S2647 An Unfortunate Association: Diffuse Large B-Cell Lymphoma With Chronic Hepatitis C

Abstract

INTRODUCTION: Hepatitis C virus (HCV) is among the most common chronic viral infections, with potential sequelae of cirrhosis and hepatocellular carcinoma. In addition to hepatic complications, there are well established links from multiple studies between HCV and B-cell malignancies. While direct-acting antiviral (DAA) therapy is effective inducing regression in low-grade B-cell malignancies, for high-grade diffuse large B-cell lymphoma (DLBCL) associated with HCV treatment includes chemotherapy in addition to DAA therapy. Here we present a case of a newly diagnosed DLBCL in the setting of chronic HCV. CASE DESCRIPTION/METHODS: A 44 y.o male with a PMH of chronic HCV, h/o renal transplant, and CKD 3 presented with complaints of R-sided posterior chest mass which grew suddenly over 3 weeks. Patient reported a renal transplant approximately 20 years ago for congenital vesicoureteral reflux from a living, non-related donor and was on immunosuppression with prednisone, azathioprine, and cyclosporine. CT chest showed a large, irregular soft tissue mass in the posterior right chest wall encasing the right 11th rib with several enlarged mediastinal and periportal lymph nodes. He underwent a core biopsy of the mass which showed a new diagnosis of DLBCL, double expressor subtype with double/triple hit negative by FISH. Outpatient HCV workup showed genotype 4 with RNA levels 4.4 million; U/S liver showed no signs of cirrhosis. Patient was followed by oncology outpatient with initial labs showing concern for spontaneous tumor lysis syndrome and advised to return to ER. On presentation to ER, patient’s labs were unremarkable except for mild AKI on CKD3 which eventually resolved and was started on dose-adjusted R-CHOP therapy. He was discharged with plans to start DAA therapy with Epclusa and close follow-up with GI to monitor for sustained virological response. DISCUSSION: It’s hypothesized HCV plays a role in sustained B-cell activation and prevention of apoptosis by chronic antigenic stimulus rather than direct oncogenic effect, thereby predisposing to B-cell lymphoid malignancies. Treatment with DAAs stops persistent activation of B-cell lymphocytes. In addition, the combination of DAAs with chemotherapy including rituximab is well-tolerated without pharmacological interactions or significant hepatotoxicity, especially in patients without abnormal LFTs at baseline. Finally, initiating DAAs after chemotherapy in these cases helps to prevent recurrence of DLBCL once SVR is achieved.Figure 1.: CT Scan of R-posterior Rib Mass 60 mm × 64 mm.Figure 2.: Rib Mass Biopsy DLBCL 100X H&E.Figure 3.: Rib Mass Biopsy DLBCL 200X Ki-67 IHC.