Case Presentation: A 71-year-old male presented with ongoing complaints of acute onset of shooting abdominal pain, polyuria, drenching night sweats, no appetite, fatigue, and constipation for the past 10 days. A CT of the chest, abdomen, pelvis, and soft tissue of the neck was ordered for further work-up with abnormal findings of marked lymphadenopathy involving multiple partially necrotic nodal stations above and below the diaphragm concerning for metastatic disease, lymphoma or other lymphoproliferative disorder. Given the severity of symptoms, the patient was hospitalized for an expedited workup. An excisional biopsy of an enlarged supraclavicular node revealed both follicular large-cell lymphoma, grade IIIa, and focal classic Hodgkin’s lymphoma within the same lymph node. Flow cytometry confirmed CD10+ B cell non-Hodgkin’s lymphoma. The patient was ultimately diagnosed with follicular lymphoma transformed to diffuse large b cell lymphoma and Hodgkin lymphoma, known as composite lymphoma, stage IIIB. The case was discussed with both pathologists and multiple oncologists who agreed the pathology findings were consistent with composite lymphoma with two distinct lymphomas instead of a gray zone lymphoma. Aggressive inpatient chemotherapy was subsequently started that covered both histologies with the regimen, DA-EPOCH (etoposide, doxorubicin, vincristine, cytoxan, prednisone) for cycle one. Rituximab was added for cycle 2 based on CD20+ identification for a regimen of, DA-R-EPOCH. This treatment regimen was continued for the remainder of the therapy with a planned total of six cycles occurring every 21 days. The patient has completed five cycles to date. Overall, the patient has had a marked improvement in health status and is currently asymptomatic. He is back at his functional baseline. An interval PET scan was performed after cycle 3 that demonstrated persistent adenopathy but substantial improvement.
Discussion: Composite lymphoma refers to a patient with two or more distinct lymphomas that are diagnosed simultaneously from the same tissue site or organ. Both non-Hodgkin’s and Hodgkin’s lymphoma can be present in composite lymphoma with the most common being low grade follicular with classic Hodgkin’s. It is an exceedingly rare diagnosis that plagues practitioners due to its aggressive nature with no standard of care. It is beneficial for hospitalists to be aware of this rare cancer as the chemotherapy regimen is aggressive and the patient response is unpredictable requiring hospitalization for each treatment cycle. As the demographic of the patient population is becoming older, diagnosis of cancer and inpatient management is something general practitioners should become comfortable with. This case highlights how complex an oncologic case can be and the need for practitioners to be adaptable for successful inpatient management.
Conclusions: Unfamiliarity with composite lymphomas and the complexity of the diagnosis proves to be challenging to manage. Even more so when the differing lymphomas are present in the same lymph nodes. While the described patient has had good response to treatment thus far, deciding his treatment regimen was uncharted territory with a still unknown final outcome. There are scarce case reports depicting management strategies that have been attempted for composite lymphoma; however, more data is needed to define an appropriate treatment course.