VOLUME 28 䡠 NUMBER 28 䡠 OCTOBER 1 2010

JOURNAL OF CLINICAL ONCOLOGY D I A G N O S I S I N O N C O L O G Y

Emphysematous Colitis of Ascending Colon A

With Portal Venous Air Caused by Diffuse
Large B-Cell Lymphoma
A 57-year-old man with a 4-year history of complete remission of
diffuse large B-cell lymphoma (DLBCL) reported a 1-week duration
of intermittent fever in association with nausea, abdominal pain, and
bloody stool. Whole-body computed tomography scans revealed re-
current lymphoma in the ascending colon (Fig 1, white arrow). The
patient was prepared for chemotherapy, but the sudden onset of
severe abdominal pain prompted an emergency room visit. Physical
examination revealed a distended abdomen, and a palpable, firm, and
elastic mass was detected at the right lower abdominal quadrant with
rebound tenderness, and bowel sound was reduced. Laboratory anal-
yses revealed a WBC of 3,360/␮L (normal: 4,000 to 11,000/␮L), he-
moglobin of 9.2 g/dL (normal: 12.3 to 18.3 g/dL), platelets of
B
10,000/␮L (normal: 120,000 to 320,000/␮L), lactate dehydrogenase of
23,591 U/L (normal: 230 to 460 U/L) and C-reactive protein level of
21.8 mg/L (normal ⬍ 0.8 mg/L). Peripheral-blood film analysis re-
vealed the presence of 3% abnormal lymphoid cells. A non– contrast-
enhanced computed tomography scan of the abdomen demonstrated
a heterogeneous lesion in the right lower abdomen (Fig 2A, white
arrow). The lesion appeared to involve a dilated ascending colon, with
necrotic tissues in lumens and gas formation in the bowel wall, con-
sistent with emphysematous colitis. Portal venous air was also identi-
fied (Fig 2B, white arrow). The patient underwent an emergency
laparotomy with right hemicolectomy. A massive, ulcerated, and ne-
crotic tumor (15 ⫻ 10 cm) located at the intestinal wall between the
terminal ileum and hepatic flexure of colon was confirmed. His-
topathologic examination showed severe infiltration of tumor cells
from mucosa to serosa over the ascending colon (Fig 3A; hematoxylin
Fig 2.
and eosin stain, original magnification ⫻40) as well as omentum and
lymph nodes. The large pleomorphic tumor cells displayed hyper-

chromatic and prominent nucleoli, admixed with many apparent

karyorrhectic bodies and tingible-body macrophages, as well as lym-
phocytes and plasma cells (Fig 3B; hematoxylin and eosin stain, orig-
inal magnification ⫻200), which were positive for CD20 (Fig 3C;
CD20 stain, original magnification ⫻200). The pathology was com-
patible with DLBCL with involvement of the ascending colon, omen-
tum, and mesenteric lymph nodes. The patient was treated with low-
dose vincristine, corticosteroids, and anti-CD20 antibody. The
patient’s general condition improved initially. However, high fever
and tarry stool developed, and death occurred despite inten-
sive therapy.
DLBCL is the most common diagnosed non-Hodgkin’s lym-
phoma, representing approximately 30% of total cases.1 Most patients
are male, and the incidence increases with age. However, DLBCL
involving the colon, as occurred in the present case, is uncommon.
Only approximately 12% of DLBCLs involve the gastrointestinal sys-
Fig 1. tem as the primary site,1 with 3% to 10% of gastrointestinal DLBCLs

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 Diagnosis in Oncology
A mary gastrointestinal DLBCL compared with other groups presented
B outcome of primary gastrointestinal DLBCLs is better than that of
C
Fig 3.
being located in the colon.1-3 The pathogenesis of DLBCL is compli-
cated, and the morphology, immunophenotyping, and genetics of
DLBCLs are heterogeneous among nodal and extranodal lymphomas,
which results in different clinical and biologic characterizations and
■ ■ ■
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outcomes.2 For example, a large case series study reported that pri-
more frequently with early-stage disease, absence of bone marrow
infiltration, normal serum lactate dehydrogenase, and low- or low/
intermediate-risk international prognostic index and showed a bcl-6
expression more frequently than nodal cases.3,4 Higher complete re-
mission rates and better 5-year overall survival rates were also noted.
On the other hand, emphysematous colitis in our patient caused by
the recurrent DLBCL revealed a radiologic finding of pneumatosis
intestinalis (air contained within the submucosa of the intestinal
wall).5 This may arise due to direct lymphoma infiltration or
obstruction-related ischemia and necrosis of bowel wall.6 To the best
of our knowledge, lymphoma-related emphysematous colitis is very
rare, and only two patients had been reported to date.7 The present
case is the first reported case of ascending colon lymphoma with
emphysematous colitis and portal venous air. Treatment of gastroin-
testinal DLBCLs is the same as that of other DLBCL groups, and
others. However, data on metastatic gastrointestinal DLBCLs is very
limited. The present case and previous knowledge highlight the need
to be alert when confronted with a patient with known lymphoma
associated with abdominal discomfort. Gastrointestinal involvement
or complications by lymphoma should be highly suspected. Immedi-
ate evaluation and treatment are needed.
Yu-Hsiang Chou and Huan-Lun Hsu
Far Eastern Memorial Hospital, Taipei, Taiwan
Jen-Chieh Lee
National Taiwan University Hospital and National Taiwan University College of
Medicine, Taipei, Taiwan
Been-Ren Lin and Kao-Lang Liu
National Taiwan University Hospital, Taipei, Taiwan
AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST
The author(s) indicated no potential conflicts of interest.
REFERENCES
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Br J Radiol 51:203-205, 1978
DOI: 10.1200/JCO.2010.29.1229; published online ahead of print at
www.jco.org on August 2, 2010
© 2010 by American Society of Clinical Oncology e497