Primary Mediastinal B-Cell Lymphoma presenting with Superior Vena Cava Syndrome: Navigating Response Assessment, Thrombosis, and Cardiotoxicity during DA-EPOCH-R: A Case Report
Materials and Methods/Case Presentation/Objective: A 20-year-old male with no significant past medical history presented with two months of progressive dyspnea and was found to have a 16-cm necrotic anterior mediastinal mass causing superior vena cava syndrome and malignant pericardial effusion. Biopsy confirmed limited-stage PMBCL with PD-L1 overexpression greater than 75%. After fertility preservation and port placement, he started DA-EPOCH-R with empiric steroids in the outpatient setting, with monitoring for tumor lysis syndrome.
Results/Description/Main Outcome Measure(s): The clinical course was complicated by catheter-associated upper-extremity deep vein thrombosis in the setting of venous compression, intermittent cytopenias, vincristine neuropathy requiring dose reduction, abnormal global longitudinal strain despite preserved left ventricular ejection fraction, migration of the port catheter tip to the terminal/intrahepatic inferior vena cava, and neutropenic fever. Interim PET/CT after cycle 3 showed clear anatomic and metabolic improvement.
Conclusion(s).:
This case highlights practical challenges of treating bulky PMBCL with DA-EPOCH-R, including successful outpatient administration despite a high-risk presentation. DA-EPOCH-R is traditionally delivered as an inpatient regimen given its 96-hour continuous infusion requirement, but growing evidence supports outpatient feasibility using ambulatory infusion pumps, with comparable outcomes and reduced cost and hospitalization burden.
Successfully managing induction entirely outpatient despite SVC syndrome and malignant pericardial effusion demonstrates that carefully selected high-risk PMBCL patients can avoid the morbidity, cost, and resource burden of prolonged inpatient admission. In PMBCL, interim response assessment is more commonly guided by CT than PET, given the well-recognized tendency for residual mediastinal fluorodeoxyglucose (FDG) avidity to persist even in patients who achieve durable remission. When interim PET is obtained, as here, a persistently positive Deauville score should be interpreted alongside symptoms, anatomic tumor shrinkage, and overall metabolic trend rather than acted upon in isolation and should not by itself prompt premature biopsy or treatment escalation.
Catheter-associated upper-extremity thrombosis can often be managed with anticoagulation while retaining the catheter, provided the line is still needed, functional, uninfected, and safely positioned. This requires close platelet monitoring, with consideration of thrombopoietin-receptor agonists to maintain platelets above 50,000/µL to permit safe therapeutic anticoagulation. Abnormal global longitudinal strain with preserved ejection fraction supports cardio-oncology follow-up and underscores the value of baseline strain imaging before anthracycline exposure. Persistent PET positivity at end of treatment should be confirmed with short-interval imaging and/or biopsy, when appropriate, before pursuing consolidative or salvage therapy.
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