Male, 74 years old, admitted to hospital on February 13, 2016 for "lymphoma in November, 3 weeks after chemotherapy."



Current medical history: On January 8, 2015, there were no obvious causes and incentives for left nose bleeding, nasal congestion, and salivation.
Patients with persistent upper extremity pain in 2015-12-16 PET-CT examination revealed: 1. Right supraclavicular fossa, right hilar, left pelvic lymph node showed, enlarged, right abdominal cavity, retroperitoneal right Irregular soft tissue mass in the ureteral area, the glucose metabolism of the above lesions increased, consistent with lymphoma manifestations; 2. Multiple bone destruction in the upper left tibia, soft tissue density filling in the medullary cavity, increased glucose metabolism, considering lymphoma invasion; The right ureter was compressed, the right renal pelvis and the right upper ureter were slightly dilated and effusion. 2015-12-23 and 2016-1-22, the CHOP program (CTX 800mg VD D1, THP 50mg VD D1, VCR 2mg IV D1, PDN 100mg PO D1-5) was given for two cycles of chemotherapy and sustained release of oxycodone hydrochloride. Tablet 30mg bid pain relief, symptomatic support and other treatments. Now we are in charge of further diagnosis and treatment of our department.
Past history, personal history, and family history are not special.
Physical examination: The vital signs were stable, the lungs were clear, and the dry and wet rales and wheezing sounds were not heard. Heart rhythm, apical murmur and pathological murmur. The abdomen is flat, no tenderness and rebound tenderness.
Admission diagnosis: 1. Nasal non-Hodgkin's lymphoma group IV group A (diffuse large B cell type), 2. left tibia infiltration, 3. right renal pelvis, ureteral mild hydronephrosis, 4. moderate cancer pain NRS score :4 points
Main inspection before admission: 2015-12-16 PET-CT: 1. Right supraclavicular fossa, right hilar, left pelvic lymph node enlargement, right abdominal cavity, retroperitoneal right ureteral irregular soft tissue mass, the above lesions increased glucose metabolism , in line with the performance of lymphoma; 2. Multiple bone destruction in the upper part of the left tibia, soft tissue density filling in the medullary cavity, increased glucose metabolism, considering lymphoma invasion. Laboratory examination after admission:
CT of the chest and abdomen: shadow of the right anterior mediastinum; thickening of the rectal wall, new organisms possible; lymph nodes adjacent to the inferior vena cava.
Flat limbs: the bone density of the left tibia is reduced, the upper and lower bones are discontinuous, the epiphysis is formed at the edge, the upper fracture line is blurred, the lower segment fracture is separated, and the surrounding soft tissue is swollen. [Impression] Left tibiofibular fracture with swelling of surrounding soft tissue.
Blood routine: white blood cells (WBC) 3.97×10^9/L; hemoglobin (HGB) 83 g/L; red blood cells (RBC) 2.74×10^12/L; platelets (PLT) 230×10^9/L.
Liver and kidney function: prealbumin 155 mg / L; lactate dehydrogenase (LDH) 228.9 IU / L.
T cell subset: CD4 208; CD8 248; CD3 480; CD4/CD8 0.8.
Admission evaluation: patients with diffuse large B-cell lymphoma after radiotherapy and chemotherapy, with abdominal lymph nodes, left tibia infiltration, pathological fracture of the left tibia. After two cycles of chemotherapy, the change in lesions was not evaluated, and the effect was PD. The patient's general condition has a downward trend, it is difficult to tolerate further chemotherapy, and rituximab treatment is rejected. For the patient's systemic assessment, the patient and the family should fully explain the importance and risk of further treatment, and obtain the consent of the patient and family to be included in the CAR-T treatment clinical trial.
CAR-T treatment goes through:
1. 2016-02-29 Pretreatment of "cyclosqualamide 1200mg fludarabine 40mg VD D1-3". Blood routine examination before returning CAR-T cells: C-reactive protein (CRP) 76.0 mg / L ↑, white blood cells (WBC) 4.95 × 10 ^ 9 / L, neutrophil percentage (NEUT%) 96.4% ↑, lymphocytes Percentage (LYM%) 0.6% ↓, absolute lymphocyte value (LYM#) 0.03×10^9/L, red blood cells (RBC) 2.81×10^12/L↓, hemoglobin (HGB) 89 g/L 红, hematocrit (HCT) 25.6% sputum, platelet (PLT) 152 × 10 ^ 9 / L. 2. 2016-03-04~06 anti-CD19-CART cell reinfusion, 5.6e6 CART cell/kg, body temperature fluctuation during infusion was 36.0-36.6 °C, respiratory fluctuation was 11-21 beats/min, pulse fluctuation was 94 -96 beats/min, blood pressure fluctuated at 148-139/77-68 mmHg. Considering the adverse reactions such as CRS, oncolytic syndrome and off-target effect after CAR-T cell reinfusion, the “first-grade care”, continuous ECG monitoring and other auxiliary supportive treatments, and close monitoring of patients' vital signs and The condition changes. 3. On the 4th day after CAR-T cell reinfusion, the blood routine showed that the white blood cells were reduced. Considering the bone marrow suppression after pretreatment chemotherapy, the “recombinant human granulocyte stimulating factor” was added to leukocytes, and the patients were prevented from going out to avoid infection. On the 10th day, the blood pressure suddenly increased to 161/87 mmHg, which was caused by the patient's walking and was treated symptomatically. On the 14th day after CAR-T cell reinfusion, there was no obvious abnormality in blood routine, liver and kidney function, electrolytes and inflammatory markers. The patient's spirit and appetite were acceptable. No complaints were complained. He was discharged from hospital and was followed up after discharge. CT monitoring before and after CAR-T treatment (before treatment, 4 months after treatment): (1) left tibia infiltration (2) right abdominal cavity soft tissue mass shadow (3) right front upper mediastinal mass CAR-T treatment outcome: efficacy evaluation (RECIST) CR; PFS time 17 months; PS score 0 "Transfer from: Liang Yihui - Oncologist APP
http://www.liangyihui.net/doc/37766