Primary diffuse large B-cell lymphoma of the bone marrow in a frail and elderly patient successfully treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone

296 Letters to the Editor Fig. 1. (A) Bone marrow biopsy (Giemsa stain, high magnification) showing a neoplastic infiltrate composed predominantly of blastic cells with centroblastic morphology, with minor components composed of small centrocyte-like cells. These findings are indicative of diffuse large B-cell lymphoma with features suggestive of a centrofollicular origin. (B) Immunostaining with CD20L26 antibodies reveals diffuse membrane expression in neoplastic cells. (C) Immunostaining with BCL2 reveals diffuse cytoplasmatic expression by neoplastic cells. Primary diffuse large B-cell lym-phoma of the bone marrow in a frail and elderly patient successfully treated with rituximab, cy-clophosphamide, doxorubicin, vin-cristine, and prednisone TO THE EDITOR: The involvement of bone marrow (BM) in aggressive non-Hodgkin lymphomas (NHLs) usually indicates systemic dissemination. However, although uncommon , extranodal involvement of the BM as an isolated and unique localization of aggressive NHLs [1] such as ana-plastic large cell lymphoma [2] or diffuse large B-cell lym-phoma (DLBCL) [3-6], has also been reported. In particular, primary DLBCL of the BM is a rare type of extranodal lymphoma with poor prognosis [1, 4]. Approximately 10 cases of primary DLBCL of the BM have been described thus far [3], and few of them have been reported in individuals of very advanced age. Here, we report a case of primary DLBCL of the BM that was successfully treated using rituximab, cyclophosphamide, doxorubicin, vincris-tine, and prednisone (R-CHOP chemotherapy; 3-week standard schedule) in a frail 76-year-old woman. The patient was being treated for pancytopenia and dysp-nea on exertion caused by severe macrocytic anemia, which required multiple red blood cells (RBC) transfusions. Her Eastern Cooperative Oncology Group performance status was 2. In terms of comorbidities, she presented with a long-standing history of hypertension, reduced renal function (creatinine clearance as estimated by the Cockroft-Gault formula was 60 mL/minㆍ1.73 m 2), and chronic cere-brovascular disease with slight cognitive and neurological impairment. Her antihypertensive medication consisted of a combination of enalapril and amlodipine. At admission, the patient presented with severe malaise and fatigue. Physical examination revealed pallor and tachycardia, but neither lymphadenopathy nor hepatosplenomegaly was observed. Morphological examination of peripheral blood smears showed marked thrombocytopenia with prominent erythrocyte and platelet anisopoikilocytosis; however, no other abnormalities were detected. Although rare circulating neutrophils were present, no immature or atypical cells were observed. Myelodysplastic syndrome (MDS) was suspected, and a comprehensive work-up was performed. BM aspiration revealed a dry tap; examination of the BM specimen by tre-phine biopsy showed involvement of large …