Follicular lymphoma transforming to DLBCL and reverting back to follicular lymphoma at relapse\u2014a case report

M C Suresh Babu,A H Rudresha,C S Premalatha,K N Lokesh,L K Rajeev,Khandare Pravin Ashok,Linu Abraham Jacob,Saldanha Smitha,M N Suma,D Lokanatha,Antony George Francis Thottian,Syed Adil Hassan

doi:10.1186/s43046-020-00035-3

Abstract

BackgroundTransformation of low-grade follicular lymphoma to high-grade diffuse large B cell lymphoma (DLBCL) is known. However, the opposite is not commonly reported. In this report, we present a case of follicular lymphoma that underwent transformation to DLBCL. Three years after treatment for histologic transformation, the patient presented again with low-grade follicular lymphoma at the same site which is unusual in the natural history of follicular lymphoma.Case presentationA 50-year-old female patient presented to us with complaints of slowly progressing swelling in the neck on the left side for a duration of 1 year. Past history of the patient revealed a diagnosis of follicular lymphoma in 2004 for which the patient had taken prednisolone and chlorambucil. Details of staging were not available with the patient. After a complete work-up, she was diagnosed as DLBCL, stage IIIE. She was treated with 6 cycles of CHOP regimen. She had very good response to chemotherapy. However, she defaulted and was lost to follow-up. She presented again after 3 years with history of painless progressive swelling in the right side of the neck for the last 1 year. Examination revealed cervical lymph nodes and ascites. This time, a repeat biopsy and immunohistochemistry was suggestive of follicular lymphoma. In view of significant ascites, she was started on chemotherapy with CVP regimen. After 6 cycles, she has good partial response and resolution of ascites. She is currently on follow-up.ConclusionsWe have presented a case of FL that has transformed to DLBCL after 10 years of diagnosis. After HT, she was treated with CHOP chemotherapy and the patient relapsed again after 3 years with follicular lymphoma histology. This case highlights the unique and varied natural history of follicular lymphoma that may be attributed to different subclones of malignant cells that may have arisen from a common progenitor FL cell and differential effect of chemotherapy on these subclones.

Highlights

Transformation of low-grade follicular lymphoma to high-grade diffuse large B cell lymphoma (DLBCL) is known
We describe a case of Follicular lymphoma (FL) that transformed to DLBCL 10 years after diagnosis and post-treatment for Histologic transformation (HT) relapsing again as FL
A bone marrow aspiration and biopsy was done, and it showed only normal marrow elements. She was staged as diffuse large B cell lymphoma, activated B cell subtype stage IIIE (Cotswold modification of Ann Arbor staging [9]) with International Prognostic Index (IPI) [10] score of 2/5

Summary

Conclusions

We have presented a case of FL that has transformed to DLBCL after 10 years of diagnosis. After HT, she was treated with CHOP chemotherapy and the patient relapsed again after 3 years with follicular lymphoma histology. This case highlights the unique and varied natural history of follicular lymphoma that may be attributed to different subclones of malignant cells that may have arisen from a common progenitor FL cell and differential effect of chemotherapy on these subclones

Background

Discussion

Findings

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