Bowel perforation during initial treatment for childhood non-Hodgkin's lymphoma

Surgery in perforated pediatric intestinal lymphoma

BACKGROUND

Perforation is the most common surgical complication in pediatric intestinal lymphoma. During operation, many surgical decisions are debatable.

AIM

To assess the outcome of surgical management of perforated pediatric intestinal lymphoma.

PATIENTS AND METHODS

This is a retrospective analysis of all pediatric patients (<18 years old) with intestinal lymphoma treated in our hospital between July 2007 and June 2017. Risk factors for perforation, type of management and outcome in cases of intestinal perforation were analyzed.

RESULTS

The study included 240 patients with intestinal lymphoma. Perforation developed in 16 patients (6.7%) with a median age of 5.3 (range: 2.8-15.7) years. Most of the patients (92.5%) had Burkitt lymphoma. The ileum was the most common site of perforation (n = 10). Perforation occurred at presentation (n = 2), during induction (n = 10), during maintenance chemotherapy (n = 2), or at relapse (n = 2). Primary resection anastomosis was done in 12 patients. The resected specimen showed a viable tumor in ten patients. Wound infection (25%) and dehiscence (12.5%) were the most common postoperative complications. The 5-year overall and event-free survivals of patients with perforation were 78.6% and 71.4%, respectively, compared with 85.5% and 81.2% in non-perforated patients; the difference was not significant (p = 0.374 and p = 0.270, respectively).

CONCLUSION

Perforation is not an adverse prognostic factor for survival in pediatric intestinal lymphoma patients. Primary resection anastomosis seems to be a safe option if complete tumor resection is feasible.

Cancer therapy-related complications in the bowel and mesentery: an imaging perspective

Cancer therapy-induced complications in the bowel and mesentery are fairly common. It is important for clinicians to be aware of these complications and the agents most frequently implicated. Cancer therapy is rapidly evolving and often encompasses both classic cytotoxic drugs and newer molecular targeted agents. Drugs from both broad classes can have numerous adverse effects on the bowel and mesentery that can be detected on imaging. These adverse effects include ileus, various forms of enterocolitis, gastrointestinal perforation, pneumatosis intestinalis, secretory diarrhea, and sclerosing mesenteritis. These complications are diverse and range from relatively benign to life threatening. The management is also variable, but many of these conditions are easily controlled and reversed with supportive care and cessation of the particular cancer therapy. The objective of this pictorial essay is to demonstrate some of the more common cancer therapy-induced complications of the bowel and mesentery, with a focus on the radiographic findings.

Jejunal perforation: a rare presentation of B-cell lymphoma

A 42-year-old man who was being treated for pneumonia developed severe, sudden-onset abdominal pain with features of shock and peritonism. The clinical picture combined with radiological investigations raised suspicion of a bowel perforation necessitating urgent surgical review and emergency laparotomy. This diagnosed a jejunal perforation with abnormal lymph nodes. Histological examination confirmed diffuse large B-cell lymphoma. The patient was subsequently started on a course of chemotherapy. While gastrointestinal perforation secondary to antilymphoma treatment is a well-recognised complication, primary perforation caused by the lymphoma itself must always be considered.

Intestinal perforation after treatment of Burkitt's lymphoma: case report and review of the literature

Non-Hodgkin's Lymphoma (NHL) is the most common intestinal malignancy in children, and Burkitt's lymphoma is the most frequently encountered histologic subtype. In pediatric patients, intestinal involvement of the lymphoma is a common finding. As over half of these intestinal tumors are unresectable at the time of presentation, chemotherapy is the mainstay of treatment. However, as the tumor responds to chemotherapy, regression of the tumor in the bowel wall can result in intestinal perforation. We report a unique case of a pediatric patient with lymphoma-related intestinal perforation which was managed with a damage control laparotomy, discuss operative management strategies in these difficult cases, and provide a review of similar cases in the literature.

Primary colorectal lymphoma: case series and literature review

Primary colorectal lymphoma is a rare disease that accounts for 0.16% of colorectal malignancies. Treatments include surgical intervention with or without chemotherapy. Outcome of this intervention among the Chinese population are lacking. Perforation resulting from chemotherapy may need further exploration. A retrospective review of patient records was performed among those who were diagnosed with colorectal malignancy in a single center from January 1998 to June 2009. Ten patients met Dawson's diagnostic criteria for primary colorectal lymphoma [0.66% (10/1516) of all colorectal malignancies]. The male-to-female ratio was 9:1, and median age at diagnosis was 76 years. The most common site was the cecum (n = 5). B-cell lymphoma was present in eight patients. Seven patients underwent surgical intervention. The median follow-up of all patients was 16.5 months. Median survival was 17 months and 13 months in the surgical and chemotherapy group, respectively. Primary colonic lymphoma is a rare disease. Surgical intervention appeared to be superior to chemotherapy alone, but the findings were limited by the small number of patients in this study. Whether surgery or chemotherapy should be offered first remains unknown and requires further research.

Intussusception due to non Hodgkin's lymphoma; different experiences in two children: two case reports

In children, non-Hodgkin's lymphoma has been found to be the lead point in intussusception involving the terminal ileum. We present here two cases of ileal primary non-Hodgkin's lymphoma which presented as intussusception, highlighting the differing presentations of these children and their outcome, with a brief review of the literature.

Spontaneous intestinal perforation due to non-Hodgkin's lymphoma: evaluation of eight cases

Primary intestinal lymphoma with spontaneous perforation and after systemic chemotherapy is rare. The present study summarizes retrospectively the outcome of eight free intestinal perforated patients diagnosed with intestinal non-Hodgkin's lymphoma. Two patients had a history of systemic chemotherapy before perforation. The most common symptoms of the patients were abdominal pain, nausea, vomiting, weight loss, and fever. Sites of perforation were ileum in four, jejunum in two, cecum in one, and sigmoid colon in one patient. Synchronous lymphoma was present in three patients. The perforation was closed by primary closure in three patients. Resection/anastomosis was performed in four patients and sigmoid colostomy was performed in one patient. Three patients were lost due to leakage or septicemia. Intestinal lymphoma might be kept in mind as a cause in free intestinal perforations. Because of the high mortality rate early diagnosis and treatment are important to improve the prognosis of bowel perforation in patients with non-Hodgkin's lymphoma.

Successful treatment of a bowel perforation after chemotherapy for Burkitt lymphoma

Chemotherapy-induced intestinal perforation after treatment for Burkitt lymphoma is a known potential complication. However, there are very few reports in the pediatric literature that discuss this complication in any detail, and most incidents are secondary to surgical complications such as anastomotic leaks. Furthermore, there are no reports of children that have survived chemotherapy-induced perforation, and thus, guidelines for the diagnosis and treatment of this complication or for the continuation of chemotherapy are lacking. We present a case of a 5-year-old boy who survived jejunal perforation after treatment for his Burkitt lymphoma, and the critical aspects of his care are discussed.

Intestinal complications in children undergoing chemotherapy for mediastinal non-Hodgkin's lymphoma

Toxicities involving gastrointestinal tract are common in patients undergoing aggressive chemotherapy for cancer. However, it is uncommon to develop severe ulceration or perforation of the small intestine in absence of direct involvement of the bowel with the malignancy. The authors describe two children who developed severe gastrointestinal complications requiring surgical intervention following initial chemotherapy for non-Hodgkin's lymphoma. Both patients had no evidence of small bowel involvement by lymphoma on clinical staging.

Poor outcome of gastrointestinal perforations associated with childhood abdominal non-Hodgkin's lymphoma

BACKGROUND/PURPOSE

With modern chemotherapeutic protocols and advances in medical care, the outcome of intraabdominal non-Hodgkin's lymphoma (NHL) in children can be excellent for limited disease. Advanced disease, however, is associated with increased tumor aggression and requires more rigorous adjuvant therapy. Hence, complications early in the course of the disease process or its management often lead to a poor outcome. Perforation of the gastrointestinal tract, either iatrogenic, tumor related or chemotherapeutically induced is one such complication and may result significant morbidity and mortality.

METHODS

The authors reviewed their experience with this disease, and present two cases of children with abdominal NHL, which poignantly demonstrate these points. Results and a review of the literature are then discussed.

RESULTS

Fifteen cases of abdominal NHL were examined with an overall mortality rate of 40%. This increased to 100% in the presence of perforation. In two cases, inadvertent entry into the bowel occurred at the time of laparotomy for tumor biopsy. In the first case, intestinal wall was included in the biopsy specimen; in the second, laparotomy unmasked an already sealed-off perforation secondary to tumor invasion. Sepsis ensued in both cases. In the first, this resulted in repeated delays in chemotherapy, and the child succumbed to the disease. In the second, chemotherapy was continued, and although the small bowel leak was controlled, the initial insult hampered marrow recovery and host defenses, resulting in fatal sepsis.

CONCLUSIONS

These data and other reported cases in the literature indicate that intestinal perforation associated with abdominal lymphomas in children portends an extremely poor prognosis. All attempts to avoid this complication should be made, including avoiding direct tumor biopsy whenever possible.

Spontaneous gastrointestinal perforation in patients with lymphoma receiving chemotherapy and steroids. Report of three cases

Spontaneous gastrointestinal perforations in three patients with lymphoma were considered to be treatment-related conditions. All three were diagnosed as having malignant lymphoma by histological examination, and treated with chemotherapy and steroids. Four to 14 days after the start of chemotherapy, they complained of abdominal pain and plain roentgenograms revealed pneumoperitoneum. The interval between the onset of peritonitis and operation was almost 24 h. Emergency operations were carried out; one patient with a jejunal perforation underwent resection of the jejunum, another with a gastric perforation received a simple closure with omental patch, and the third with a gastric perforation underwent gastrectomy. Two patients recovered from the surgery, while the gastrectomy patient died due to sepsis. The favorable outcome of the surgical intervention is attributed to early diagnosis, prompt exploration, and selective operative procedures. We recommended a simple closure with omental patch for gastroduodenal perforation. Resection and primary anastomosis are possible only in the small bowel.

Non-Hodgkin's lymphoma

Pediatric lymphomas are the third most common group of malignancies in children and adolescents. Unlike lymphomas in adults, pediatric lymphomas are diffuse, aggressive neoplasms with a propensity for widespread dissemination. Intensification of conventional treatment approaches along with improvements in supportive care have resulted in dramatic improvement in event-free survival rates of close to 90% in patients with B-cell lymphomas and only slightly lower in patients with T-cell lymphomas. Lymphoid neoplasms arise because of genetic changes that result in altered growth and differential patterns of lymphoid cells. The characterization of these molecular abnormalities and an understanding of their consequences has led to new approaches to diagnosis and the detection of minimal residual disease and also provides the basis for the future development of novel treatment approaches targeted specifically to the neoplastic cells.

Aggressive chemotherapy in the treatment of Burkitt's and non-Burkitt's undifferentiated lymphoma

Because of the aggressive nature and frequent recurrence of malignant lymphomas of the undifferentiated type, we used a multi-drug induction chemotherapy regimen that has met with some success in children with similar type of histopathology followed by intensification and 8 cycles of consolidation chemotherapy in an attempt to prolong the duration of remission and survival in adult patients with this diagnosis. Fifty-one patients (median age 35 years) with undifferentiated malignant lymphoma were collected over a 4 year period (1984-1988) and entered into a phase III protocol done under the auspices of the Eastern Cooperative Oncology Group (ECOG). Six patients who had their diagnosis made at surgery and had resection of their tumor were excluded from analysis of response to therapy. Sixty percent of the patients had Stage IV disease. Sixteen patients had marrow involvement and five had central nervous system (CNS) disease. None of the patients received CNS radiation therapy. The 45 patients evaluated for response showed a response rate of 67% (30/45) and a complete response rate of 40% (18/45). Thirteen responders continue disease-free with a median follow-up of > 40 months and have an estimated 5 year survival of 80%. Only two treatment related deaths were reported for the entire group. Patients with undifferentiated non-Burkitt's lymphoma had a longer survival than those with undifferentiated Burkitt's. We concluded that adult patients with undifferentiated lymphomas could be treated successfully with an aggressive multi-drug chemotherapy regimen, consisting of multiple alternating cycles of non-crossed-resistant chemotherapy. Toxicity with this aggressive prolonged regimen was acceptable.

Primary malignant lymphoma of the intestine

Primary intestinal lymphoma is uncommon but not rare. Its pathology and potential therapy are complex. Its epidemiology has changed radically over the past century, reflecting a sharp surge in the incidence of intestinal lymphoma, particularly that associated with immunosuppression. Recent advances in diagnosis, a new approach to pathologic classification by immunotyping, and a new staging system have influenced therapy. New multimodal therapeutic protocols have improved the prognosis of this once deadly disease.

A complete ileo-tumor-colic fistula in a child with Burkitt's lymphoma

A boy with abdominal Burkitt's lymphoma developed rectal bleeding, abdominal distension, pain, and fever three weeks after diagnosis. Imaging studies revealed a necrotic tumor mass allowing a fistulous pathway from the ileum to the proximal colon. A laparotomy was performed, with resection of the large necrotic tumor. The child recovered, and has had no further evidence of Burkitt's disease. The radiological evaluation performed in this case ensured proper medical management and surgical intervention during a life-threatening event. The possibility of bowel perforation as a complication of therapy for abdominal lymphoma must be recognized.

The role of surgery in abdominal non-Hodgkin's lymphoma: experience from the Childrens Cancer Study Group

To determine the appropriate role of surgical intervention in non-Hodgkin's lymphoma primary to the abdomen, we analyzed the effect of multiple prognostic determinants on event-free survival for patients entered into the CCG-551 study. Eighty-four patients were identified with abdominal lymphoma and of these adequate data for analysis was available on 68 (81%). Variables of interest included: extent of disease at diagnosis, completeness of resection, use of bowel resection, radiation to the primary site, and sex/age/race. The median age on study was 8 years; 79% of patients were white and 85% were male. Thirty-three patients (49%) presented with localized disease. Laparotomy was performed in 67 children (99%) with complete gross resection in 28 (42%). Of the 10 reported surgical complications, 8 occurred in those with extensive disease who were incompletely resected. Radiation to the primary site was given in 60% of patients with median dose of 2,000 cGy. Analysis was performed both for the overall group and for the subgroup receiving optimal chemotherapy for histopathology. Variables with significant predictive effect on event-free survival in univariate analysis included extent of disease (P less than or equal to .001), complete resection (P less than or equal to .002), and use of bowel resection (P less than or equal to .004). However, in multivariate analysis, only extent of disease was an independent predictor of outcome. The data support a role for complete operative excision of localized lymphomas especially when accomplished with bowel resection. Aggressive attempts at debulking extensive retroperitoneal or mesenteric lymphomas are contraindicated.

Burkitt cell acute leukaemia (L3 ALL) in adults: a report of 18 cases

Between 1981 and 1987, L3 ALL was diagnosed in 18 adult patients, with a median age of 26 (range 16-66) and M/F ratio of 3.5. At diagnosis, 11 patients had splenomegaly, 11 had enlarged lymph nodes, and 15 patients had central nervous system (CNS) disease, of whom 10 had mental neuropathy. Anaemia was found in 13 patients, thrombocytopenia in 17 and the median white cell count was 25.5 x 10(9)/I (range 8.6-89). Surface immunoglobulins were found on the blasts of every patient. Seventeen patients had a t(8;14) (q24;q32) translocation. One had an apparently normal karyotype, but only six mitoses could be examined. During the period of the study different treatment protocols, which comprised increasingly intensive systemic and CNS chemotherapy, were used. Six patients died less than 3 weeks after admission, two of them of acute tumour lysis syndrome and two of CNS haemorrhage. In two other patients, rapid progression of CNS leukaemia was seen in spite of the treatment. Ten patients (56%) achieved complete remission (CR). Two were allografted and two were autografted early in CR. Four patients relapsed, three of the four relapses involving the CNS. A median actuarial disease-free survival was not attained, and a plateau was achieved at 57% after 7 months, with no later relapse. Median actuarial survival of the 18 patients was only 6 months, but a plateau was obtained at 31% after 11 months. Prognosis seemed related to the intensity of chemotherapy: recent patients, treated more aggressively, achieved CR more often than earlier patients, treated with less intensive protocols, although the number of patients was too small to draw any firm conclusion. The initial white cell count was also a prognostic factor, as none of the patients with more than 30 x 10(9)/I leucocytes achieved CR. Our results suggest that the outcome of adult L3 ALL can be improved, as in children, by increased intensity of treatment, particularly with regard to CNS leukaemia therapy. Early deaths are still frequent, however, but their incidence can probably be reduced by better prevention and early management of the acute tumour lysis syndrome.

The acute abdomen in the immunocompromised host

Immunocompromised hosts are a heterogeneous group, including patients receiving transplants, those receiving chemotherapy for malignant disease, and those receiving steroids for autoimmune disease, as well as patients with AIDS. Each group has specific abdominal conditions, and the clinician must be familiar with the specific causes of the acute abdomen within each subset. The causes of the acute abdomen in immunocompromised patients may be divided into two broad categories: (1) those disorders that are closely associated with the immunocompromised state and (2) those processes that can occur in any patient regardless of the immune status. Physicians at every level of specialization must become familiar with the unusual complications that occur in this population and with the ways in which the underlying disease and its therapy can modify the clinical presentation and management of common abdominal conditions. This article outlines broad principles of common clinical findings and surgical therapy in these patients.

Small bowel metastases from primary carcinoma of the lung

Although about half of all patients with carcinoma of the lung have metastases at initial presentation, only nine with metastases to the small bowel have been previously reported. This study was performed to determine the incidence of occult and clinically apparent metastases of lung cancer to the small intestine. Small bowel metastases were present in 46 of 431 patients with primary lung cancer who underwent autopsy during an 11-year period. These patients had an average of 4.8 metastatic sites. Small bowel metastases were present in 12 of 31 (39.0%) patients with large cell carcinoma, 13 of 108 (12.3%) with adenocarcinoma, six of 73 (8.0%) with small cell carcinoma, 15 of 199 (7.5%) with squamous cell carcinoma, and none of 20 with undifferentiated carcinoma. During the same interval, six of 78 patients undergoing small bowel resection for metastatic tumor had lung cancer primaries. Among the nine previously reported clinical cases of small bowel metastases and the six in this series, 14 were operated upon for small bowel perforation and one for obstruction. Nine patients died perioperatively, and no patient survived longer than 16 weeks. These data demonstrate that the incidence of lung cancer metastases to the small bowel is higher than is clinically apparent. Lung cancer metastases to the small bowel often present as intestinal perforation and indicate a poor prognosis; surgery is indicated for palliation.

Small bowel metastases from primary carcinoma of the lung

Although about half of all patients with carcinoma of the lung have metastases at initial presentation, only nine with metastases to the small bowel have been previously reported. This study was performed to determine the incidence of occult and clinically apparent metastases of lung cancer to the small intestine. Small bowel metastases were present in 46 of 431 patients with primary lung cancer who underwent autopsy during an 11-year period. These patients had an average of 4.8 metastatic sites. Small bowel metastases were present in 12 of 31 (39.0%) patients with large cell carcinoma, 13 of 108 (12.3%) with adenocarcinoma, six of 73 (8.0%) with small cell carcinoma, 15 of 199 (7.5%) with squamous cell carcinoma, and none of 20 with undifferentiated carcinoma. During the same interval, six of 78 patients undergoing small bowel resection for metastatic tumor had lung cancer primaries. Among the nine previously reported clinical cases of small bowel metastases and the six in this series, 14 were operated upon for small bowel perforation and one for obstruction. Nine patients died perioperatively, and no patient survived longer than 16 weeks. These data demonstrate that the incidence of lung cancer metastases to the small bowel is higher than is clinically apparent. Lung cancer metastases to the small bowel often present as intestinal perforation and indicate a poor prognosis; surgery is indicated for palliation.