Triple Lymphoma and Transformation to Diffuse Large B-Cell Lymphoma Finding at the Time of Diagnosis

In this report, we present the case of a patient with an uncommon triple diagnosis of (1) follicular (nodular) lymphoma, (2) nodular lymphocyte predominant Hodgkin lymphoma, and (3) diffuse large B-cell lymphoma non-germinal center B-cell (non-GCB) subtype. Although transformation of follicular lymphoma and nodular lymphocyte predominant lymphoma to more aggressive forms such as diffuse large B-cell lymphoma is possible; it generally happens many years after diagnosis. Moreover, there have been reported cases of follicular lymphoma with transformation and nodular lymphocyte predominant Hodgkin lymphoma with transformation at the time of diagnosis, but it is very uncommon to see all three present on initial diagnosis. Our patient presented with a large right axillary mass, which, upon excisional biopsy and subsequent histology, showed the aforementioned lymphomas. The patient did not present with a prodrome of any symptoms except intermittent night sweats. The unique aspect of our case is that transformation and all three lymphomas were seen at the time of diagnosis. The R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy regimen is still the standard method of treatment as it has been shown to be effective in treating follicular lymphoma and nodular lymphocyte predominant Hodgkin lymphoma with and without transformation. However, there is insufficient literature on its efficacy when all three are present concurrently.