YO21 - Sanctuary Site Central Nervous System Relapse-Refractory DLBCL Responding to Nivolumab and Lenalidomide.

Case summary

We are presenting a thirty-eight year old man who, presented with neck nodes, axillary nodes, altered sensorium, abnormal body movements, unconsciousness, weight loss and, fever, with a past history of DLBCL in May 2008, treated with 6 cycles of CHOP and completed in November 2008. After 9 years in April 2018, the patient developed similar symptoms and treated with salvage chemotherapy with R-DHAP which was completed in September 2018. Post-treatment PET-CT showed partial metabolic response. After completion of radiotherapy to bulky disease, the patient was very reluctant for any type of therapy and went home. After one month he presented to us with persistent vomiting, abnormal body movements and, altered sensorium. On examination, his GCS was E2V3M2 and was managed with mannitol, dexamethasone, antiepileptics, antibiotics and other supportive care medicines. His brain MRI was showing multiple heterogeneously enhancing lesions & his CSF analysis was positive for malignant cells. He was managed with triple intrathecal chemotherapy with methotrexate 12mg, Cytarabine 50mg, and Hydrocortisone 50mg, & after 4-5 days he regained consciousness & was able to talk and understand verbal commands. In view of improvement in GCS & PS, we started biweekly triple intra-thecal therapy, and Inj. Nivolumab 3 mg per kg q 2 weekly. From the second cycle, we started Lenalidomide 10mg once a day for 21 days with 7 days gap along with 2 weekly nivolumab and biweekly triple IT. After one month his CSF analysis was negative for malignant cells. Now he is on regular treatment with weekly IT chemotherapy, 2 weekly nivolumab and 3 weeks on and one week off lenalidomide. After 2 months of treatment, his MRI Brain was normal. At the time of submission of this article, he has completed the 10 cycle of immunotherapy and 5 cycles of lenalidomide. Patient tolerated immunotherapy, triple IT therapy and lenalidomide very well without much intolerable side effects. Therefore, we concluded that nivolumab and lenalidomide was well tolerated and exhibited antitumor activity in extensively pretreated patients with relapsed or refractory sanctuary site CNS B- cell lymphomas. Additional studies of Nivolumab and lenalidomide in these diseases are ongoing.

Clinical trial identification

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