St. Luke's University Health Network Bethlehem, PA, United States
Janak Bahirwani, MD1, Brian Kim, DO2, Manoj Mittal, MD1, Ying Lu, MD1 1St. Luke's University Health Network, Bethlehem, PA; 2St. Luke's University Health Network, Fountain Hill, PA
Introduction: Diffuse large B-cell lymphoma (DLBCL) of the spleen is a distinctive clinical and pathological entity that has a characteristic large, destructive mass with extensive central necrosis and early capsular penetration. Gastrosplenic fistulization can occur due to the proximity of the spleen with the gastric fundus. The gastro-splenic ligament also helps facilitate the invasion of tumor cells into the gastric mucosa. This can present with upper GI bleeding.
Case Description/Methods: A 72-year-old female presented to the hospital complaining of lethargy after an episode of melena. Vital signs were stable on presentation. Laboratory tests showed a hemoglobin of 8.0 mg/dL (baseline approximately 11 mg/dL), leukocytosis, acute kidney injury, and lactic acidosis. She was admitted to the ICU for further care. CTA of the abdomen revealed a 7.3 x 7.2 cm splenic mass invading into the stomach with a connection in the posterior wall of the fundus consistent with a gastrosplenic fistula. The mass infiltrated into the splenic hilum and artery. A contiguous pancreatic tail mass measuring 4.2 x 3.4 cm was also identified. The patient underwent successful coil embolization of the splenic artery due to active bleeding. She subsequently underwent an upper endoscopy which showed a fungating, ulcerated, malignant-appearing mass in the fundus/body of the stomach that appeared to erode through the gastric wall. An endoscopic ultrasound showed an irregular, heterogeneous, and hypoechoic mass measuring 8.4 x 5.6 cm with poorly defined margins in the tail of the pancreas with an indeterminate layer origin. Cytology results demonstrated atypical cells. Cold forceps biopsies of the stomach mass confirmed DLBCL. The patient was started on R-CHOP chemotherapy with 50% dose of Cytoxan, Adriamycin, and Oncovin.
Discussion: Spontaneous gastrosplenic fistula formation from DLBCL of the spleen is rare. Fistulas are more commonly seen after starting chemotherapy for splenic lymphomas that have invaded the stomach due to rapid regression of the tumor size. When occurring spontaneously, extensive splenic necrosis and gastric wall infiltration is necessary for fistulization (as seen in our patient). Treatment of GI lymphomas can be especially challenging in cases involving ulcerated masses due to a high risk of perforation following the first cycle of chemotherapy. To reduce the risk of perforation in our patient, the decision was to initiate R-CHOP with a 50% dose reduction of Cytoxan, Adriamycin, and Oncovin.
Figure: A- CT Abdomen showing splenic mass with extensive air and gastrosplenic fistula B- EGD showing a fungating friable/ulcerated mass along the posterior wall of the fundus C- H&E showing extensive atypical large cell proliferation with prominent nucleoli and mitotic figures D- CD20+ revealing that the large cells are B lymphocytes that are also positive for BCL-6 and c-MYC
Janak Bahirwani indicated no relevant financial relationships.
Brian Kim indicated no relevant financial relationships.
Manoj Mittal indicated no relevant financial relationships.
Ying Lu indicated no relevant financial relationships.
Janak Bahirwani, MD1, Brian Kim, DO2, Manoj Mittal, MD1, Ying Lu, MD1. P2576 - Primary Splenic Lymphoma Complicated by Spontaneous Gastro-Splenic Fistula Presenting as Upper GI Bleeding: A Case Report, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.