Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor

Transcription

1 Precursor T-Cell Lymphoblastic Lymphoma of the Mediastinum Post Chemotherapy with Disease Progression Post Radiotherapy and Salvage Chemotherapy with Residual Mediastinum Masses Post Re-Irradiation with Pericardial Effusion and Pleural Effusion: the Treatment Consideration of Further Care Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of precursor T-cell lymphoblastic lymphoma of the mediastinum post chemotherapy with near complete response then rapid tumor re-growth post radiotherapy and salvage chemotherapy with residual mediastinum disease post re-irradiation with significant pericardial effusion and pleural effusion; to discuss the treatment consideration of further care Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 14 year-old male patient, 徐 OO, was referred to us for radiotherapy assessment of refractory mediastinum T-cell lymphoma. S: 1. In 2008/08, a huge mediastinum mass was found. 2. In 2008/09, tumor biopsy was done and pathology reported precursor T-lymphoblastic lymphoma. Definitive chemotherapy was done and good response was found. 3. In 2008/12, however, severe dry cough was found and chest CT showed tumor re-growth to near the original huge size. 4. In 2009/01, RT (2009/01, 1950 cgy in 13 fractions) was given, and partial response after RT was noted. Then, salvage chemotherapy was given. 5. In 2009/03, gross residual tumor mass (3-4 cm) was noted by a follow-up CT. 6. During 2009/ /04, incomplete re-irradiation with 2700 cgy in 15 fractions was given to the residual mediastinum mass. 7. In 2009/04, he suffered from dyspnea and was sent to our ER for help. A following CT reported still residual mediastinum mass with significant peri-cardial effusion and pleural effusion. Histories: NDKA O: 1. General Condition: ECOG: 1-2, sitting on a wheelchair, mild dyspnea pattern 2. PE: (1). HEENT & SCF: no neck LNs, significant face and neck edema due to steroid effect was noted; (2). CHE: mild decrease breathing sound, right; (3). Others: neg. 3. ***Pathology in 2008/09, mediastinum tumor biopsy: precursor T-lymphoblastic lymphoma 4. Images: (1). Chest CT in 2009/04: still residual mediastinum mass with significant peri-cardial effusion and pleural effusion; pending formal report.

2 Key Image(s): Fig /04, Chest CT Fig /04, Chest CT Fig /04, Chest CT

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: Ann Arbor stage IB (2008/08, 13-cm bulky tumor); Ann Arbor r-stage IB (2008/12, 10-cm re-growth tumor); Ann Arbor rr-stage IB (2009/03, 4-5 cm) Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no pathology stage can be defined in this case. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Precursor T-lymphoblastic lymphoma of the mediastinum, predominate on the anterior-upper mediastinum, Ann Arbor stage IB (2008/08, 13-cm bulky tumor), post definitive chemotherapy with near complete response (2008/10), with rapid disease progression (2008/12), Ann Arbor r-stage IB (2008/12, 10-cm re-growth tumor), post RT (2009/01, 1950 cgy in 13 fractions to the mediastinum mass), with partial response, post incomplete salvage chemotherapy, with gross residual tumor mass (2009/03), Ann Arbor rr-stage IB (2009/03, 4-5 cm), post re-irradiation (2009/04, 2700 cgy in 15 fractions, mediastinum mass), with disease progression (2009/04, peri-cardial effusion and pleural effusion) Q5: What is your Oncology Plan for this case? A5: Suggest peri-cardial and pleural effusion tapping for symptoms alleviation and cytology studies; suggest further salvage chemotherapy or bone marrow transplantation if indicated; no definitive indication for radiotherapy now; it may be a relative contra-indication for RT to the mediastinum region in this case due to prior high dose of RT in this region. Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: no definitive indication for radiotherapy now; it may be a relative contra-indication for RT to the mediastinum region in this case due to prior high dose of RT in this region. (2). Goal: NA (3). Target & Volume: NA (4). Technique: NA (5). Dose & Fractionation: NA Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/04/22

5 Key Image(s): (with marked) Fig /04, Chest CT Fig. 1. Residual lymphoma mass over the pre-vascular space with size more than 5 cm (as the short white arrows); right pleural effusion (as the long white arrow) and minimal left pleural effusion were noted (as the white arrow head). Fig /04, Chest CT Fig. 2. Significant right pleural effusion was noted (as the long white arrow); peri-cardial effusion was also found (as the short white arrow); minimal left pleural effusion was seen (as the white arrow head). Fig /04, Chest CT Fig. 3. The caudal portion of the heart/peri-cardium showed significant peri-cardial effusion (as the short white arrows); significant pleural effusion was also noted (as the long white arrow); minimal left pleural effusion was seen (as the white arrow head).