This case report was approved by the Institutional Review Board of Bucheon St. Mary’s Hospital (HC21ZASI0020), and informed consent was obtained from the patient.
A 65 year-old man was referred to our hospital with Rt and neck mass for 1 month. The patient had a history of hypertension and an old cerebral infarct with medication. There were no specific findings on the patient’s laboratory findings. Findings on neck and chest computed tomography (CT) showed multiple enlarged homogeneous enhancing lymph nodes in the right neck, right supraclavicular, right upper, lower paratracheal, subcarinal, right hilar, and interlobar areas (Fig. 1A). Positron emission tomography (PET-CT) scan showed fluorodeoxyglucose (FDG)-avid uptake in the right, neck, right, supraclavicular area, mediastinum, portocaval, both axillar, and distal ileum (Fig. 1B). An excisional biopsy of the Rt level II neck node was performed. The. Immunohistochemical staining results were positive for BCL2, CD20, MUM1, and Ki-67 at 70%. This was consistent with malignant lymphoma, diffuse large B-cell lymphoma, and activated B cell (ABC) type (Fig. 1C).
For workup of lymphoma, we conducted bone marrow biopsy, and the result was normocellular bone marrow with no evidence of lymphoma involvement. The patient was diagnosed with stage III diffuse large B-cell lymphoma by Ann Arbor staging. He was treated with six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin hydrochloride, vincristine, and prednisone). After 6 cycles of chemotherapy, the involved lymph nodes regressed, but there was remnant focal FDG uptake in the distal ileum (Fig. 2A). However, the patient had no symptoms, such as abdominal pain or hematochezia. Abdominal CT scan showed no definite wall thickening in the distal ileum. Therefore, the patient was examined again by a CT scan 3 months later. Abdominal CT showed eccentric wall thickening in the distal ileum with homogeneous enhancement, suspicious of recurrent lymphoma. The PET scan showed aggravation of intense focal FDG uptake in the distal ileum (maximum standard uptake value, 31 → 48) (Fig. 2B). The patient was treated with two cycles of DL-ICE (dexamethasone, L-asparaginase, ifosfamide, carboplatin, and etoposide) every three weeks. Seven days after the start of 2nd cycle of chemotherapy, the patient visited the emergency room for hematochezia. His vital signs were as follows: blood pressure, 130/80 mmHg; pulse rate 100/min-respiration rate 20/min-body temperature, 36.5°C. The hemoglobin level decreased to 11.0 g/dL. Abdominal CT scan and duodenoscopy/colonoscopy were performed. Abdominal CT showed improvement in wall thickening of the distal ileum (Fig. 3A). Endoscopically, there was fresh blood in the colon, but no definite bleeding focus was found (Fig. 3B). As bloody stool persists and hemoglobin level was decreased from 11.0 g/dl to 8.5 g/dl, he was underwent angiography. However, there was no active bleeding on mesenteric angiography. The patient underwent emergency surgery for ongoing bleeding. Segmental resection of the ileum was performed, and there was a mass with ulceration in the distal ileum (Fig. 3C). The pathology result was malignant lymphoma, diffuse large B-cell lymphoma, ABC type consistent with initial neck biopsy. After surgery, hematochezia was stopped, and the patient was discharged.
After 5 weeks of small bowel surgery, the patient recovered, and he maintained a normal diet. He was treated with 3rd cycle of DL-ICE. Eight days after 3rd cycle of chemotherapy, the patient complained of sudden abdominal pain. The patient’s white blood cell count was 1,190/, ㎕ and the absolute neutrophil count was 240/㎕. Abdominal CT scan revealed leakage at the distal ileoileal anastomosis site with scanty pneumoperitoneum (Fig. 4A). He received conservative treatments, such as Non Per Os, G-CSF, and antibiotic therapy. After 1 week, an abdominal CT scan was performed, which showed about 6 cm-sized fluid collections in the right lower quadrant area (Fig. 4B). Pig tail drainage was performed for these fluids, and there was no documented growth of microorganisms. After several days, the patient did not experience abdominal pain and had a diet. The pigtail catheter was removed, and the patient was discharged. We decided to stop the chemotherapy because there was no definite recurred lesion and concerning about complications such as leakage, dehiscence and perforation of bowel. He is now visiting an outpatient clinic with a follow-up response evaluation.