary anastomosis, and a mesenteric lymph node was simultaneously removed. On histopathological analysis, the terminal ileum mass showed diffuse large B cell lymphoma (DLBCL), while the mesenteric lymph node revealed classic Hodgkin lymphoma (CHL) with mixed cellularity. Currently, discussions are under way to establish further plan of care for the patient.
Discussion: The simultaneous occurrence of Hodgkin and non-Hodgkin lymphoma is uncommon, with a small number of reported cases. These two lymphomas may present metachronously, occurng at different times in the same patient, or synchronously. The synchronous lymphomas may be composite, meaning that two different lymphomas occur in the same anatomical location. The majority of reported cases demonstrate a presentation of nodular lymphocytic predominant HL (NLPHL) followed by DLBCL. Fewer publications report metachronous or synchronous CHL and DLBCL, with nodular sclerosis CHL being the most common reported subtype. Only a few of cases of metachronous presentation of mixed cellularity CHL and DLBCL have been reported in the literature so far, and after a thorough literature search we found that this is the first reported case of non-composite synchronous lymphomas consisting of mixed cellularity CHL and DLBCL involving two closely related anatomic sites. Many of the reported cases aimed to discuss the clonal relationship of the different types of neoplastic cells. Three theories attempt to explain the association between CHL and non-Hodgkin lymphoma; one, this is the result of a coincidental occurrence derived from two unrelated lymphoid elements; two, there was a progression of HL to DLBCL; and three, these lymphomas resulted from a common precursor cell. Some studies demonstrated a lack of clonal relationship between the two types of lymphomas, while others suggested that the lymphomas may stem from a common precursor cell. In the case discussed herein, an identical IgH gene rearrangement was found in both the classical HL and DLBCL cells, thereby suggesting a clonal relationship between the two.
Conclusions: In this case we discussed a patient with non-composite synchronous lymphoma consisting of mixed cellularity classical HL and DLBCL involving two closely related anatomic sites. To the best of our knowledge, this is the first reported case with such unique presentation. More studies are needed to provide insight into the clonal relationship between these two entities, which will perhaps help in better prognostication and treatment of such patients.
Kendric K, Goyal G, Caponetti G. Synchronous Hodgkin Lymphoma and Diffuse Large B Cell Lymphoma: A Rare Coexistence. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 605. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/synchronous-hodgkin-lymphoma-and-diffuse-large-b-cell-lymphoma-a-rare-coexistence/. Accessed July 19, 2019.