Combined Modality Management of Sinonasal Anaplastic Lymphoma Kinase Negative Anaplastic Large Cell Lymphoma in a Geriatric Patient-Report of a Rare Case

Sinonasal anaplastic lymphoma kinase(ALK)-negative anaplastic large cell lymphoma(ALCL) without nodal involvement is exceedingly rare and the rarity of this tumor often engenders diagnostic dilemma. It has been mostly reported in pediatric, adolescent and young adult patients, mostly of Asian origin. A 70-year-old female patient presented with a mass in the left nasal cavity causing nasal obstruction for 5 months. On clinical and radiological examination, there was a 5.7 cm mass in the left nasal cavity, completely obliterating the left ethmoid sinus. Biopsy from the nasal mass showed a poorly differentiated malignant tumour with large cells arranged in sheets. On immunohistochemistry, the tumour cells were positive for leukocyte common antigen(LCA), CD30, CD43, BCL6 and focally for CD5, TIA1, granzyme B and epithelial membrane antigen(EMA), and were negative for CD56, EBV-LMP1, CD79a, PAX5, myeloperoxidase, CD34, CD7, CD4, CD8, CD138, ALK and p63, suggestive of ALK-negative ALCL. Rest of the lymphoma work-up was essentially normal and she had stage IE disease. She was treated with prephase chemotherapy (Vincristine and Prednisolone) followed by 4 cycles of CEOP[Cyclophosphamide, Etoposide (from 2nd cycle onwards), Vincristine and Prednisolone] regimen and local radiotherapy (36 Gy/20 fractions/4 weeks) by intensity modulated radiotherapy(IMRT) technique resulting in complete clinical and radiological response. At last follow-up visit, 15 months from the initial diagnosis, she was alive and disease free. Sinonasal ALK-negative ALCL is a rare tumor which can be effectively treated with a combination of multi-agent CHOP/CHOP-like regimen and local conformal radiotherapy in geriatric patients.