67-year-old male, in early-to-mid 2023 with an enlarging testicular mass in combination with palpable left supraclavicular lymphadenopathy. CT imaging then demonstrated a 2cm RUL pulmonary nodule, a smaller LLL nodule, a destructive left sacral lesion reaching 6cm and a icm peri-pancreatic lymph node. A biopsy of a representative left supraclavicular node diagnosed with Stage IV Diffuse Large B-Cell Lymphoma (DLBCL) on May 4, 2023.
Stage IV with extranodal involvement including:Testes, Skin, Lungs, Retroperitoneum, Multiple lymph node regions (inguinal, iliac, hilar, supraclavicular) IPI Score: High-intermediate (3 points) CD20-positive, meaning responsive to anti-CD20 immunotherapy (like rituximab)
Initial Treatment: IP received 6 cycles of R-CHOP, a standard first-line regimen for DLBCL, completed in September 2023.
He showed excellent response initially with complete metabolic remission on post-treatment PET scan.
Relapse: A PET/CT in December 2023 revealed new metabolically active disease in: Left retroperitoneal nodes, Inguinal nodes, Possibly the left testicle, Biopsy confirmed recurrent DLBCL.
Note from oncology re Treatment Plan Post-Relapse:
“Compelling options for disease which has progressed at such a short interval post-chemotherapy include the cellular therapies: bispecific T-cell engaging agents versus a CAR-T cell based approach. Regarding the autologous CAR-T approach, significant additional time would be needed for line placement, steroid washout followed byT-cell collection, and then finally the CAR-T manufacturing process (if viable), and in his case his disease appears to be progressing relatively rapidly. Either BiTE therapy, which would necessitate frequent visits to and from the clinic for a prolonged duration of treatment/ serial dosing, or allogeneic (i.e. "off-the-shelf") CAR-T stand out as acceptable and appealing options. The pros and cons of each approach were discussed with the patient, who favors being screened for our caribou (ANTLER) trial -- which may hopefully culminate in him receiving an allogeneic CAR-T product at a shorter duration than would be the case with autologous CAR-T. In this case, any native T-cell compromise from prior chemotherapy and/ or recent prolonged steroid therapy would not be an issue.”
Bone marrow biopsy in April 2024.
Prior to any further treatment, died in May 2024.
Genetic Testing in This Case Attached.
The family was told that other options and/or bone marrow biopsy was possibly indicated earlier for possible different outcome.
Thank you in advance for any opinion on this.
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Do you believe there might have been medical error?
He was only treated with R-CHOP. This is high-risk DLBCL, which should have been treated with R-CHOP along with high-dose methotrexate for CNS prophylaxis with alternate cycles. Also now data is replacing RCHOP with Pola-R-CHP. But high-dose methotrexate not being given is a deviation from SOC. Also Not giving radiation treatment to the affected testis is a deviation of SOC.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
he was inadequately treated only with R-CHOP. He recurred, as this is a high-risk DLBCL. Also, there was a delay in starting his bispecific or CAR-T therapy. If there was a delay in getting CAR-T, he should have gotten R-ICE in preparation for transplant.
What makes you a good expert for this case?
I have testified on the defense side in 8 cases and done 5 depositions.
How often do you encounter cases similar to this one in your practice?
this is a rare case. I have treated testicular DLBCL.
Do you believe there might have been medical error?
This patient clearly had a very aggressive DLBCL and relapse within 3 months of completing treatments shows that. In the past patients with testicular involvement from DLBCL were considered high risk and we would do CNS prophylaxis however the study published in 2023 outlined that it was not always necessary. What is concerning is that the pet scan in Dec 2023 showed progression of disease and the attached lymph node biopsy reports are from Feb 2024. Bone marrow was apparently suggested in April and he did not get any treatment until May 2024 when he passed away. Not getting any treatment for 5 months is absolutely inappropriate for an aggressive lymphoma unless it is due to patient factors such as delay due to second opinion etc.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Again, the delay is starting the treatment could have resulted in adverse outcomes. However, we need to know the reason for the delay and the exact cause of patients death.
What makes you a good expert for this case?
I am board certified hematologist and oncologist practicing over 10’years and have managed severe cases of DLBCL. I also get referrals from other oncologists for complex DLBCL for patients to guide management.
How often do you encounter cases similar to this one in your practice?
I see about 20-50 new cases annually
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