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December-B 2020, Volume 70, Issue 12


Targeting the neighbour: Primary gastric lymphoma with concealed splenic perforation

Tehreem Zafar  ( Department of Radiology, Shaukat Khanum Memorial Cancer Hospital and Research Center Lahore, Pakistan )
Waqas Ahmad  ( Department of Radiology, Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan. )
Humayun Bashir  ( Department of Nuclear Medicine, Shaukat Khanum Memorial Cancer Hospital & Research Center, Lahore, Pakistan. )


Primary gastric lymphoma is a rare entity which manifests with vague abdominal symptoms and occasionally presents as complications including perforation and haemorrhage requiring urgent management. Chemotherapy has surpassed surgery with advancing medical era. We hereby present an unusual case of primary gastric lymphoma with splenic involvement complicated by localized perforation.

Keywords: Gastric Lymphoma, Perforation, FDG PET CT.


Case Image


A 42-year-old male with fever, weight loss and heaviness in left hypochondrium for 2 months; was found to have a mass in stomach and spleen on CT. Gastric biopsy showed primary gastric lymphoma. F18 FDG PET-CT demonstrated hypermetabolic heterogeneously enhancing left hypochondrial gastric mass and a large splenic lesion with non-avid areas of internal necrosis (Figure-1).

During treatment with chemotherapy he presented with acute pain. CT with oral and IV contrast showed contrast extravasation and air specks within the splenic lesion along with defect in the posterior gastric wall suggesting concealed gastric perforation into the spleen (Figure-2). Post treatment PET-CT scan showed significant regression in the primary disease, healed perforation with minimal residual disease (Figure-3). Stomach is the commonest gastrointestinal organ to be involved by primary extra nodal lymphoma. Clinical presentation is nonspecific ranging from abdominal pain and weight loss to dyspepsia or discomfort which may mimic benign conditions resulting in diagnostic delay. Rarely, complications like haemorrhage and perforation are seen on initial presentation.1 Imaging plays a vital role in staging and assessing local extent of disease. PET-CT as baseline investigation differentiates gastric lymphoma from other types of gastrointestinal cancer and helps rule out any gross complications. Endoscopic biopsy confirms the diagnosis.2 Spontaneous perforation may result from ulceration and tumour necrosis reaching the subserosa as in our case. Chemotherapy remains the main stay of treatment in uncomplicated cases. Although surgery is not the first line of treatment, multimodal approach through gastrectomy and adjuvant chemotherapy can be considered when complications occur.3




1. Ohkura Y, Lee S, Kaji D, Ota Y, Haruta S, Takeji Y, et al. Spontaneous perforation of primary gastric malignant lymphoma: A case report and review of the literature. World J Surg Oncol.2015;13:35

2. Cuccurullo R, Govi S, Ferreri A J. De-escalating therapy in gastric aggressive lymphoma. World J Gastroenterol.2014;20:8993-8997

3. Vetro C, Romano A, Amico I, Conticello C, Motta G, Figuera A, et al. Endoscopic features of gastrointestinal lymphomas: From diagnosis to follow-up. World J Gastroenterol.2014;20:12993-13005.


Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: