A 55-year-old Indonesian woman complained of bulky mass of the right neck. The patient also experienced massive upper gastrointestinal bleeding within last 2 months requiring a total 26 bags of PRC. Right neck mass size was 12 cm in diameter, hard in palpapation, and fixated. It deviated the trachea to the left side. Hematological profile showed the hemoglobin 8.2 mg/dL, leukocyte count 1.91 x103 /μL, platelet count 67 x103.The core biopsis of mass showed diffuse large B cell lymphoma (DLBCL). Bone marrow puncture showed Myelodysplastic Syndrome (MDS) with dyserythropoiesis and dysgranulopoiesis without lymphoma cell infiltration. Gastroscopy revealed gastropathy with multiple errosion in corpus and antrum. Because the mass endangered airway patency, we decided to perform chemotherapy despite the very high risk of rebleeding if trombosipenia deteriorated. During chemotherapy preparation, the patient experienced melena that needed 8 bags of packed red cell transfusion. We started CHOP regiment after transfusion with the baseline of blood count: Hb 11.3 g/dL, leukocyte count 2.42 x103/μL, platelet count 68 x103/μL. In order to minimize the cytopenic effect leading to reccurent bleeding, we reduced the dose of cyclophosphamide (50%) and doxorubicin (25%). One week after chemotherapy the right neck mass completely disappear, but the patient complained malaise and black tarry stool melena. A complete blood count revealed pancytopenia with hemoglobin 3,6 g/dL, leukocyte count 0,45 x103/μL,platelet count 34 x103/μL. We performed blood transfusion, filgrastim injection and lanzoprazol injection to manage the condition.
Conclusion: Chemotherapy in bulky neck mass of DLBCL which endangers airway patency concurrent with recurrent upper gastrointestinal tract bleeding and thrombocytopenia related MDS was a difficult choice. The decision to treat should be made based on the benefits outweigh the risk.