Large gastrosplenic fistula after effective treatment of abdominal diffuse large-B-cell lymphoma

Abstract

Dear Editor, The monoclonal antibody rituximab, which binds to the CD20 antigen expressed on normal B cells and the malignant cells of more than 90% of diffuse, large B-cell lymphomas demonstrated its efficacy as a single agent or in combination with chemotherapy (e.g., CHOP) without adding relevant toxicity [1]. Its potent efficacy in combination with CHOP, together with its favorable toxicity profile, establishes rituximab as an important part of modern standard immunochemotherapy of diffuse, large B-cell lymphomas. However, the potency of the combined treatment regime may cause severe side effects in case of infiltration of the gastric wall as described in our case. A 56-year-old man suffering from general weakness, obstipation, and a weight loss of 18 kg in the previous 3 months was admitted to our hospital to rule out cancer. The patient denied having any other symptoms (e.g., fever and sweating), and a recently performed colonoscopy was unremarkable. On initial abdominal sonography, a mass, 15 cm in diameter, was detected in the upper left quadrant. Subsequent computed tomography (CT) verified the presence of a tumor that infiltrated the spleen and had direct contact to the stomach. Although infiltration of the gastric wall was assumed, it could not be verified by CT (Fig. 1). No other abdominal tumor manifestations were found; the peripheral lymph nodes were unremarkable, and no pathologic findings were noted on bone marrow biopsy or on chest CT. Finally, CT-guided biopsy of the tumor led to the diagnosis of a diffuse large B-cell lymphoma (stage IIBE, IPI1). The patient was then treated according to the R-CHOP 21 regimen [2]. Several days after the end of the third cycle, the patient presented with fever and signs of acute infection. Follow-up CT showed complete remission which had resulted in a large opening in the stomach wall (Fig. 2). The patient was referred to surgery and underwent splenectomy with resection of the greater curvature of the stomach. Histopathologic analysis revealed normal splenic parenchyma and gastric tissue with necrotic areas but only avital tumor cells were found. The patient recovered well, was discharged on day 12 after surgery, and received the remaining cycles of chemotherapy. Gastrosplenic fistula resulting from a gastric or splenic lesion is a rare entity. Gastric adenocarcinoma, Crohn’s disease, benign gastric ulcer, and splenic lymphoma are known causes [3]. For a gastrosplenic fistula to develop in a splenic lymphoma, invasion of the gastric wall is required. If most or even all gastric wall layers are infiltrated, rapid necrosis of the tumor tissue may result in the formation of a fistula to the adjacent spleen [4]. In this context, five cases of gastrosplenic fistula occurring after chemotherapy have been reported [5], most of them describing the formation of quite small fistula. However, if a larger part of the stomach is infiltrated, it is possible for a large opening in the stomach wall to arise, as reported in our case. Ann Hematol (2008) 87:337–338 DOI 10.1007/s00277-007-0404-5