Mycophenolate mofetil/prednisone/tacrolimus
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Recurrence of anaplastic large-cell lymphoma: case report A 51-year-old woman developed recurrence of anaplastic large-cell lymphoma (ALCL) after orthotopic heart transplantation, during immunosuppressive drug therapy with mycophenolate mofetil, prednisone and tacrolimus [routes, dosages and time to reactions onset not stated]. The woman, who was diagnosed with systolic heart failure 6 months prior, presented with fulminant cardiogenic shock, for which she required an intra-aortic balloon pump insertion. Echocardiography demonstrated severe biventricular failure with declining left ventricular systolic function. Biopsy of her right ventricular septum demonstrated lymphocytic myocarditis. She received treatment with unspecified corticosteroids, but she remained dependant on the mechanical support. Hence, heart transplant candidacy evaluation was expedited. Four weeks later, she underwent orthotopic heart transplantation (OHT). Based on further histological and immunohistochemical staining, she was diagnosed with anaplastic large-cell lymphoma (ALK-negative)-related heart failure. Thereafter, her management was discussed, and a decision was made to closely monitor her without any additional lymphoma therapy. On post-operative day 18, endomyocardial biopsy was performed, which showed no rejection. She was discharged on immunosuppressive therapy with tacrolimus, mycophenolate mofetil and prednisone. Her routine surveillance endomyocardial biopsies were unremarkable, until 9 months after the OHT, when biopsy revealed atypical lymphoid cells. Fluorescence in situ hybridisation (FISH) testing confirmed MYC duplication/low level amplification, which was indicative of disease relapse. The woman was treated with brentuximab. She completed six cycles of brentuximab, following which positron emission tomography (PET)/CT scan showed complete remission. Seven months later, she was admitted with the clinical symptoms similar to that of her original presentation. Serial endomyocardial biopsies revealed an increase in component of large lymphocytes in the biopsied sample. MYC immunohistochemistry was positive, and FISH showed duplication/low-level amplification, suggestive of a second relapse of the disease. She received salvage radiation therapy for 5 weeks. Five days after completion of radiation therapy, she was admitted due to fatigue, dysuria and fever. CT scan of the abdomen, chest and pelvis showed large loculated right pleural effusion, development of bulky diffuse lymphadenopathy and diffuse paraseptal nodular thickening, which raised a concern for metastatic involvement. PET scan demonstrated an increase in the activity of the left supraclavicular, gastrohepatic lymph node, mediastinal and the posterior wall of the lesser curvature and the posterior wall of the stomach. Cytology of the biopsied sample from the pleural effusion and stomach demonstrated diffuse involvement of relapsed ALCL. Thereafter, she developed worsening renal function, which was further complicated by hypercalcaemia of malignancy and tumour lysis
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