A 57-year-old Chinese woman (155 cm, 60 kg, 1.58 m2) presented with lumbosacral/low extremity pain for 2 months. The patient did not have any history of lumbar disk herniation or fracture. Her family history was also negative. Before presenting to our hospital, she had received treatment in several institutions. Initially, she had visited a local hospital and had received acupuncture and moxibustion, which showed no efficiency. A lumbar MRI revealed an abnormal signal in L4, L5, and S1, accompanied by soft tissue shadows in the paravertebral and the spinal canal. Previously, in other hospitals, the patient had received empirical anti-tuberculosis treatment for 4 weeks, which showed poor efficiency. She developed a new symptom of cauda equina syndrome (CES) later. To her relieve the pain and determine the pathology, we performed disk decompression and a biopsy of paralumbar soft tissue. We carried out immunohistochemistry tests to determine the pathology, which indicated that tumor cells were positive for LCA, CD20, CD79, CD10, and BCL-2; were negative for CD3, CD56, MUM-1, CD138, and CD99; and showed a Ki-67 proliferation index of greater than 80%, which is a characteristic of DLBCL. The diagnosis was reconfirmed by the pathologists in our institution. Bone marrow aspiration came out negative and the echocardiogram appeared normal.
Initially, the patient was administered one cycle of the CHOP regimen (cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 2 mg, day 1, and prednisone 100 mg, days 1-5, administered every 21 days) and six cycles of the R-CHOP regimen (rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, vincristine 2 mg, day 1, and prednisone 100 mg, days 1-5, administered every 21 days). The average relative dose intensity (RDI) was 100%. One month after the last chemotherapy, lumbosacral pain recurred. 18F-FDG PET/CT showed diffuse hypermetabolic foci in C2, C3, and C5 (SUVmax 13.5) and T11-L2 (SUVmax17.8). Considering the response evaluation of the R-CHOP regimen showed progressive disease (PD), local doctors changed one course of the MA regimen (methotrexate 1 g/m2, day 1 and cytarabine 3 g/m2, 12 h apart, days 2-3, administered every 21 days) and two courses of DHAP regimens (dexamethasone 40 mg, days 1-4, cisplatin 100 mg/m2, day 1, and high-dose cytarabine 2 g/m2, 12 h apart, day 2, administered every 21 days), both of which were unsuccessful.
Then, the patient presented to our department. She suffered from severe bone pain and developed paralysis of both lower limbs. Her laboratory tests were normal. A spine MRI revealed an abnormal signal in T8 and L5, and a hip MRI revealed an abnormal signal in the femoral head (Figure 1). We treated her with adjuvant radiotherapy, with a total dose of 30 Gy in 2.0 Gy daily. However, the bone pain lingered. Given that the involved sites in this case were mainly bone lesions and that multi-line chemotherapy including the R-CHOP regimen showed low efficiency, the patient was given repeated infusions of HD-MTX (MTX 3.2 g/m2, iv drip, day 1, administered every 21 days), followed by leucovorin (LV) rescue administration. The patient had an adverse reaction of neutropenic fever after receiving HD-MTX chemotherapy, which improved with symptomatic treatment. After 10 courses of HD-MTX treatment (six cycles of induced chemotherapy and four cycles of maintenance chemotherapy), the patient achieved complete metabolic remission, as confirmed by 18F-FDG PET/CT, and pain lessened. No therapy was applied to the patient after 2 August 2013. The efficacy evaluation showed complete remission during later follow-ups (Figure 2). During the last follow-up (February 2022), the patient showed a high quality of life, was free from pain, and walked smoothly. The treatment process of this case is shown in Figure 3.