Takeuchi Hideyuki, Kamada Teppei, Ohdaira Hironori, Takahashi Junji, Nakashima Keigo, Nakaseko Yuichi, Yoshida Masashi, Okada Shinya, Yamanouchi Eigoro, Suzuki Yutaka
Department of Surgery, International University of Health and Welfare Hospital, Japan.
Department of Pathology, International University of Health and Welfare Hospital, Japan.
Ann Med Surg (Lond). 2021 Feb 27;64:102198. doi: 10.1016/j.amsu.2021.102198. eCollection 2021 Apr.
Primary gastrointestinal lymphoma is relatively rare and typically treated by chemotherapy. In some cases, surgery for obstruction in the proximal small intestine is challenging and has a high risk for anastomotic leakage. An 80-year-old woman presented to our hospital with vomiting and abdominal distension. Enteroscopy showed a type 2 circumferential tumor in the proximal jejunum 6 cm on the anal side from Treitz ligament. Biopsy showed solid and diffuse proliferation of large atypical cells with round and irregular nuclei. On immunohistochemistry, these cells were positive for CD20, CD79a, and CD138. Diffuse large B-cell lymphoma (DLBCL) was diagnosed and classified as Ann Arbor stage IIE and Lugano classification stage II 2 and scored 1 point on the International Prognostic Index (i.e., low risk). Given the risk of anastomotic leakage due to lesions and residual obstructive enteritis, surgery was not performed. The patient received double percutaneous transesophageal gastrotubing (dPTEG) to facilitate decompression and enteral nutrition. Enteral nutrition and chemotherapy were initiated immediately after dPTEG insertion. After one course of rituximab plus cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone (R-CHOP), the tumor showed a partial response, and the obstruction was improved. Oral ingestion was started, and the dPTEG tube was removed. After six courses of R-CHOP, enhanced CT, positron emission tomography-CT, and serum interleukin-2 levels indicated complete treatment response. During treatment, gastrointestinal perforation did not occur, oral intake was good, and careful follow-up will be continued. dPTEG for obstructive small intestinal DLBCL could help avoid high-risk surgery, and a complete response to chemotherapy was achieved.
原发性胃肠道淋巴瘤相对罕见，通常采用化疗进行治疗。在某些情况下，近端小肠梗阻的手术具有挑战性，且吻合口漏的风险很高。一名80岁女性因呕吐和腹胀就诊于我院。肠镜检查显示，在距Treitz韧带肛侧6 cm的空肠近端有一个2型环形肿瘤。活检显示大的非典型细胞呈实性和弥漫性增殖，细胞核圆形或不规则。免疫组化显示，这些细胞CD20、CD79a和CD138呈阳性。诊断为弥漫性大B细胞淋巴瘤（DLBCL），Ann Arbor分期为IIE期，Lugano分类为II 2期，国际预后指数评分为1分（即低风险）。鉴于病变和残留梗阻性肠炎导致吻合口漏的风险，未进行手术。患者接受了双腔经皮经食管胃造瘘术（dPTEG）以促进减压和肠内营养。dPTEG插入后立即开始肠内营养和化疗。在接受一个疗程的利妥昔单抗联合环磷酰胺、羟基柔红霉素、长春新碱和泼尼松（R-CHOP）治疗后，肿瘤出现部分缓解，梗阻得到改善。开始经口进食，并拔除dPTEG管。经过六个疗程的R-CHOP治疗后，增强CT、正电子发射断层扫描-CT和血清白细胞介素-2水平显示达到完全缓解。治疗期间未发生胃肠道穿孔，经口摄入量良好，将继续进行密切随访。对于梗阻性小肠DLBCL，dPTEG有助于避免高风险手术，并实现了化疗的完全缓解。
