Perforation in an intestinal malignant lymphoma case

Abstract

BackgroundThe 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 presentationThe 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. 18F-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.ConclusionsWe were able to avoid the neutropenic period and safely conducted the surgical treatment for the subclinical perforation by using CE-CT. The combination of 18F-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.

Metastatic osteosarcoma bowel perforation secondary to chemotherapy-induced tumour necrosis

“…Both small cell carcinoma and lymphoma, along with osteosarcoma, are known to be highly chemosensitive malignancies. In the case of intestinal lymphomas, multiple studies advocate for elective bowel resection prior to chemotherapy to prevent the development of tumour lysis and subsequent complications 25 39 40…”

Necrosis and massive perforation of the small intestine in the course of lymphoma: a case report

“…The ischaemic fragment of the bowel was resected followed by anastomosis of the stumps. The post-operative course was uneventful and after 2 weeks the discontinued chemotherapy was recommenced [10].…”

Complicaciones quirúrgicas del linfoma con compromiso gastrointestinal

“…La perforación intestinal es una de las complicaciones más conocidas del linfoma no Hodgkin, presente del 1 al 25 % de los linfomas con compromiso intestinal, relacionada o no a la quimioterapia 15 . En una serie reportada de 1062 pacientes, 9 % presentaron perforación intestinal luego del inicio de la quimioterapia, la media fue de 46 días, más común en intestino delgado, subtipo linfoma difuso de células B grandes (DLBCL, por sus siglas en inglés) 16,17 . Las razones para la perforación en pacientes que reciben quimioterapia son la rápida necrosis del tumor, lisis tumoral y alteraciones del tejido por la rápida granulación.…”

“…El manejo quirúrgico electivo con resección del segmento intestinal afectado por linfoma se ha propuesto como una estrategia para evitar las complicaciones posteriores al inicio de la quimioterapia, ya que una intervención urgente por perforación se asocia a un riesgo aumentado de morbimortalidad. Sin embargo, esta práctica se ha abandonado en los últimos años pues no ha demostrado mejorar tasas de supervivencia a tres y cinco años 17,20 .…”