Abstracts
PO79
Recurrent Non-Hodgkin Lymphoma's transformation to Diffuse Large B-Cell Lymphoma Presenting with Severe Hypercalcemia and Bulky Cervical Lymphadenopathy in an Elderly Male: A Case Report
Introduction/Background/Significance: Transformed Diffuse large B-cell lymphoma (DLBCL) presenting with severe hypercalcemia and rapidly progressive bulky cervical lymphadenopathy poses significant diagnostic and therapeutic challenges. This case highlights the complexity of managing relapsed aggressive lymphoma complicated by life-threatening metabolic derangements in a patient with limited prior treatment records.
Materials and Methods/Case Presentation/Objective: A 67-year-old male with a history of non-Hodgkin's lymphoma previously diagnosed in the year 2000 and treated with CHOP, with remission for 13 years before recurrence in 2013 when he was treated with rituximab, presented to the ED with a two-week history of progressive cervical lymphadenopathy, dysphagia, and an 18-pound weight loss. CT imaging revealed a massive 8.5 x 11.4 x 13.6 cm right cervical mass with tracheal deviation and extensive retroperitoneal, mesenteric, and pelvic lymphadenopathy. Shortly after admission, critical hypercalcemia (16.2 mg/dL) was identified and managed with aggressive hydration, calcitonin, and pamidronate. Hyperuricemia (10.1 mg/dL) was treated with rasburicase. Biopsy confirmed diffuse large B-cell lymphoma, germinal center type, with Bcl-2, BCL6, and c-Myc positivity and Ki-67 of 70%. Due to unavailable prior treatment records and concern for cumulative anthracycline cardiotoxicity, R-CVP was initiated as inpatient chemotherapy with consideration for polatuzumab-based therapy pending further risk stratification. Patient tolerated chemotherapy well and was placed with a multidisciplinary oncology team to direct future chemotherapy treatments.
Results/Description/Main Outcome Measure(s): The concurrent presentation of relapsed DLBCL with severe hypercalcemia, hyperuricemia, and widespread lymphadenopathy necessitated urgent multidisciplinary management. The absence of prior treatment records complicated regimen selection, particularly regarding anthracycline re-exposure. The co-expression of Bcl-2 and c-Myc (double-expressor phenotype) confers an adverse prognosis and may warrant intensified or novel therapeutic approaches.
Conclusion(s).: This case underscores the importance of rapid diagnostic workup and metabolic stabilization in aggressive lymphoma recurrence. It also illustrates the challenges of treatment selection when prior oncologic records are unavailable, and highlights the prognostic significance of molecular characterization in guiding therapy for relapsed DLBCL.
Trademarked Items:
References: Silkenstedt E, Salles G, Campo E, Dreyling M. B-cell non-Hodgkin lymphomas. Lancet. 2024;404(10461):1283-1300. doi:10.1016/S0140-6736(24)01573-0
Falade AS, Ansell SM. Treatment of diffuse large B-cell lymphoma. Mayo Clin Proc. 2026;101(1):143-160. doi:10.1016/j.mayocp.2025.05.028
Fabbri N, Mussetti A, Sureda A. Second-line treatment of diffuse large B-cell lymphoma: evolution of options. Semin Hematol. 2023;60(5):305-312. doi:10.1053/j.seminhematol.2023.09.001
Sehn LH, Salles G. Diffuse large B-cell lymphoma. N Engl J Med. 2021;384(9):842-858. doi:10.1056/NEJMra2027612
Dickens LT, Derman B, Alexander JT. Endocrine Society hypercalcemia of malignancy guidelines. JAMA Oncol. 2023;9(12):1733-1734. doi:10.1001/jamaoncol.2023.4086
El-Hajj Fuleihan G, Clines GA, Hu MI, et al. Treatment of hypercalcemia of malignancy in adults: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023;108(3):507-528. doi:10.1210/clinem/dgac621
Guise TA, Wysolmerski JJ. Cancer-associated hypercalcemia. N Engl J Med. 2022;386(15):1443-1451. doi:10.1056/NEJMcp2113128
Walker MD, Shane E. Hypercalcemia: a review. JAMA. 2022;328(16):1624-1636. doi:10.1001/jama.2022.18331
Xu PP, Song YQ, Shen JZ, et al. Tucidinostat plus R-CHOP vs R-CHOP in MYC/BCL2 double-expressor diffuse large B-cell lymphoma: a randomized clinical trial. JAMA. 2026;335(3):225-234. doi:10.1001/jama.2025.24816
Riedell PA, Smith SM. Double hit and double expressors in lymphoma: definition and treatment. Cancer. 2018;124(24):4622-4632. doi:10.1002/cncr.31646
Materials and Methods/Case Presentation/Objective: A 67-year-old male with a history of non-Hodgkin's lymphoma previously diagnosed in the year 2000 and treated with CHOP, with remission for 13 years before recurrence in 2013 when he was treated with rituximab, presented to the ED with a two-week history of progressive cervical lymphadenopathy, dysphagia, and an 18-pound weight loss. CT imaging revealed a massive 8.5 x 11.4 x 13.6 cm right cervical mass with tracheal deviation and extensive retroperitoneal, mesenteric, and pelvic lymphadenopathy. Shortly after admission, critical hypercalcemia (16.2 mg/dL) was identified and managed with aggressive hydration, calcitonin, and pamidronate. Hyperuricemia (10.1 mg/dL) was treated with rasburicase. Biopsy confirmed diffuse large B-cell lymphoma, germinal center type, with Bcl-2, BCL6, and c-Myc positivity and Ki-67 of 70%. Due to unavailable prior treatment records and concern for cumulative anthracycline cardiotoxicity, R-CVP was initiated as inpatient chemotherapy with consideration for polatuzumab-based therapy pending further risk stratification. Patient tolerated chemotherapy well and was placed with a multidisciplinary oncology team to direct future chemotherapy treatments.
Results/Description/Main Outcome Measure(s): The concurrent presentation of relapsed DLBCL with severe hypercalcemia, hyperuricemia, and widespread lymphadenopathy necessitated urgent multidisciplinary management. The absence of prior treatment records complicated regimen selection, particularly regarding anthracycline re-exposure. The co-expression of Bcl-2 and c-Myc (double-expressor phenotype) confers an adverse prognosis and may warrant intensified or novel therapeutic approaches.
Conclusion(s).: This case underscores the importance of rapid diagnostic workup and metabolic stabilization in aggressive lymphoma recurrence. It also illustrates the challenges of treatment selection when prior oncologic records are unavailable, and highlights the prognostic significance of molecular characterization in guiding therapy for relapsed DLBCL.
Trademarked Items:
References: Silkenstedt E, Salles G, Campo E, Dreyling M. B-cell non-Hodgkin lymphomas. Lancet. 2024;404(10461):1283-1300. doi:10.1016/S0140-6736(24)01573-0
Falade AS, Ansell SM. Treatment of diffuse large B-cell lymphoma. Mayo Clin Proc. 2026;101(1):143-160. doi:10.1016/j.mayocp.2025.05.028
Fabbri N, Mussetti A, Sureda A. Second-line treatment of diffuse large B-cell lymphoma: evolution of options. Semin Hematol. 2023;60(5):305-312. doi:10.1053/j.seminhematol.2023.09.001
Sehn LH, Salles G. Diffuse large B-cell lymphoma. N Engl J Med. 2021;384(9):842-858. doi:10.1056/NEJMra2027612
Dickens LT, Derman B, Alexander JT. Endocrine Society hypercalcemia of malignancy guidelines. JAMA Oncol. 2023;9(12):1733-1734. doi:10.1001/jamaoncol.2023.4086
El-Hajj Fuleihan G, Clines GA, Hu MI, et al. Treatment of hypercalcemia of malignancy in adults: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2023;108(3):507-528. doi:10.1210/clinem/dgac621
Guise TA, Wysolmerski JJ. Cancer-associated hypercalcemia. N Engl J Med. 2022;386(15):1443-1451. doi:10.1056/NEJMcp2113128
Walker MD, Shane E. Hypercalcemia: a review. JAMA. 2022;328(16):1624-1636. doi:10.1001/jama.2022.18331
Xu PP, Song YQ, Shen JZ, et al. Tucidinostat plus R-CHOP vs R-CHOP in MYC/BCL2 double-expressor diffuse large B-cell lymphoma: a randomized clinical trial. JAMA. 2026;335(3):225-234. doi:10.1001/jama.2025.24816
Riedell PA, Smith SM. Double hit and double expressors in lymphoma: definition and treatment. Cancer. 2018;124(24):4622-4632. doi:10.1002/cncr.31646
