A 61-year-old man without any B-type symptoms complained of an enlarging mass in the abdomen for one month. Physical examination revealed a firm, rubbery swollen lymph nodes in the bilateral neck and axilla, of which the biggest one was about 4 × 2 cm. Furthermore, a 10 × 10 cm abdominal mass could be touched in the hypogastric region. He does not have any chronic diseases, and his family has no related genetic medical history. Complete blood count and other serum chemistries were normal except for LDH levels and serum CA125 concentration which were as high as 343U/Land 117.8 U/ml. Computed tomography (CT) of the chest, abdomen, and pelvis demonstrated multiple enlarged lymph nodes, the abdominal mass, and the thickening wall of the gastric antrum (Fig. 1A). Immunohistochemistry (IHC) of cervical lymph node biopsy showed strongly stained with CD20, CD79a, CD19, CD5, Bcl-2 and CyclinD1, which indicated mantle cell lymphoma (MCL). The Levels of Ki67 expression in tumors is 20%. Meanwhile, a bulge under the mucosa of the stomach was found by gastroscope and intestinal lymphoma was discovered by colonoscopy (Fig. 2A, B, C). Microscopically, a large number of small lymphocytes infiltrated in the intestinal mucosa of the ileocecal area. IHC revealed CD20(+), CyclinD1(+), CD23(-), Bcl-6 (-) and Ki-67 (30%). MCL can be confirmed histopathologically. The IHC of the bone marrow biopsy demonstrated that the bone marrow cells were partially positive for CD20, CD79a and CyclinD1. In summary, we also found evidence of MCL involvement in both the bone marrow and ileocecal. The patient was diagnosed with MCL (Ann Arbor stage IV, International Prognostic Index (IPI) score of 4), with bone marrow and alimentary tract infiltration. In order to show the patient’s immunohistochemical pictures, we went to the department of pathology in our hospital to choose the pathological slides. Unfortunately, they have deteriorated so we did not show them in this report.
Because of the patient’s limited financial resources, he refused to use rituximab to treat the disease. After one cycle chemotherapy regimen of FCD (fludarabine 50 mg, d1-3 + cyclophosphamide 400 g, d1-3 + dexamethasone 20 mg, d1-5), red rashes and blisters came out on the patient's right lower extremity, with no pain and itching (Fig. 3A). The skin biopsy of right thigh revealed lymphoid hyperplastic lesions. IHC revealed that the skin cells were strongly positive for CD20, CD79a, CD10, Bcl-2 and Bcl-6 and negative for CyclinD1, CD3, CD21, CD23 and SOX-II, the expression of Ki-67(90%). To our surprise, diagnosis of diffuse large B-cell lymphoma, leg type, non-GCB was confirmed. After four cycles of chemotherapy regimen of FCD, the patient had no obvious benefit. We recommend that the patient be injected with rituximab, but he refused to follow our recommendation to use rituximab. Then two cycles of chemotherapy with CHOPE regimen (Cyclophosphamide 1.3 g, d1 + Pirarubicin 90 mg, d1 + Vinorelbine 40 mg, d1 + Dexamethasone 15 mg, d1-5 + Etoposide 100 mg, d1-3) and five cycles of TGDP regimen (Thalidomide 100 mg qd + Gemcitabine 1.8 g d1, 8 + Cisplatin 130 mg d1 + Dexamethasone 40 mg d1-4) were applied. The only side-effect during chemotherapy was neutropenia, which could be alleviated after treatment. After 8 months of chemotherapy, CT review showed swollen lymph nodes and retroperitoneal masses are significantly shrunk than before (Fig. 2B). An electronic colonoscopy review suggested a microscopic bulge of the mucosa (Fig. 2D, E, F). After six cycles of TGDP regimen chemotherapy, some of the rashes were dissipated. Meanwhile, no obvious side effects and new rash were observed, and the superficial lymph nodes all over the body were significantly shrunk (Fig. 3B). The partial remission (PR) was achieved because we did not see tumor performance through gastrointestinal endoscopy. The patient has been remaining asymptomatic and clinically stable until now.