PMC5902089_01
Contrast abdominal CT (coronal) image upon admission. The scan shows (a) prominent thickening of the duodenal wall from the second to third portion (arrow), and (b) perforation 17 days after gastrojejunostomy revealing an enlarged duodenal mass (arrow), free air (arrow heads), ascites (long arrow), and expansion of the common bile duct/intrahepatic bile duct (*) due to tumor-related stenosis.
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Contrast abdominal computed tomography (CT) images showed a mass in the duodenum (Figure 1(a)). Seventeen days after laparotomy during the time waiting for PET-CT, the duodenal mass had enlarged, resulting in obstructive jaundice and perforation of an ulcer in the second to third segment of the duodenum (Figure 1(b)), when the patient complained of severe abdominal pain, resulted in a state of shock with hypotension (76/42 mm Hg) and physical signs suggesting peritonitis.
Endoscopic findings. Endoscopy revealed an ulcer and bulging of the thickened duodenal wall (second to third portion), where the perforation occurred.
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Esophagogastroduodenal endoscopy revealed marked thickening and bulging of the duodenal wall from the second to third portion (Figure 2).
Histopathological findings. A biopsy led to a diagnosis of DLBCL. The tissue was diffusely infiltrated by lymphoblasts with nuclear atypia (a) (H&E stain; original magnification, x400), which were diffusely stained with CD79a+ (b) and Ki67+ (c) (original magnification, x400). CD20+ staining not shown.
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Histological examination of a biopsy from the duodenal lesion revealed DLBCL (phenotype: CD20+, CD79a+, Ki67+) (Figure 3).
Time course of changes in laboratory data in response to treatment. Serum levels of lactate dehydrogenase (LDH) and sIL-2R in response to duodenal perforation and various therapeutic regimens. Details of treatment regimens are in the text.
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Serum LDH and sIL-2R increased rapidly (Figure 4). As shown in Figure 4, the patient received two cycles of rituximab, although because she was anti-HBs-Ab-negative and anti-HBc-Ab-positive, we were careful to monitor reactivation of HBV.
Time course of PET-CT findings regarding the duodenal mass in response to treatment, PET-CT shows (a) high FDG uptake (SUV max = 9.2) at the duodenum prior to immunochemotherapy, (b) reduced uptake (SUV max = 5.1) after radiation, and (c) barely detectable uptake (SUV max <1.0) after finishing treatment.
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After completing chemotherapy, the patient's condition improved markedly, although a residual high signal remained in the third segment of the duodenum and in the jejunum upon PET-CT (Figure 5). One month after finishing chemotherapy, the patient received radiotherapy (50 Gy; 25 fractions over 5 weeks) to treat residual lymphoma, after which the hot FDG uptake signal observed on PET-CT images disappeared (Figure 5).