Intrapleural Rituximab (R) Is Effective in Refractory Pleural Effusion Due to Non- Hodgkin's Lymphoma

Abstract

We report the case of a 65 years old woman with a NHL, CD20 +, BCL-2 negative, Grade III, CS: IVBX, FLIPI High Risk, diagnosed on September 2005. The patient was treated with several chemotherapy regimens (CHOP, chlorambucil/prednisone, cyclophosphamide/prednisone), while on treatment a large pleural effusion was found on a chest X-ray. On pleural fluid cytology we observed numerous abnormal lymphocytes. We did repeated thoracocentesis without success, finally a pleural tube was inserted and intrapleural bleomycin instilled, again with no success (Table 1). Six weeks later, after signing informed consent, we administered 50 mg of intrapleural R (50 mg in 50 cc of SS 0.9%) without immediate or delayed adverse events. On day +4 a new chest X-ray showed marked improvement. We planned to repeat the dose every week × 4, unfortunately the patient could not afford it. After seven months the patient is asymptomatic and without recurrence of the pleural effusion.Table 1Date (2007)Fluid drained (ml)ActionSeptember 12DyspneaSeptember 211,500October 41,500October 6570October 8400October 1220Bleomycin 10 UNovember 6Dyspnea/1,300November 940November 16400November 17200November 20100Rituximab 50 mgDiscussion Although the pharmacology of IV R is welll known, there is scarce information about dosage, penetration into the tissues and efficacy of intracavitary R. It is likely that the intrapleural instillation of R was effective in the control of this complication in a definitive way, without adverse effects, Our case supports the results reported by Schmidt et al (Table 2). The mechanism of action at the local site is not known, but it could be the same as described with the systemic use. Pleural effusion secondary to refractory lymphoma is a rare complication, we propose the integration of an international registry of this cases to study the pharmacokinetics, pharmacodynamics, efficacy and safety of intrapleural rituximab.Table 2FeaturesOur patientSchmidt PatientAgeage 65 years57 yearsDiagnosisFollicular NHL, Grado IILymphoplasmacytic NHLNo. Previous Therapy31Effusion therapyThoracocentesis and drainage by pleurostomyThoracocentesisRituximab Dose50mg, single dose50mg day 1 200mg day 2 400mg day 3Time to Response4 days3 days