Gastric emphysema in chemosensitive gastric diffuse large B cell lymphoma
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LETTER TO THE EDITOR
Gastric emphysema in chemosensitive gastric diffuse large B cell lymphoma Makoto Nakamura 1 & Kyosuke Saeki 1 & Ryoko Egashira 2 & Yoshiaki Egashira 2 & Kensuke Kojima 1 Received: 7 May 2020 / Accepted: 1 June 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020
Dear Editor, A combination of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) is currently the first-line treatment of choice for diffuse large B cell lymphoma (DLBCL). Although R-CHOP has achieved excellent outcomes in patients with primary gastric DLBCL, gastric complications such as bleeding, perforation, and stenosis have been reported [1]. Gastric emphysema occurs when air enters the gastric wall, usually after trauma to the gastric mucosa, and it is characterized by the accumulation of gas within the gastric wall [2, 3]. A 46-year-old man presented with a 2-month history of nausea and appetite loss. Upper gastrointestinal endoscopy showed a circumferential soft tumor with a friable surface lying between the lower gastric body and the pylorus. The mucosa of the gastric fornix appeared normal. A biopsy specimen of the tumor showed histological features of DLBCL with the non-GCB immunophenotype (CD20+CD10 −BCL6−MUM1+). 18FFluorodeoxyglucose positron emission tomography-CT showed intense uptake a bulky gastric tumor (10-cm long-axis diameter). The fornix appeared uninvolved in the gastric tumor. The patient underwent CHOP chemotherapy, which led to > 75% regression in the tumor size after one cycle. Six days after the second cycle, during which rituximab was added to CHOP, the patient presented with sudden-onset of upper abdominal pain. A hemoglobin level was 11.4 g/dL; white blood cell count was 4.6 × 109/L with 62% segmented neutrophils, 1% band neutrophils, and 37% lymphocytes; and platelet count was 233 × 109/L. An emergency abdominal CT showed venous gas in the hepatic portal vein, gastro-omental vein, and superior mesenteric vein, and accumulation of gas within the wall of the gastric
fornix (Fig. 1a, b). In the fornix, contrast-enhanced CT showed a lack of early mucosal enhancement and hypo-attenuation of the gastric wall, with mild contrast enhancement in the delayed phase (Fig. 1c, d). He received intravenous fluids and broad-spectrum antibiotic therapy. The patient’s abdominal pain spontaneously resolved within 1 h, and his subsequent clinical course was uneventful. He did not present with fever, hematemesis or melena. A follow-up CT scan obtained 1 week later showed the disappearance of gas and a normal appearance of the fornix. Gastric emphysema has not been reported in association with primary gastric DLBCL. In our patient, gastric emphysema developed after the addition of rituximab to the CHOP regimen. As rituximab in combination with CHOP has successfully improved the outcomes in patients with DLBCL [4], we speculate that rituximab- or R-CHOP-induced rapid breakdown of the gastric lymphoma lesion transiently reduced the blood supply to the fornix, which led to acute damag
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