Tracheostomy Before Polatuzumab Vedotin-Containing Therapy for Airway-Threatening Cervical Diffuse Large B-Cell Lymphoma: A Case Report of Two Patients.

Abstract

Background: Bulky cervical diffuse large B-cell lymphoma (DLBCL) with impending airway compromise presents an urgent management dilemma, particularly when diagnostic confirmation and timely initiation of definitive therapy must be balanced against the risk of abrupt airway deterioration. Evidence guiding airway-first management before polatuzumab vedotin-containing frontline therapy remains limited.

Case presentation: We describe two older men with bulky cervical DLBCL who presented with progressive airway-related symptoms and marked upper airway narrowing on endoscopic and radiologic evaluations. In both cases, semiurgent tracheostomy was prioritized over emergent radiotherapy or immediate systemic therapy, allowing pathological confirmation and treatment planning under controlled conditions. After DLBCL was pathologically confirmed, full-dose polatuzumab vedotin, rituximab, cyclophosphamide, doxorubicin, and prednisone (Pola-R-CHP) were initiated 15 and 10 days after tracheostomy, respectively, and delivered without dose reduction or treatment delay. No perioperative or tracheostomy-site complications occurred. Both patients completed six cycles of Pola-R-CHP followed by two cycles of rituximab. One patient achieved a partial metabolic response; after receiving salvage chemoimmunotherapy followed by CD19-directed chimeric antigen receptor T-cell therapy, he achieved a complete metabolic response. In the other patient, residual fluorodeoxyglucose uptake without corresponding structural lesions was managed with close surveillance after negative follow-up evaluations, including laryngoscopy and thyroid fine-needle aspiration.

Conclusions: Although limited to two patients, these cases suggest that proactive airway stabilization can create a controlled window for diagnosis and treatment planning and may facilitate safe delivery of full-dose Pola-R-CHP in selected patients with airway-threatening cervical DLBCL.