Double-hit lymphoma (DHL) is associated with MYC gene translocation and either the BCL2 or BCL6 gene or both translocations, and is considered a subtype of diffuse large B-cell lymphoma (DLBCL) among the malignant lymphomas. We encountered a case of DHL in an elderly patient with a giant tumor, severe renal dysfunction, and unfavorable performance status (PS).

The patient was a 75-year-old woman. Three months previously, she had experienced chest pain. A computed tomography (CT) examination displayed an anterior mediastinal mass and an intrahepatic mass. Two weeks after, she was brought to our hospital by ambulance owing to dyspnea, and was admitted. B-cell malignant lymphoma was suspected on thyroid biopsy.

A physical examination on her admission showed that she had E3V4M5-level disturbance of consciousness in the Glasgow Coma Scale, epigastric tenderness, and pitting edema all over her body. The results of her blood test on admission are shown in Fig. 1A. Head magnetic resonance imaging (MRI) revealed no intracranial metastasis. A positron emission tomography-CT (PET-CT) scan taken before admission displayed a giant tumor with signal accumulation in the anterior mediastinum and liver, and lesions with signal accumulation in the parotid gland, pancreas, adrenal glands, and systemic lymph nodes (Fig. 1B).

Considering the patient's condition, especially considering the risk of tumor lysis syndrome, treatment of her malignant lymphoma by chemotherapy was concluded to be difficult.

The patient's renal dysfunction temporarily increased to about Cr 7.0 mg/dL, and hemodialysis was started on the 11th hospital day. On the 12th hospital day, the patient was treated with steroid pulse therapy with methylprednisolone 1000 mg/day for 3 days. Her renal function subsequently improved, and she was weaned off dialysis. Although there was no change in tumor burden, a decrease in lactate dehydrogenase (LDH) was observed. We were considering a best supportive care policy until we started administering steroids, but her general condition also improved, so we decided to try chemotherapy.

As the interim pathological results indicated that the patient had B-cell lymphoma, rituximab was administered for the first time on day 22, followed by cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisolone (CHOP) therapy at two-thirds of the reduced dose, which resulted in tumor shrinkage. The final report of the pathological examination was high-grade B-cell lymphoma with MYC/BCL6 rearrangements; that is, DHL involving MYC and BCL6.

A total of four courses of rituximab-cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisolone (R-CHOP) therapy were then administered. Imaging results indicated further improvement (Fig. 1C), and her activities of daily living (ADL) also improved to almost independence. Figure 1D shows the patient's progress. However, the patient's condition subsequently worsened owing to tumor recurrence, and chemotherapy could not be continued. She survived for 12 months after onset of symptoms.

DHL involves translocation of the MYC gene, and translocation of either the BCL2 or the BCL6 gene or both, with MYC-BCL2 DHL in 2% to 8% of DLBCL patients and MYC-BCL6 DHL, which is a rare subtype, in 0.8% to 1% of patients. R-CHOP therapy is considered to be ineffective for DHL,¹ and no treatment has been established to date. Rituximab-etoposide, prednisolone, oncovin, cyclophosphamide, and doxorubicin hydrochloride (R-EPOCH), etc., are being considered as potential treatments.² The median overall survival of MYC-BCL6 DHL patients is reported to be 17.2 months, and the 1-year survival rate is 58%, which is considered to be similar to that of MYC-BCL2 DHL patients.³

One of the reasons that we performed chemotherapy on this patient was the improvement of her general condition and renal dysfunction after steroid pulse therapy. As her renal dysfunction was caused by interstitial nephritis, steroid administration may have resulted in its improvement. In addition, it is assumed that the patient's malignant lymphoma originally metastasized to the adrenal glands, resulting in a decrease in physiological steroid production, and steroid supplementation may have improved her general condition.

Another reason that chemotherapy was performed on this patient is associated with the cancer pharmacotherapy guidelines for the elderly.⁴ The guidelines suggest that comprehensive geriatric assessment (CGA) should not be used to determine treatment strategies for elderly DLBCL patients. As DLBCL often responds favorably to chemotherapy, we suggest that chemotherapy should be performed regardless of CGA results. In the present case, the possibility of DLBCL was considered in the pathological interim report, which encouraged us to try chemotherapy without relying on the CGA evaluation. However, the use of chemotherapy for DLBCL patient in these guidelines is only a “suggestion,” and as this patient was ultimately diagnosed as having DHL, we believe that more caution should be exercised in making decisions to perform chemotherapy.

Elderly patients with malignant lymphoma require a more comprehensive evaluation than younger patients regarding whether or not treatment should be performed. On the other hand, active treatment that is not necessarily bound by the results of geriatric functional evaluation may be effective, and we believe that this case demonstrates this point.

双重打击淋巴瘤（DHL）与MYC基因易位和BCL2或BCL6基因或两者易位有关，被认为是恶性淋巴瘤中弥漫性大 B 细胞淋巴瘤（DLBCL）的一个亚型。我们遇到了一例 DHL 病例，患者患有巨大肿瘤、严重肾功能不全、体力状态 (PS) 不佳。

患者是一名75岁的女性。三个月前，她出现胸痛。计算机断层扫描（CT）检查显示前纵隔肿块和肝内肿块。两周后，她因呼吸困难被救护车送往我们医院并入院。甲状腺活检怀疑 B 细胞恶性淋巴瘤。

入院体检显示格拉斯哥昏迷量表E3V4M5级意识障碍、上腹压痛、全身凹陷性水肿。她入院时的血液检查结果如图1A所示。头部磁共振成像（MRI）显示没有颅内转移。入院前进行的正电子发射断层扫描-CT（PET-CT）扫描显示前纵隔和肝脏有一个巨大的肿瘤，有信号积累，腮腺、胰腺、肾上腺和全身淋巴结有信号积累的病变（图1）。 .1B）。

考虑到患者的病情，特别是考虑到肿瘤溶解综合征的风险，化疗治疗恶性淋巴瘤的难度较大。

患者肾功能障碍暂时升高至Cr 7.0 mg/dL左右，入院第11天开始血液透析。住院第12天，患者接受甲泼尼龙1000 mg/天的类固醇冲击治疗，持续3天。她的肾功能随后得到改善，并停止了透析。尽管肿瘤负荷没有变化，但观察到乳酸脱氢酶（LDH）下降。在开始使用类固醇之前，我们一直在考虑最佳的支持性护理政策，但她的总体状况也有所改善，因此我们决定尝试化疗。

由于中期病理结果表明患者患有B细胞淋巴瘤，第22天首次给予利妥昔单抗，随后以减少剂量的三分之二进行环磷酰胺、盐酸阿霉素、长春新碱和泼尼松龙（CHOP）治疗，从而导致肿瘤缩小。病理检查最终报告为高级别B细胞淋巴瘤伴MYC/BCL6重排；即DHL涉及MYC和BCL6。

然后进行总共四个疗程的利妥昔单抗-环磷酰胺、盐酸阿霉素、长春新碱和泼尼松龙（R-CHOP）治疗。影像学结果显示进一步改善（图1C），她的日常生活活动（ADL）也改善到几乎独立。图 1D 显示了患者的进展情况。但随后患者因肿瘤复发病情恶化，无法继续化疗。症状出现后，她存活了 12 个月。

DHL 涉及MYC基因易位以及 BCL2或BCL6基因或两者的易位，2% 至 8% 的 DLBCL 患者中存在MYC - BCL2 DHL ，0.8% 存在MYC - BCL6 DHL（一种罕见亚型）。至 1% 的患者。R-CHOP 疗法被认为对 DHL 无效，¹并且迄今为止尚未确定治疗方法。利妥昔单抗依托泊苷、泼尼松龙、oncovin、环磷酰胺和盐酸阿霉素（R-EPOCH）等被认为是潜在的治疗方法。²据报道， MYC - BCL6 DHL 患者的中位总生存期为 17.2 个月，1 年生存率为 58%，被认为与MYC - BCL2 DHL 患者相似。³

我们对这位患者进行化疗的原因之一是类固醇冲击治疗后她的一般状况和肾功能障碍得到改善。由于她的肾功能障碍是由间质性肾炎引起的，服用类固醇可能会有所改善。此外，推测患者的恶性淋巴瘤最初转移至肾上腺，导致生理性类固醇产生减少，补充类固醇可能改善了她的一般状况。

对这名患者进行化疗的另一个原因与老年人癌症药物治疗指南有关。⁴指南建议不应使用综合老年评估（CGA）来确定老年 DLBCL 患者的治疗策略。由于 DLBCL 通常对化疗有良好反应，因此我们建议无论 CGA 结果如何都应进行化疗。在本例中，病理中期报告考虑了DLBCL的可能性，这鼓励我们尝试化疗而不依赖CGA评估。然而，本指南中对DLBCL患者使用化疗仅是一种“建议”，由于该患者最终被诊断为DHL，我们认为在做出化疗决定时应更加谨慎。

老年恶性淋巴瘤患者需要比年轻患者更全面的评估是否应该进行治疗。另一方面，不一定受老年功能评估结果约束的积极治疗可能是有效的，我们相信这个案例证明了这一点。