Pralatrexate as a bridge to allogeneic hematopoietic stem cell transplantation in a patient with advanced-stage extranodal nasal-type natural killer/T cell lymphoma refractory to first-line chemotherapy: a case report

Abstract

Background: Extranodal natural killer/T cell lymphoma, nasal type, is one of the more common subtypes of mature T cell lymphoma, especially in the Far East Asian population. This aggressive histologic subtype of peripheral T cell lymphomas is frequently susceptible to exposure of Epstein-Barr virus infection. The optimal treatment is not well elucidated. For stage IV disseminated extranodal natural killer/T cell lymphoma, induction chemotherapy with consolidative autologus or allogeneic hematopoietic stem cell transplantation is recommended as the major first-line treatment. However, there is controversy over which type of chemotherapy is most appropriate and effective as a bridge to autologus or allogeneic hematopoietic stem cell transplantation in patients with newly diagnosed disseminated advanced-stage or relapsed extranodal natural killer/T cell lymphoma because of cancer chemoresistance or associated complications. Pralatrexate is the first US Food and Drug Administration-approved novel agent for the treatment of refractory/recurrent peripheral T cell lymphomas. In our case, pralatrexate was used as a successful bridge to allogeneic hematopoietic stem cell transplantation in a patient with advanced-stage disseminated extranodal natural killer/T cell lymphoma refractory to first-line chemotherapy.

Case presentation: We presented a case report of a 29-year-old Asian man diagnosed as having stage IV disseminated extranodal natural killer/T cell lymphoma, nasal type, with skin and bone marrow involvement, whose disease was primary refractory to first-line dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide chemotherapy, but obviously responded to treatment with two cycles of single-agent pralatrexate treatment. Monitoring Epstein-Barr virus viremia revealed dramatic downregulation. In addition to complete remission of the involvement of bone marrow and nasal cavity, skin involvement also obtained partial remission. The extranodal natural killer/T cell lymphoma successfully achieved complete remission after a bridge to allogeneic hematopoietic stem cell transplantation.

Conclusions: This is the first study to present pralatrexate as a successful bridge to allogeneic hematopoietic stem cell transplantation in a 29-year-old Asian male patient with advanced-stage extranodal natural killer/T cell lymphoma refractory to first-line dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide chemotherapy. This case provides a novel treatment opinion for extranodal natural killer/T cell lymphoma, especially for the Far East Asian population.

Keywords: Allogeneic hematopoietic stem cell transplantation; Chemotherapy; Natural killer/T cell lymphoma; Peripheral T cell lymphoma; Pralatrexate.

Fig. 1

The scattered Epstein–Barr virus-encoded small RNA-positive small lymphocytes were also positive for CD3, CD56, and TIA-1 stains and negative for CD20. EBER Epstein–Barr virus-encoded small RNA, H/E hematoxylin and eosin

Fig. 2

Epstein–Barr virus viremia showed significant decrease at follow-up. AHSCT allogeneic hematopoietic stem cell transplantation, EBV Epstein–Barr virus, PCR polymerase chain reaction, SMILE dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide

Fig. 3

Skin lesions of face and trunk at diagnosis (a) and after allogeneic hematopoietic stem cell transplantation (b) revealed complete remission

Fig. 4

Positron emission tomography-computed tomography scans for nasal lesions and lymphadenopathies showed complete metabolic response after one cycle of pralatrexate and maintained the response after allogeneic hematopoietic stem cell transplantation. AHSCT allogeneic hematopoietic stem cell transplantation, SMILE dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide