Perforation in an intestinal malignant lymphoma case

Abstract

Background: The gastrointestinal tract is a relatively common involvement site in lymphoma and, in such cases, intestinal perforation is a concern before and during chemotherapy. The prediction of intestinal perforation prior to chemotherapy is difficult, and there is no standard strategy to minimize the frequency of severely adverse gastrointestinal events in lymphoma cases.

Case presentation: The 61-year-old female patient had a history of primary central nervous system lymphoma (PCNSL), diagnosed histologically as diffuse large B cell lymphoma (DLBCL). We administered six courses of intensive chemotherapy consisting of high-dose methotrexate and sequential whole-brain irradiation (40.5 Gy). After a 3-year remission of the PCNSL, the patient's lymphoma recurred, involving the small intestine. (18)F-FDG-PET/CT upon the recurrence before chemotherapy showed multiple nodular lesions in the patient's gastrointestinal tract. Central nervous system lesions were not detected. We administered intensive salvage chemotherapy consisting of cyclophosphamide, high-dose AraC, methyl-prednisolone, etoposide, and rituximab. The response was a rapid partial response, but on day 10 after the initiation of salvage chemotherapy, she complained of abdominal pain with tenderness. The contrast-enhanced (CE)-CT revealed transmural ischemia of the intestine. On the 7th day after the onset of urgent abdominal symptoms, follow-up CE-CT showed that the ischemic lesion had become thin. We conducted elective surgery after waiting for the complete recovery of the patient's white blood cell count. The pathological findings of resected intestine confirmed the elimination of the majority of lymphoma cells and concomitant partial necrotic tissue.

Conclusions: We were able to avoid the neutropenic period and safely conducted the surgical treatment for the subclinical perforation by using CE-CT. The combination of (18)F-FDG-PET/CT before chemotherapy and CE-CT scanning for the targeted involvement site helped us evaluate the surgical indications and optimal timing of surgery in a lymphoma patient with gastrointestinal involvement.

Keywords: Chemotherapy; Malignant lymphoma; Perforation.

Fig. 1

Pathological findings at the onset (brain). Hematoxylin-eosin (HE) staining showed a diffuse infiltration of morphological large lymphocytes (magnification 40×) (a). Immunochemical staining revealed positive results for CD20 (b) and CD79a (c) and a negative result for EBER (d)

Fig. 2

Pathological findings at the recurrence (intestine). HE staining showed a diffuse infiltration of morphological large lymphocytes (magnification as noted) (a). Immunochemical staining revealed positive results for CD20 (b) and CD79a (c) and a negative result for EBER (d), phenotypically similar to the primary site, brain (Fig. 1)

Fig. 3

Radiological imaging and pathological findings of the ischemic intestinal site. (a) ¹⁸F-FDG-PET/CT before the patient’s chemotherapy demonstrated the involvement of malignant lymphoma in multiple intestine sites and the liver. The open triangle indicates the tissue involvement. (b) The ¹⁸F-FDG-PET image superimposed in red on the CT image obtained before the chemotherapy illustrates the transverse image of the involvement (left). CT on day 10 after chemotherapy depicting transmural necrosis of the intestine (middle). On day 14 after the initiation of the chemotherapy, the enhancement of intestinal wall on CT were recovering (right). The open triangle indicates the involved intestine. (c) Pathological findings of resected intestine confirmed the elimination of the majority of the lymphoma. Macroscopic findings identified the incomplete perforation site covered with a thin serous membrane (left column, yellow arrow). The pathological findings elucidated the elimination of the majority of lymphoma cells and concomitant partial necrotic tissue (right column)